Building a Practice

“Pick up the baby! Can’t you hear her howling?” Rema shouted from the kitchen to add to the din. “And why are you so late? Don’t you get study leave at least during the last month? Where are the milk and eggs? And the diapers I asked you to get on your way home? If, as usual, you have forgotten them, please go back and get them. Can’t you see me wasting away here, toiling day and night in this mangy apartment? Imagine, I left the three-storied bungalow of my father’s teeming with servants for this!”

          “Should I pick up the baby, or go and buy the things I forgot to get?” Raghavendra muttered. He decided to exit the noisy surroundings, and closed the door gently behind him as he stepped out. The milk and the diapers provided an excuse for a relaxing walk to the store. He thought wistfully about the rustic charm of the village of his childhood. Depression began to creep in.

From the son of a poor panwallah in a village in south India, to a proud and respectable physician with both an MBBS and an MD to his name, had been a long and difficult journey. He had had the fortune of being born with good brains. And he was a tenacious bastard. State-funded education helped, of course.

It was during his internship that he had met her. Even the prettier medical students usually escaped his attention. He was too serious about his work.

But, hormones do work, don’t they?

“What is your name?”


Chocolate brown skin, shapely nose. Shapely, everywhere!

Getting married is easy. Your parents would approve, when they are penniless and her parents are rich, and from a higher caste.

But don’t forget. In India, they can cut her off, and consider her dead, just like that. That is what they did.

“I have got into the Indian Institute of Neurological Sciences at Hyderabad. Isn’t it great?” he said jubilantly, a few days later.

“But how will we live in Hyderabad? It is an expensive place. And you have to send money home, isn’t it?”

They moved to Hyderabad. For some time, the one-room bachelor accommodation, and the princely stipend, kept them happy.

Then Rema discovered she was pregnant. They blamed each other. Raghavendra offered the excuse that he had not had the time to buy condoms. But he did not resent the baby. Being a father thrilled him. The oxytocin flow exhilarated him when he held the tiny baby close. The first steps, the first words, “Da-da.”

“The future physician,” he said.

“Shut up,” said Rema.

Finally. He passed. Not before he realized that fifteen thousand was nothing. He was now in a rented apartment, and had a Honda City on loan. Rema was not working. She couldn’t. That made her cranky.

Come on! He had to get on with life!      

A neurologist from IINS! It was no small thing. Prof. Krishnamachari, the sole neurologist at the Government Medical College, Gulbarga, where he had done his MD, was a local chief – no, a king – amongst the local population. And in the college hospital, he was the ultimate professional hero. Raghavendra treasured the autograph he had got from him when he left Gulbarga.

          He polished his resume. A DM from IINS. Who would fail to be impressed with that? And the two papers he had presented at the last national conference? They enhanced his credentials. He was particularly proud of his thesis on childhood epilepsy. He promptly sent off his resume to Apollo, Fortis, Columbia Asia, Wockhardt and Sahara Medicity. He was aiming for Apollo. If he got through, he was willing to settle for a relatively lower salary. He waited excitedly for the job offers to pour in. The thought of the top corporate hospitals bidding desperately for his services made his skin tingle.

          No calls came. Two weeks passed; then three. Whatever was left of his bank balance, evaporated. The EMIs loomed menacingly before him. In desperation he decided to call Sravan Shanker, a former professor at IINS, who was now a consultant neurologist at Sahara. It was a busy hospital. Who knew? Maybe he would welcome someone with his credentials to share the burden.

“Hello, Raghavendra. How are you?” The cordial voice was reassuring.

“Sir, I have passed my exam.”

“Congratulations. Heard the news from Bhaskara, your HOD. He told me you were very good. What can I do for you?”

“Sir, I have been looking for a job.” He continued softly, “I … er … does Sahara … I mean … are you looking for another neurologist, by any chance?”

“Hmm … well … no. To tell you the truth, the management here is very stingy. They tell me to pay a junior from my own pocket if I want one.”

A junior. That was not what Raghavendra wanted. He knew what it meant. He would have to write all the case sheets, give discharge summaries, maybe fill up investigation forms. Attending night calls on someone else’s behalf was not very thrilling. The patient would scream, “I don’t want you; I want the neurologist!” And none of them would be his own patients. That was no way to build a practice. But there were loans and other expenses to consider.

“I am willing to join, sir. It would be good to work with you. The experience … would be … er … worthwhile.”

“Mmm … Raghav, the thing is, most of the work can be done by an MBBS. At the most, an MD Internal Medicine chap is enough for me. I can afford only around twenty a month.”

Twenty thousand was hardly more than what he was getting as a resident at IIMS. He hung up telling Shanker that he would think about it.

          Next, he did some research and realized that things were not as bright as he had believed. He was surprised that there were no talent scouts eager to snap him up and offer a starting salary of two lakhs. Rural India especially – some of the northern states like Bihar and UP – was languishing without qualified doctors, and specialists catered for areas with a huge population. But, in the metro cities like Bombay, Bangalore, and Hyderabad, super-specialists seemed to be crawling out of the woodwork.

