medical management: from where we come, to where are we going

Summary of the speech given by Márcia R. F. Campiolo in the closing of the Allergan symposium during the XXXIV Brazilian Congress of Ophthalmology, held in Brasilia, in September, 2007.



Ophthalmology is a medical specialty whose high competitiveness in the market, as well as the constant need of investments in professional and technology upgrade make from the Management of the medical clinics an area of high importance to the chances of success of these professionals.

So that we can understand a little better what is happening with the healthcare market nowadays, specially regarding the client’s traits that we treat daily in our clinics, we need to go back in time.

Understanding the past allows us to obtain a better comprehension of the present, to extend our vision of the future market, as well as having a clearer delineation of the best strategies facing the high complexity of the market.

As Karl Marx said, a German philosopher who died in 1883:

“Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past.”
The remarkable facts which built the history of the healthcare market and its clients are many, and in my book “Management of the Medical Clinic” I make a more extensive analysis, but we will mention only some of them that are interesting and which enlightens the covered paths:

• During the era of King Hamurabi of BABYLONIA (18th century AC), the “Code of Hamurabi” was written, composed of laws to deal with issues related to various matters of the citizens’ life, including obligations of liberal professionals such as surgeons. The sentences usually involved body mutilations. In some of its articles, we can identify references to an “ancestor of the actual ophthalmologist”. One of the articles says that if the doctor, when making an incision in someone’s eye (a free man), and this leads to the loss of this person’s eye, the punishment would be the cutting off of the doctor’s hand.

• In the 15th of Mars, 1962, John Fritzgerald Kennedy sent to the American Congress a letter where he asked the congressmen laws giving a special attention regarding the consumers’ rights, related to four aspects: The Right of Security, or protection against the marketing of some products which are dangerous for health and life. The Right of Information, which include the general aspects of advertisement and the need to have information about the product itself and the best way of using it; The Right to Chose, fighting monopolies and the antitrust laws and considering the competition a favorable factor for the consumer; The Right to be Heard, which started to consider the consumers’ interests when elaborating new government policies and procedures of regulation. Currently, 15th of Mars is celebrated as the World Consumer Rights Day.

• In September of 1990, the Consumer Protection Code – CPC was approved in Brazil, which also created the Department of Consumer Protection and Defense, of the Secretary of Economic Rights in the Ministry of Justice. It was a landmark in the sense of providing rapid changes in the customer market. Since the approval of this code, there started a process to accelerate the awareness of the Brazilians so that they demand their rights more firmly, complaining about what he doesn’t agree, and of what doesn’t satisfy him and is not the way he expected to be. The greatest impact wasn’t legal, but social: the customer being aware of his rights.

• In Brazil, only since 1995, users who were outside research and educational institutions started to have the opportunity to use the internet, through the opening of the private sector for its marketing exploitation. This fact is revolutionizing and democratizing more and more the communication and the circulation of information.

We can see clearly through the history that the events happen in such a straight way so that we have in our society individuals who are well informed, demanding, critical, aware of their rights, and with a greater concern with respect to the environment and social issues.

In addition to the factors above, we need to point out that, in Brazil, we are witnessing an accelerated and disordered growth in the number of medicine faculties, which put each year in the market a big number of professionals who are eager to establish themselves and be stable professionally.
According to the article published in the São Paulo Newspaper on 13/06/2007;

“The number of faculties of Medicine in Brazil is only lower than in India. Till 2002, they were 115. Today they reach up to 167 (making available 17.836 vacancies every year). This data are from the survey presented by the Brazilian Medical Association (BMA), during the 11° National Meeting of the Medical Entities (Enem), in Brasilia.”

In 02/06/1999, the Veja Magazine published an article titled by “The hard routine in white” that demonstrated, already at that time, the huge number of professionals in the market. In an excerpt of this article the magazine cites:

“There exist 220.000 doctors in the country, one for every 700 inhabitants. It is a relation much bigger that what is recommended by the World Health Organization which is of one doctor for every 1000 inhabitants. To make it worst, 60% of the professionals are concentrated in the Southeast Region.”

The IBGE (Brazilian Institute of Geography and Statistics) estimated that in 2006 Brazil had 186.770.562 inhabitants, which shows according to the number of active doctors in the country, a ratio of one doctor for each 583 inhabitants. (Source: Jota Zero Magazine jul/ago/07).

In 2001, The Brazilian Council of Ophthalmology (CBO) published the results of a census which showed a detailed radiograph of the Ophthalmology in Brazil. In spite of it was held from some years ago, its data are still very important and concrete for the comprehension of the Brazilian ophthalmology market. It shows, without any doubts, that this market is moving quickly to a very delicate situation regarding the number of professionals, as well as their distribution across the country.

Here are some of these data:
? Brazil has the second largest ophthalmologist community in the world.
? 98,14% are found in cities with more than 50.000 inhabitants.
? From the 170 million inhabitants, only 40 million can pay a private covenant (23,5%).
? Within 12 years, the number of ophthalmologists in Brazil will have doubled and the population will have grown 17%.
We can observe a graphic projection of this growth below:



Moreover, the Brazilian Council of Ophthalmology-CBO considers that the ratio of one ophthalmologist for every 17.000 inhabitants is very balanced, but even in 2001, these numbers were already critical and far from the ideal in many Brazilian cities, whether capitals or inland cities. We can see this through the table below which cites only a few capitals.


