When Sam and I were project-less and speaking with the executive chairman of LAICO about our plans for the rest of the summer, he expressed his dream of us getting really involved in the hospital so as to get a comprehensive, on-the-ground understanding of how Aravind operates. We scoffed to ourselves when he painted a rosy picture of us escorting patients from place to place in the busy retina clinic, in which we were proposing to launch a study. Two weeks later, I have become a regular fixture at the front desk, preparing case sheets for patients as they check into the clinic and passing them onto the preliminary examination stage. Amidst the hectic atmosphere of the clinic, doctors stop to chat with me, sisters (nurses) crack jokes with me, and patients even try to speak Tamil to me every once in a while. Whereas a few weeks ago, I felt perpetually out of place and in the way, I now feel totally invested and comfortable working side-by-side with the sisters.
Sam and I have decided to work on a project aiming to optimize patient flow in the Retina & Vitreous Clinic. Aravind famously thrives on a lean operations business model, which allows it to provide consistently high-quality, low-cost ophthalmological care at a high volume. While the microsystem works seamlessly in the cataract clinic, it is unable to generate the same results when applied to the retina clinic, in part caused by the complex nature of retinal disorders. In this clinic, patients regularly wait up to 3-4 hours to see a doctor in an overcrowded waiting room. Patients are forced to stand anywhere there is space and often bombard the front desk to inquire why they have been waiting for so long.
After learning about patient flow from the doctor with whom we are working, the clinic manual, and patient shadowing, our next step was to track patient flow by inserting route cards into each patient’s case sheet. We asked the doctors and sisters to write down on these cards the start and end times of each interaction with patients, from which we would then calculate process length and wait time length and identify the bottlenecks in the system. We attempted to pilot the use of route cards last Monday afternoon, and to begin our official data collection period on Friday.
However, we had failed to foresee the roadblocks to the successful execution of this timeline. Pragmatically, we forgot to account for the time it would take to get a large order of forms printed, which afforded us a two-day delay. We also drastically underestimated how many meetings, gentle reminders, and bribes in the form of Indian desserts it would take to ensure that all the doctors and sisters would write on the route cards the information we were seeking. During the first few days of our pilot, before I started working at the front desk, we were exceedingly frustrated by the challenges we were facing in getting the clinic staff to comply with our requests. On the first day, doctors recorded nothing; on the second day, the sisters recorded nothing. We lacked the authority to enforce the use of the route cards, the clinic manager was out sick with bronchitis, and our supervising doctor had gone to the U.S. for two and a half weeks to attend a class for his masters program.
Faced with these issues, I realized I needed to plunge headfirst into the daily operations of the clinic, showing the staff how much I cared by actually working with them everyday. If I invested my time and energy into trying to make their jobs easier on a daily basis, they would no longer view the extra paperwork as an added annoyance and instead want to support us in our study. When the clinic manager returned on Thursday, we agreed that I would begin working at the front desk to help the medical records sister with attaching route cards to the case sheets. Since there was only room for one in the small space, Sam would spend the time analyzing the data and managing the flow of the cards through the clinic. When I first reached for a retina case sheet form (the required paperwork separate from our route cards), the sister exclaimed that I was only supposed to fill out the route cards for our study. I conveyed my desire to help facilitate the entire process, and asked the manager for permission to fill out all the forms.
So began my new job at the front desk. I inserted myself as a cog into the system, preparing case sheets as they entered the clinic and handing them to the medical records sister to check into the system. The clinic sees about 350-450 patients a day, and the sisters at the front desk handle patients both checking in and checking out, so working there is extremely fast-paced and high-stress. My first day on the job, I barely had a full minute of downtime and thought I was on the verge of a heart attack. By the end of the work-day at 6pm, the respect I held for the sisters was overwhelming, as was my feeling of exhaustion. That evening, I stayed after work to collect route cards from each file. I had suspected that if I stayed after hospital hours, I would finally have a chance to hang out with the sisters once they weren’t inundated with their work responsibilities.
I was right. When the clinic emptied out, the sisters suddenly transformed into playful and lighthearted young women. I learned their names along with some Tamil words and phrases, and they asked me all the questions on their minds about Sam and me. They begged me to wear a sari to work, offering recommendations for color combinations I would look good in, and jumped in alarm when I pretended I was drinking scooter fuel, which in India apparently closely resembles diluted fruit punch Gatorade.
Most of the sisters are around my age, having left their families in rural areas to begin training at around sixteen years old. Aravind has a stringent screening process for hiring sisters and purposely recruits girls from rural areas on the basis that these girls know how to work hard. And they certainly do. They are constantly on their feet, conducting tests and managing the agitated crowd. After lunch, as I inevitably slide into a post-lunch food coma, the sisters dive right back into handling the pool of case sheets that have built up during the lunch break. They work six days a week from 6:30am to 8:30pm, sometimes spending their Sundays working at rural outreach eye camps. When they do get Sunday off, they’ve told us they cannot go out due to Indian culture. Sam and I were planning to buy the sisters some Indian sweets to thank them for their efforts, and when I asked a sister for her favorite thing to get from the nearby bakery, she shrugged and replied, “I can’t go there because of caste.” Yet these sisters view their jobs at Aravind as an escape from a harder life at home, and feel empowered by the position of prestige. They are highly trained and efficient, and arguably form the backbone of the Aravind hospital system.
And yet, in the retina clinic, it’s often not enough. No matter how hard they work, everyone in the clinic is constantly firefighting, extinguishing problems as they arise but not able to reform the system to avert those problems from happening in the first place. Aravind is built on a policy of no appointments, except for investigations, so the rush of patients into the clinic is inevitable. Last Thursday, the hospital reached a record high since 2009 of admitting over 2500 patients in one day. At noon, the chief of the retina clinic, who doubles as the chief medical officer of the hospital, had to stop all registration for the retina clinic from the front desk until after 2pm.
With this sort of crowd, doctors see each patient for about two minutes, churning them out like clockwork and barely having a chance to explain anything to them about their diagnosis. Counselors trained to discuss diagnoses and treatments to patients face the same time constraint, also using hardly more than two minutes to explain and to schedule daunting procedures like retinal detachment surgery for the next day. The doctors sprint out of the clinic at 6pm even if there are patients still waiting because the last thing they want at the end of a long and grueling day is to have Aravind swallow yet another hour of their already scarce time with their families. All of Dr. V’s descendants work for the organization, and Aravind is all they eat, drink, breathe, sleep, live. But for those not in the family, balance is needed. The mission of Aravind is noble and the success it has achieved has subverted all expectations of what is practical and feasible, but at the end of the day, the challenges Aravind faces are real and plenty.
It has been a week since we first started the study, and it is still nowhere close to being an easy task. For the route card to be complete, we need every staff member involved in each step of the patient visit to record times accurately; if one step is missing, the wait time we calculate will be inaccurate. Although everyone tries to cooperate, when the clinic gets busy, doctors stop recording times. As a result, I am forced to fill in the missing information as case sheets pass through me at the front desk and to spend the last hour of the day digging through piles of disposed cases to ensure we have a decent yield rate. Yes, the twelve-hour work-days are tiring, but as I observe the hard work put in by the sisters and doctors every single day, I know I really can’t complain. And so as I do my part to get the cases in the system as fast as possible, I laugh and I sing. I whistle Nokia ringtones I hear in the waiting room, I attempt to speak Tamil, I wear saris to work and let sisters decorate me with yellow gold chains and bangles. While I sincerely hope that our project can help make their jobs easier in the long-run, I’m doing everything I can day-to-day during the short time of my internship to make sure my presence is a positive one.