Dr Gullapalli Nageswara Rao, the founder of LV Prasad Eye Institute in Hyderabad, may have built a legacy with his healthcare delivery model but in this Outliers podcast with Pankaj Mishra, he also emerges as a health-tech visionary. In Amaravati, the new capital of Andhra Pradesh, he wants to build an eye institute of the future. “We want to think about how eyecare will be delivered 20 years from now, 50 years from now, so we can create a model,” he says.
Read this lightly edited transcript of the conversation from August 2018 to understand why Dr Rao believes the future in healthcare will be won by whoever strikes the best balance between man and machine. As always, thanks to Kanika Berry for transcribing the conversation for us.
Pankaj: Welcome to Outliers. This is a Podcast with Outliers and I am so excited to sit down with Dr Rao, who is the founder of LV Prasad Eye Institute. You know, I will be honest, the first time I really got interested in learning more about you was when I was reading something and I saw there were eye hackathons being organized with a lot of focus on technology and innovation. And then I started digging more and went back to my conversation with Dr Shetty and others and I said I must meet you because this seems to be a very rare combination of doing good with disruptive new-age technology. So welcome to the podcast, Dr Rao.
Dr Rao: Thank you. I think doing good is in-built into the medical profession, isn’t it? So we are in a unique profession where you can do well and do good. That combination is not easy in other professions. So it’s automatically in-built into our profession. That understanding is not given to the next generations of medical students. That’s where the problem is. If that understanding is given right at that level, at that stage, then it becomes easier subsequently to build a good healthcare system.
Pankaj: Give us a sense of where you come from, Dr Rao. Why are you doing what you are doing and how did you build this?
Dr Rao: I come from the coastal part of Andhra Pradesh. The first 10 years of my life I lived in a village near Vijayawada, 12-13 km from Vijayawada. The typical 1950s village. So, looking back, I still feel very strongly that those 10 years made me what I have become for the rest of my life. I strongly believe any doctor working in India should spend a part of his or her life in a village to become a really good Indian doctor. For that matter, any Indian. Without having lived in a village, what we see in the big cities of India is all superficial, glass and steel, without substance.
Pankaj: That describes the mission part very well but how did you get to building this institution and what were the milestones on the journey?
Dr Rao: Several inspirations. But I think the final inspiration was when I was working in the United States. Looking at the quality of medical care there and the kind of institutions they have built in that country always raised a question in my mind, ‘Why can’t we build similar institutions in our country?’ That’s one thing. And my wife and I always strongly felt that people like us got the best out of this country even though the country is very poor. And for people like us coming from families, like we both came from doctor’s families, so we should be giving back to our country. So these are the two simple feelings that led to coming back and trying to build an organization that replicates an American academic eye centre. That was the only limited vision I had when I came back.
In Hyderabad, a high-quality academic eye centre that would encompass patient-care, education and research. The only thing new that traditional western institutions don’t incorporate as an integral part, that we have done, is rehabilitation also. The idea being that everything in eye-care should be available under one umbrella. So with that, we started with these four segments – functional segments of the institute. Then as we went along, 5-6 years later, we realized that the real problem is out there, not here, in rural areas where 70% of India lives. And then I woke up, in some sense realizing, ‘Yes, that’s where I came from and am not doing much for the people living in those areas, sitting in Hyderabad.’ So how do we deal with it?
Because I was absolutely against eye camps because of the quality issues and I felt very strongly, wherever we go, whatever we do, it has to be an ongoing commitment. It can’t be that I go there, screen them, bring them to Hyderabad, operate, send them back and then forget. We wanted to be there permanently in those communities wherever we go. With that idea, we started developing models for rural eye care. We started with what we call secondary level eye-care centres for half a million population and providing high-quality care with one ophthalmologist or two ophthalmologists, depending on the demand. The team is drawn almost entirely from the local population and put them back in their own community after training.
Pankaj: How did you excite others with your vision? Because one of the challenges in scale is, it’s one thing to have your own vision but another thing to scale it.
Dr Rao: I think 2-3 things helped us. One is we made a deliberate decision in the beginning when we started that we will not recruit anybody with previous work experience so that we build our own culture. So everybody that we recruited came out of schools, colleges, medical colleges, training programs, and this was their first job. So this was the only culture they knew, so made our job lot easier.
The second thing was that relative, unfamiliarity with anybody in Hyderabad for me. I didn’t know anybody because I never lived here. So that gave me complete freedom. Even then, of course, lots of advisers from everywhere were coming and telling me, ‘This doesn’t work, that doesn’t work, this is not America.’ I politely listened to them and we went our own way. Then setting a direction and then going in that direction without getting distracted.
Pankaj: How do you balance future vision with current problems? Because that’s one of the things that fascinated me when I first heard about you.
Dr Rao: Always we made sure that we took care of all the micro details and also continued to look out for the macro vision. We also did not do too much of deliberate strategy. I think our institute has evolved on Emergent Strategy — as the opportunities appear and the needs appear you grab on to them and try to take advantage of those opportunities. That’s what we did most of the time. Fortunately for us, as and when we thought of a new idea, a new project, support came along and then we could realize our dreams. So, to date, we never had to stop any idea from realization because of lack of this or lack of that. The only limitations since the beginning until now is ‘people’. People of compatible standards and values.
