‘There can be no stress if your heart is in it’

Rajendra Badwe has an uncommon knack for rendering the complicated in simple terms. He has skills of a greater order as well: the director of the Tata Memorial Centre (TMC) in Mumbai is counted among India’s outstanding cancer surgeons and he is an administrator of rare acumen.

Dr Badwe speaks here about what makes TMC an extraordinary institution, the way ahead in coping with the country’s mounting cancer burden, and how, at a personal level, he manages the stress that is a cancer surgeon’s constant companion.

What is it about TMC that makes it special, particularly in the Indian context?

There are three parts to the TMC vision of cancer care in India: uniform treatment across the country; an affordable care model; and the providing of care through a network that is sentient to local needs. To create a network, make it functional and then to develop its brand equity is a 20-year effort. But we had to build this immediately and that’s why we now have the National Cancer Grid, which connects about 180 centres across India and covers 75% of patients. The target here is uniform care.

Uniform care means uniform guidelines. Our consensus guidelines have predefined what needs to be delivered and how it can be delivered. The stress is on evidence: is it good enough, unequivocal, robust and implementable? And the evidence shows this is implementable. The National Institute of Health, United States, conducted a survey in low- and middle-income African countries on their practises in cancer care. The most common guidelines being followed, it was found, were from TMC.

Were these guidelines designed for poor countries?

No, they were designed so as to be implementable even in countries such as the United States, but the focus was on evidence and on cost-effectiveness. I could give you equal-outcome options; some cost $100,000, some 100. We know from evidence they are identical; the outcomes are no different.

We have done some tweaking to address an essential question: what do I do with these guidelines if I don’t have the infrastructure for everything? So the guidelines defined the minimum infrastructure required to treat a cancer patient. There’s another aspect and this is gaining importance globally.

If I am treating 10 patients a year, my outcome is different than if I am treating 100 patients a year, and different again if I am treating 150. Somewhere it plateaus off and you arrive at a critical number where you get the best results.

We have pooled resources to treat patients properly. There are limitations, essentially with human resources. Finding this is not easy because human resources to treat cancer patients are not available off the shelf — they have to be created. We need a convergence of human resources and infrastructure. What to deliver is known, who to deliver to is being expanded, and how to deliver is managed by infrastructure and personnel.

What is the TMC model?

It’s a sustainable model that delivers high-quality service. It is a model that has stood the test of time, with a unique culture of care that we inherited from the Tatas. We would like to implant this culture at the places we are spreading to, in Uttar Pradesh, Punjab, Assam and Odisha.

The TMC model emphasises treating the entire spectrum of society, and that is vital. Government hospitals for the poor and high-end private hospitals for the rich make for a polarised healthcare delivery system. It’s not sustainable. You need a system that will treat everybody under one roof.

There are two advantages in this approach. One, you get to see the disease in its full range. Understanding the whole picture is what TMC has done since its inception. We have 30% of patients who don’t pay us anything, another 30% who pay 5% of what we spend on them, a further 20% who pay 20% over the cost of treatment, and the final 20% paying 60-70% over cost. Such cross-subsidising enables us to treat everybody.

We look after 85,000 new cancer patients a year and we have 550,000 follow-up cases. We have a recurring budget of 3 billion a year and a further 1 billion for education and 1 billion for research. With our payment model, we generate 2.6 billion. That means the government shells out just 400 million a year for the entire load of patient treatment at TMC. There is no other model like this.

Uniform care and focused clinical services can fuel a 10% improvement in outcomes in a year. Compare that with the 2-3% improvement that new drugs have delivered globally in the last decade and what can be achieved is clear.

As for the culture, our doctors, nurses, technicians and others are stakeholders in the hospital. This is a group of individuals who have their heart in the right place.

The Tata Memorial Hospital in Mumbai has become a role model in cancer care

How successful have you been in taking the TMC culture to other places?

I think we have been pretty successful. The people we have in Varanasi, for example, had three years of training at TMC in Mumbai. A few don’t fit into this culture and they go way. That’s better than to have square pegs in round holes.