Should he go back to his village? What a thought. Where were the hospitals? The shopping malls for Rema? Gulbarga was a good place. He knew the language, and it was familiar territory. There was less competition.

“I should follow you around wherever you want to go. Is that what you expect?” Rema said sullenly, when he announced his plans to her.

“But dear, it’s for the sake of our future together. We may be happier there.”

“Hyderabad is good enough for me. At least Kiran will have more opportunities here. Growing up in a metro is better.”

“There may be more patients there, Rema. I may be useful to poorer people there.” He did not sound too convincing, even to himself. And he realized another thing. Super-specialization was a double edged sword. As an MBBS doctor, he could practise medicine in his village. As an MD, he could get an attachment with any clinic or hospital in the city. The more specialized you were, the narrower your field became. Fortunately, neurology had better scope than nuclear medicine, sports medicine, or hand surgery. And some neurologists became paediatric neurologists or neuro-psychiatrists. Super specialization in their fields raised their expectations. Spending more years on training needed to translate into benefits – largely monetary. The hospitals needed to be classy, the clientele rich, and prestige high.

So, Raghavendra kept his eye on the posh five-star hospitals in the city:  Apollo, Fortis, Columbia Asia, and a few others. But he found it was not easy to enter any of them. Medicine was one of those rare branches where your market value increased as you aged. The older the doctor, the wiser he was considered. Raghavendra had heard of younger consultants, who dyed their jet–black hair in various shades of grey; and thin physicians, who secretly put rolled sheets inside their vests to fake a paunch. At least surgeons went through a natural decline when their hands started shaking, and their sphincters began to rebel. Even then they tried to lord over junior surgeons to operate on their behalf, riding on the strength of their reputation.

A month passed in indecision. Until now he had thought only about the passion for his work, curing patients, their grateful smiles. Money was almost an afterthought. Then his father arrived one morning. His brother had been admitted into the engineering college at Vijayawada. Could he spare fifty thousand rupees? Rema was so cold to her father-in-law that he left without staying the night.

Finally, St. Joseph’s Hospital, a large-volume mission hospital popular amongst the poor, called him for an interview.

“Congratulations, Doctor. We have been through your CV, and have decided to take you on as the second neurologist here,” the director of the hospital informed him. “Actually, we have work for only one person but, since you showed keen interest, we’d be happy to employ you. You need to be at this building by eight in the morning, and you can start on Monday.”

The interview appeared to be over. Raghavendra shifted uneasily on his seat.

“The pay, Father? Approximately…?” he stammered.

          The director was surprised. “Fifty thousand rupees a month – before tax, of course. All white.”

The monthly rent for a decent apartment near St. Joseph’s was around twenty thousand rupees. He regretted the Honda City. A Maruti would have sufficed. If he had been careful, he could have managed without the student loan he had taken. Was his brother still waiting for his fifty thousand? He had to provide that for him, even if it meant keeping the fact secret from his wife. Desperation broke through his usual timidity.

“Any professional fee or performance incentive in addition to that, sir?”’ he ventured after a pause.

          The old priest’s tone was paternal. “New graduates with your specialty, many of them, want to join this place, Dr Raghavendra. And you know surgeons earn money for the hospital through surgery and theatre charges. The physicians are a liability. The OP charges and the ward rent are meagre.”

Raghavendra knew that the largest chunk of a hospital’s income came from the investigations, expensive ones, like CT and MRI, or from routine or special blood tests, and the pharmacy. Large hospitals got expensive drugs directly, dirt cheap from the pharma companies, and sold it at an enormous profit to the patients. Dare he go further?

“But Father, the scans, the pharmacy…?”

“The lab, radiology, and pharmacy are the hospital’s profit, Doctor.” The director’s voice had turned to ice in a matter of seconds. “The fifteenth, at eight-thirty, if you are interested. Thank you.”

The interview was indeed over.

Without the doctors bringing in patients, on their reputation, the lab and pharmacy would have no clientele at all. But Raghavendra had to leave that unsaid, as he slowly rose to leave.

He worked day and night. He was good. He gave his number to patients. They called him day and night. He was pleasant, all the time. And that is difficult when you haven’t slept the previous night.

Rema became pregnant again, and his entire family turned up with gifts. His brother needed some more money. Maybe he could manage some. He had a lot of patients now. But the director had not given him a raise. Still, he kept up his hopes.

On a Tuesday, some weeks later, from the outskirts of Hyderabad came a man who complained of a persistent backache. Raghavendra detected a component of neuralgia, and asked for an MRI. The hospital scan centre gave him a date for the next week, as they had a tight schedule.

          “Doctor,” the patient said, “should I get the MRI done from Rajeev’s Diagnostic Centre near my house? Please could you write a prescription? I could return to you tomorrow with the reports. You see, I am a busy man, but I’m on leave for the next two days so it’ll save me time.”