Pankaj: What are those compatible standards?
Dr Rao: Very high quality, no compromise on quality, absolutely no compromise. So for that, every carder has to be of a certain standard and that standard is not available in plenty in our country. Secondly, we compete with a very high paying, information technology, pharmaceutical sector kind of thing in Hyderabad whereas we are not-for-profit. So how do we still attract people that come and work with us? So I think, even though there is no one easy answer, the satisfaction that a lot of people get out of the work here, I think is what keeps them here. At least for the doctors I know, the main reason is, one is that, that they can treat everybody that comes to them with the problem that they are best at handling, they could take care of without hesitation of how much it costs, doesn’t matter how much it costs, they can go ahead and treat them, whether they pay or don’t pay. That freedom they have 100%. So that’s a big attraction for a lot of them.
The second is, complete freedom in decision-making, in how to take care of a problem. Nobody looks down their noses and tries to tell them, ‘Oh, don’t do this, don’t do that’, unless they go and ask for a second opinion, unless they are making mistakes, otherwise nobody… that freedom to use their knowledge to the full is the other attraction.
The third is, a lot of people who come to us are those who would have become professors if we were to have good eye centres in this country. Since we didn’t have, we have become an attraction for all such people who want to pursue research and become academic an ophthalmologist, rub shoulders with the giants in ophthalmology in the world, because we have all those opportunities here. So these are some of the reasons what keeps them here… the environment, the work, the freedom.
And then, while we have carders and all that, relatively, (we have) non-hierarchical institutions. We still have it but not as rigid as most places in India because we are, all said and done, a hierarchical society. That we try to break deliberately all the time. Like, for example, we constantly discourage the use of the words ‘sir’ and ‘madam’ among ourselves. It should be limited to ‘patients’ and ‘visitors.’ So those kinds of simple things. I think these are some of the things that keep them going. But in terms of innovation, everything we did was out of the box.
I am very fond of the Robert Frost poem The Road Not Taken. So we pursued The Road Not Taken throughout, right from the beginning. When everybody was doing only cataracts in India in eye-care, we started with the concept of comprehensive eye-care. All of eye-care along with prevention programs and rehabilitation.
Pankaj: Dr Rao, one more point is, in healthcare, especially these days, we see an assembly line thinking wherein everybody is trying to look at healthcare as an opportunity and a problem and trying to say, how can I reduce the cost, become more efficient and so on? And clearly, the trigger is, you are trying to provide it to the massive population so you need to think of economies of scale and things like that. In your experience, how have you balanced that, if I may call it, assembly line model with the kind of quality you are talking about, with the kind of innovation you are talking about?
Dr Rao: I think if you train your teams yourselves, with your standards, or if you re-train them if they came with previous work experience, and bring them on to the system that you have, then it becomes easy, then the efficiency comes in. The so-called higher cast of high quality is not really true. You can still provide high-quality care without spending an awful lot of money. That is possible and we have demonstrated that we can easily treat half the patients completely free and yet operationally self-sustain. And we also know that if we cut it down to 30% non-paying and 70% paying, we can pay all our things including our capital without dependence on any external sources.
So it is possible in medical care and healthcare to provide care at no cost to a large segment of the population if we want to do it. The question is, do we want to do it? So, that’s how we have been able to work, we have been able to demonstrate, we learnt from other models that existed, we modified them, and then created our own system. So it is possible to do it, it is possible to deliver care.
Pankaj: And you have demonstrated clearly.
Dr Rao: High-quality care we have demonstrated. Like, for example, we have a system where whether they are paying or non-paying patients, they are all seen in the same facility. We don’t have two separate areas, two separate buildings. Once you geographically separate these two groups of patients, the non-paying never get the same quality care. Because the non-paying are then treated by only trainees, never the consultants. All over the world, you see that. It’s not just in India.
Pankaj: Dr Rao, what technologies do you see shaping the future of everything you do? And how are you learning about them?
Dr Rao: All of information technology, mobile technology, biomedical, biotechnology, everything, all technologies are going to affect the shape of healthcare as it moves forward. But my personal belief is, ultimately whoever can bring the best balance of man and machine will be the winner.
Pankaj: Why is that?
Dr Rao: If technology eliminates the human element, I think healthcare will not be very successful or reach a stage where it should be. Because somebody who is suffering will always want to have some degree of comfort from another human being. Unless that is provided in some form through a human being, it will not be complete, the care is not complete. Yes, you can make a diagnosis, you can perhaps give medication, you can provide treatment mechanically, but if you want to have the so-called complete treatment, that kind of bringing in a human using judgment, and then also showing that empathy is very important in medical care.
Pankaj: Human intelligence versus artificial intelligence.
Dr Rao: Yes, there’s a term… Enhanced Intelligence. Also, natural intelligence plus artificial intelligence. I believe personally that’s what it is. Because technology while it has given us many benefits, it has also brought us several negative factors and how do we minimize the effect of negative and maximize the positives is where the human judgment comes. So that will impact. I think it will help us in two ways, one is scale, second is coverage. You can reach out to distant areas with fewer people, so that’s going to be a big advantage of technology if it is leveraged properly.