You mentioned Africa learning from the TMC model. What, and from whom, has TMC itself adopted over the course of its evolution?

We are the most cost-effective of cancer care centres. We have had teams from the Yale and Wharton business schools visiting us in Mumbai to understand how we do this. The MD Anderson Cancer Center registers 25,000 new patients annually and has about 1,300 full-time medical staff. We register 85,000 new patients a year and we have some 600 staffers. That’s less than half their staff strength, dealing with a patient load that’s thrice as much.

A TMC doctor cannot treat all and sundry; he or she has to concentrate on one facet. I treat breast cancer and nothing else. I cannot solicit patients from outside; the hospital decides who I should treat. I do research and it’s in the public domain — which means everybody can benefit from it — and that is incentivised.

Why does India not have more institutions like TMC across the country?

That will happen. The model we are following is being sought by the [Union Department of Health and Family Welfare], which wants to implement it at various places. The model is socialistic in nature. Fees collected from paying patients are pooled and then distributed to our doctors based on their research output and grade. The more research I do and the greater impact this has, the higher my pay grade. This grade decides how much of the shareable income generated comes to me.

Every year, TMH treats 85,000 new patients and does 550,000 follow-ups
>And that gets some extra money in the doctor’s hands?

It doubles their salary.

What is your view on the distributed care model for cancer care and treatment that the Tata Trusts have been pushing ahead with?

That model is no different from the model we have suggested for the whole country: a spoke for every 15 million people and a hub for every 50-60 million. The idea is to bring service delivery in cancer closer to the patient’s home. It’s exactly the same as that which we are looking to create.

Does cancer research get prominence in India?No, it does not, not at the moment. There is a fair amount of support being given for laboratory research, but clinical research, which finally puts the molecule under the microscope, is not supported so well. There is a reason. The instrument that supports laboratory research is typically calibrated for a three-year period. Clinical research, on the other hand, takes up to 10 years. We have no mechanism to support such long-term endeavours in greater numbers.

What about you personally? Do you get time for research?

Well, we need to create the time — get into that minute and stretch it a bit. Delegation of work is what gives me time.

There must be a lot of administration work as well?

Yes, for sure. It’s a killer because it’s not my core competence. I was not trained in it; I have learned it on the job. But I find administration is about people management. It is about common sense.

It is said that cancer surgeons are the most psychologically distressed people in the doctor community.

As far as I am concerned, quite the contrary. In whichever walk of life you may be, there can be no stress if your heart is in it. The stress may come because of that little difference between sentiency and sensitivity. You are receiving and interpreting everything with a great amount of affection, but you are not affected by it.

These are life-and-death situations that you deal with.

Of every 100 patients being treated at TMC, 50 of them, in general, live 10 years or more after treatment has commenced. Comparisons with other diseases are not valid. If I treat 100 ageing patients with diabetes, about 70% will die within 20 years and the deaths begin from year 10 onwards. In cancer, the deaths will occur within the first three-four years. That’s because cause and effect are very close to each other in cancers. When cause and effect are far separated, the perception of something being lost is not as substantial.

I remember telling this lady she had breast cancer. She started crying and I tried convincing her that it was curable, to no effect. I then asked her to wait outside my consulting room. She went out and I must have had two more consultations before she walked back in. She was smiling and I asked what had happened? “I saw this poster on the wall that said one out of 30 women in India will get breast cancer,” she said. “I just felt that since I have got it, 29 others will not.” What had changed? Nothing; it was a matter of looking at it differently.

Is it true that you tossed a coin to decide whether to pursue medicine or engineering?

Yes, it’s true. I had stood first in mathematics in Bombay University but I also wanted to get into medicine. I was fortunate in that I went for medicine, although I was better in mathematics.

So you could have become an engineer?

Yes, and I’m sure the universe would have conspired to make me as successful.

How has the collaboration with the Tata Trusts gone?

I think there is a feeling that the Trusts are a sanctuary that will always be there for us. But I must also say that the Department of Atomic Energy [under which TMC functions] has been extremely generous with the hospital.

The modern-day TMH has come a long way from what it was