          Raghavendra could see nothing wrong with that. The next day he saw the MRI result, and advised the patient accordingly. After a week, an envelope arrived from Rajeev Scans: a one-third commission for the MRI scans. Two thousand rupees was not bad. Raghavendra had not asked for the money. He had not even heard of the place.

This incident made him encourage his patients to get their scans done from Rajeev Diagnostics if they were from that part of the city. Slowly, he found that it didn’t matter at which centre the MRI, CT scan, or angiogram was done. The communications arrived, as did the cheques. He always received one-third of the amount. And the payment was remarkably prompt. Gradually, the cash flow from these commissions grew to more than double of his salary from the hospital.

Raghavendra had a special interest in epilepsy. By the end of the year, he had a fair number of referrals and lot of epileptic patients. Many of them needed a drug called carbamazepine, which they had to take for a long period. Recently, Banaska Pharma had come out with a modified formulation of the same drug, ‘Fanzipine’. It was a much more expensive version. Raghavendra never prescribed it, however, as be believed that the cheaper version worked just fine. One day, a representative from Banaska came to meet him.

“Have you heard of Fanzipine, Doctor?” he asked deferentially.

“Yeah, I have.” Raghavendra continued to scribble on his pad, and didn’t raise his eyes.

“Are you supporting it?”

“Why should I? I don’t see any advantage.”

“But the bio-availability, Doctor … the revised formulation…” The sales rep started a barrage of technical jargon, as if he had memorized it for some test.

Raghavendra countered each of his arguments effectively.

Finally, the Banaska representative leaned forward. “Your car, sir, may I ask how much the EMI is…?”

“Seven thousand, Mr – ah – Mr Ravi.”

“Done, sir. The bank details, sir?”

Could he push it some more?

“And four thousand a month education loan,” he said, pokerfaced.

Ravi paused to ponder over it. “Sure, sir, we will pay them. But we will be monitoring your support, sir. I am sure you understand, sir. The recession and everything, sir…” Ravi withdrew with a broad smile. “Okay, sir. See you, sir…”

By the end of eight months, Raghavendra’s frustrations had eased remarkably, and he worked enthusiastically. As his practice soared, lot of patients with neurosurgical problems like brain tumours, slipped spinal discs, and intra-cranial aneurysms, which required surgery, began to be referred to him.

Dr Balananda Pai, the chief neurosurgeon at St. Joseph’s, was a formidable and unlikable character, and Raghavendra found it difficult to refer cases to him. He was an unpleasant man, who snubbed him at every opportunity. Many believed he wasn’t too good with the scalpel himself. So, when Ramprakash, a distant cousin, called him regarding a meningioma in his skull, Raghavendra was confused. Should he suggest Balananda Pai?

Then he remembered Suresh Machiavalli. Suresh was a neurosurgeon four years his senior, and had been trained at IINS. He was said to be very good, and had once been a friend, although they had lost touch. So he suggested his name over the phone to Ramprakash, and told him that he thought Suresh still worked in Muthuswamy Memorial Hospital at Banjara Hills. Three weeks later, Raghavendra was visited by a young man who introduced himself as a public relations officer from Muthuswamy Memorial Hospital. He offered a sealed packet to Raghavendra. Raghavendra was not totally mystified, but he was astonished at the amount – twenty five crisp notes of a thousand rupees.

“Our standard, sir. One fourth of the total bill the patient had to pay,” the man informed him, mistaking his surprise for disapproval.

Raghavendra quickly regained his composure. “How much was the total bill?”

“A hundred and sixty thousand, sir.”

“How much did the surgeon get?”

“Twenty-five thousand rupees, sir.”


His younger child, Prema, was three years old when he purchased a villa in the suburbs. A week later, Rema’s parents came for a visit – to see the grandchildren, they said. The mother embraced Rema and cried. The father said, “We were wrong about you, son.”

But there was no let-up for him. The competition was fierce. If he took time off, there were other doctors. His parents and sister had moved in with him now. They needed a larger car. Raghavendra had an SUV in mind. His sister had received a marriage proposal from an IIT graduate. His brother was still a college student. Rema wanted to do MD Dermatology at St. Joseph’s. The director was willing to lower the capitation fee for her. Ten lakhs. She was thrilled.

Some general practitioners and physicians from peripheral areas, who used to refer cases to Raghavendra, had begun dropping discreet hints that they had to be given commission for each patient they referred or else they would send their cases elsewhere. He would have to work out a system for obliging them as well. Building a practice was more complicated than studying medicine. You got better with practice.

Dr Jimmy

I am a Doctor, Writer and Science Communicator. I am a member of Info- Clinic, and have written a few books. This site features my blog posts and stories. Thank you for visiting. ഞാൻ എഴുതാൻ ഇഷ്ടമുള്ള ഉള്ള ഒരു ഡോക്ടർ ആണ് . നിങ്ങളുടെ താത്പര്യത്തിന് നന്ദി .