We probably are going to build a campus in Amaravati, the new capital of Andhra Pradesh. So there, we are taking our time because we want to build an eye institute of the future there. We want to think about how eyecare will be delivered 20 years from now, 50 years from now, so we can create a model. So that’s what we are thinking after this point. Because innovation has always been in everything and then the entire model of eye care in rural areas, what we call the pyramidal model, has been an innovation for us.
And then, integrating the different layers of the pyramid – primary care, secondary care, tertiary care, its complete integration of different segments of care and using the right kind of people at each level. So there’s no point using an ophthalmologist in the primary eyecare centre, it’s not required. More than 60% of the time we are just giving a pair of glasses. For that, you don’t need an ophthalmologist. A one-year trained high school graduate can take care of that very well. So, in the next level, in the secondary level, where you have to take care predominantly of problems like cataract or some medical treatment of a disease, you don’t need a super qualified ophthalmologist. And the really highly talented, the best of the talent should be used at the tertiary level.
If you segment that in terms of infrastructure, in terms of human resources, the cost will come down. So that’s the other thing that we did by differentiating that kind of thing, even within the teams. And the other thing that we do is using a team approach. Even here, one ophthalmologist, when we are in the outpatient, is supported by five technicians of ophthalmologists. And then we have the trainees. The entire team helping the ophthalmologist makes it much more efficient, cost-efficient, and then we can serve more people without compromising on the quality.
Pankaj: A lot of times people think of technology as if it will eat their jobs!
Dr Rao: Probably will not. In some other sectors, it might. In healthcare, it may have some impact. In some sense, it’s ok because we will never be able to produce the number of people that are required, professionals that are required to meet the ever-increasing demands of healthcare. Because now, as you look into the future, at least in India, we are going to have this great convergence of, ‘this is a set of the past, this is the set just emerging.’ So the old infections are still there, TB, malaria and all that. And then, we have cancer, heart diseases. The two converge. We have a major public health crisis and to deal with that we will not be able to produce professionals at the same rate. That’s where technology should help us. Fewer people, greater impact, better quality, that’s the formula we have to arrive at.
Pankaj: Can you share some of the life lessons from your career as an entrepreneur or as an individual?
Dr Rao: If you have a dream, chase it. Don’t give up halfway. The thing is, somebody said, if you want something badly enough, you can get it. How badly you want it, is the question.
Second, have a clear picture of your destination and keep moving towards that destination without getting distracted, pushed or pulled from that path. You can reach there. Of course, you have to put in your effort, hard work.
The third is sincerity and transparency. Goes a long way. Sometimes it’s painful being honest. Unfortunately, in our country being honest is something to be ashamed of. They make you feel like that but, in fact, that helps in the long run to build credibility. Once you build credibility, things become easy.
Pankaj: But then how do you protect your reputation? And how do you handle critique?
Dr Rao: Your reputation will have no problem as long as you are credible, as long as you are honest, as long as you are transparent, your reputation is intact. And the best advertisement is word-of-mouth from your patients. When we started this institute, by the time we started, the very first day, we had a three-month waiting list. Most of our paying patients in the initial 5-6 years came from Mumbai.
Dr Rao: They came here for corneal transplants because nobody else was doing corneal transplantation very well in the country at that time. So they saw what we did, how we did simple things. Like, for example, we used to serve a glass of cold water when they are waiting in the waiting room. You come from the hot sun, suddenly you sit in an air-conditioned room and somebody is actually serving a glass of cold water. You think that person is god!
And then we have our philosophy that if an examination room is free and a patient is waiting to be seen and I am free, I would go and get the patient from the waiting room. I don’t want to wait for somebody below me to go and get the patient. So that became a big topic for discussion all over the town. So these are all simple things that attracted people. So you do simple things that touch the hearts of people, then that will be your best advertisement. And, of course, the clinical results.
Pankaj: Have you ever failed at anything? And if you have, how did you cope with the failure?
Dr Rao: Actually, I can’t recall any major failure. Minor headaches are always there. Nothing major. And in all fairness to our system, everybody talks about India being corrupt, this and that. In all these 31 years, we never paid anybody a single paisa in bribe nor did I ever run after people touching their feet for favours. Even with that kind of a thing, we have been able to make all this progress. So there is some fairness somewhere in the system. And I think we stayed under the radar for the first 8-9 years and by the time people woke up to the reality that we are here, we had already made our name.
Pankaj: Final question. What does legacy mean for you? Give us a sense of that.
Dr Rao: I strongly believe the legacy should be an institutional legacy. Individuals come and go, individuals don’t matter, and fame is very fleeting. So you have to build a legacy as an institution that really cares for people in the field of healthcare. That’s all I can hope for. And then help as many as possible with a true sense of dedication.
Pankaj: Thank you Dr Rao. Great talking to you.
Dr Rao: Thank you.
(Kanika Berry has a Masters in Business Administration and has been a communications specialist for over eight years.)
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Updated at 11:00 am on February 1, 2019 to change a fullstop to a comma.