CITY ST POPULATION OPHT. OPHT. /INHABIT.
SÃO PAULO SP 10.406.166 1428 1:. 7.287
RIO DE JANEIRO RJ 5.850.544 1171 1:. 4.996
BELO HORIZONTE MG 2.229.697 520 1:. 4.288
FORTALEZA CE 2.138.234 274 1:. 7.804
SALVADOR BA 2.440.886 270 1:. 6.597
RECIFE PE 1.421.947 266 1:. 5.346
CURITIBA PR 1.586.898 261 1:. 6.080
PORTO ALEGRE RS 1.359.932 252 1:. 5.397
BRASÍLIA DF 2.043.169 206 1:. 9.918
GOIÂNIA GO 1.090.581 170 1:. 6.415
VITÓRIA ES 291.889 91 1:. 3.243
Source: CBO Census 2001

The world, the professions, medicine and consequently, ophthalmology lives today a moment without precedents when it comes to the market’s competitiveness, which has a strong bound with a large number of complicating factors, known from many time in ophthalmology, and which does not summarizes in the issue having a high number of ophthalmologists in the market.

The changes in the market and in the client’s behavioral traits started to require from the doctor and his staff more preparation and investments regarding the acquisition and the upgrading of knowledge, technology, quality in service, comfort and facilities in the physical space, quality and reliability of the medical services provided, as well as the high level of information to the client.

So, we can conclude that the doctor, besides practicing a competent, up-to-date and ethical medicine, he also should be the leader of his clinic’s work, should be a competent manager of his career and of his clinic.
And now I ask the healthcare professionals:

Are you prepared to work successfully in this world facing these harsh market conditions?

It is worth quoting here the words of Albert Eisntein:
“In the middle of difficulty lies opportunity.”

The difficulties of the market must and can be overcome through a better preparation of the professionals so that they confront these conditions; especially through a greater investment in the preparation to manage your clinic. This is not an easy task, but it’s not impossible, thus, the search for knowledge which leads to an effectiveness within this sector is certainly a viable and necessary alternative.

Unfortunately, what we can see in the market in large numbers is an alarming lack of preparation with respect to the managing forms adopted by the healthcare professionals in different specialties.

The medical training, over time, has had its focus exclusively on the medical knowledge. By that, we see the new professionals arriving in the market urging to start their work, and in many cases, while setting up their clinics they are confronted with a huge challenge: the need of a gear around him which moves competently, so that he can do his role as a doctor and have greater chances to achieve professional success.

This structure which is fundamental for the doctor’s work can be briefly mentioned in the items below:

1. PHYSICAL STRUCTURE,
2. HUMAN RESOURCES,
3. LINEATION OF THE SERVING PROCESSES,
4. BILLING,
5. LEGAL DOCUMENTS WITH CURRENT OPERATING LISCENSES,
6. CONTRACTS WITH COVENANTS,
7. PARTICIPATION IN COOPERATIVES AND OTHER MEDICAL ENTITIES,
8. LEGAL KNOWLEDGE
a. MEDICAL ETHICS CODE,
b. CIVIL CODE,
c. PENAL CODE,
d. CONSUMER PROTECTION AND DEFENSE CODE,
e. CLT
f. others
9. BILLS TO PAY,
10. BILLS TO RECEIVE,
11. BANKS,
12. INVESTMENTS,
13. COSTS,
14. SUPPLIERS.

Adding to these factors, he will have in front of him a client who wants information, explanation, solution without any possibility of error, because the society asks from the doctor perfection in his work. The society, the citizens and their social mechanisms such as the press have no merci with this professional.
There is a huge lack of information and preparation of the professionals in this area, which ultimately leads to situations, related to the management of clinics, where the doctor eventually “migrates” to the extremes:

1. In the eagerness to master the situation, the progress of all works and decisions concentrates excessively on his person, even the small bureaucratic services that could be easily done by one collaborator of his team. This team which can be only of one employee or many others that exist in the structure.

2. Delegates excessively the execution of works and decisions over his staff. Thus, he winds up being in a “comfortable zone” where he has a false idea of security and stability. The manager is often the secretary who has been delegated the powers of the “clinic’s owner”.
In both cases, these extremes are not the best route to be followed in the Medical Management area. Correcting these distortions raises within us a huge and challenging mission.
The propulsion spring for this, the secret of success, certainly is in the vision that the doctor has towards his profession and the market. The chances to success are directly linked to this. The doctor Paul-Ferdinad Gachet lived with Van Gogh (1890) during the last months of the painter’s life and was the only one to accept his paintings as a payment to his consultations. He probably saw there an opportunity that others did not see.

Considering what has been said till now, we can try to see some of the demands that the future hides and which is not so difficult. The future has its arrows pointing in the direction of various points, but I can say that the factor information turned to the client’s education in the medical field for sure is one of the key elements that we are strongly being directed to.

People want and are wanting more and more information about his “case”. This is the propulsion string of the current society and will be increasingly strengthened in the future, that is, the information is the face of the present and the future in the medical field.

The Época Magazine of 20/08/2007, brought on its cover the article titled as “Doctor Google” and you can see clearly in this article that the search of information, from the patients’ side, is the heart of the moment in the route of the transformations in the doctor-patient relationship, and that for the individual, the knowledge is as important as doctors, technology, medicines, hospitals, and therapies.

It is possible to see a large number of medical clinics where there are no works with high level of educational information and appropriate quality focused on the served clients, but we should think seriously about this issue, we should be tuned to the market changes, as well as the society’s desires.

The painting “The Incredulity of Saint Thomas” by Caravaggio is an image which has a great power. We can take from it an important message, which shows us that, many times, it is not necessary for us to put the finger in the wound so that we can see what is happening. The clues can be percept and interpreted through various signs which are just in front of us, and for that we only need to have the desire and a wider vision.


The Incredulity of Saint Thomas – Caravaggio – 1599


If as Pythagoras said “The words are soul’s whispers”, this reflection of mine about the management of this very noble area as the medicine is, for sure was a very pleasant and deep whisper from the bottom of my soul. Thank you!