If you want to build a ship, don’t drum up people to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea.
Antoine de Saint-Exupery
Yesterday, we saw an announcement in a business paper about an upcoming workshop on improving work systems, to make manufacturing and services more efficient: this is for Lean Sigma Six. If you want to be certified to be a consultant or to do lectures for this particular way of approaching quality control and efficiency analytics, they have different grades, black belt being one of the highest. Wow. What caught our attention was the mention that on the area of service efficiency, a vice president of one of the biggest banks is there to talk about how to delight and serve the customer. It caught our attention because every time we are asked to deposit money in someone’s bank account, say a travel agency in an emergency to book plane tickets and hotels, we always dread it when the name of this bank comes up.
Their branch in Ortigas may yet qualify as one of the longest lines in Philippine banking (yes, some hyperbole, but some reality there as well) with only three, at times because of the lunch-hour break each of them deserves, only two tellers, even one when someone is sick or is needed in the vault to process the entry of cash from the armored van. Our office is in a business center of Metro Manila (Ortigas): you can imagine how chaotic it must be in other business centers like Makati, Binondo, and Cebu. The same top bank just had its president retire to high accolades; a bright, popular, certainly a nice guy who has an Ateneo de Manila University undergraduate degree and a Harvard Business School MBA tucked under his belt. Never mind the Management Man of the Year Award. This same bank has a cutting-edge leadership program for its executives, tie-ups with Harvard Business School, a resident Caucasian-American to just provoke and challenge the way things are done.
But in the end we realize: all that does not mean anything. “Culture,” according to Peter Drucker, “eats strategy for breakfast.” And unless there is a massive overhaul of its culture in this bank, all the Michael Porter-photocopied reading materials on strategy and competitive advantage, all the right diplomas plastered on the walls, all the right sound bites won’t save it from the bad service it offers customers. Why they cannot figure it out and us geniuses here in Sunfu Solutions can? The bank’s size alone protects it from having customers flee in droves, as its branch network is one of the most extensive in a country of islands.
Is it simply because, as legendary editor Tina Brown said: “It’s really, really difficult for the old behemoths to stay nimble in an era of such disruptive innovation. Elephants can’t tap dance” ? We doubt if it is that easy. To say what Brown said is to buy into the mantra that corporations are by default slow, wasteful, and unresponsive to customers. Organizing corporations is easily justified because of its ability to get massive undertakings executed, but supposedly in an efficient and timely way. You can’t get to build an oil rig or hospital building without a massive organization. Sunfu is able to detect the flaw in the Bank of Philippine Islands because it is small, nimble, always desperate for time? We think it is because senior managers are expected to routinely, even if only occasionally, as part of our company exercise to do the work of its most junior staff. Meaning our senior management people go to the bank, pick up a customer from the airport, and join in equipment installations in far-flung provinces (Palompon in Leyte anyone?), as a management rule in making sure we face reality and not just face the balance sheet, we do not just meet long-existing and happy customers, and we do not just drink the kool-aid we offer. Every time one of us senior managers do this kind of work, or exposure, or quality/reality check, inevitably something will come up in the next company-wide meeting about how to avoid complacency, how to serve the customer better, what equipment or systems need to be upgraded, what rest period a personnel will need from the daily grind of a routine. Knowing reality and experiencing it is definitely one of the most important management tools: certainly better than a piece of paper saying you have gone through the Harvard Business School. A doctorate degree holder in business management who happened to be a president of one of the biggest universities in downtown Manila once told us she had never taught a single class in this university where she was president. She did not see it as being part of her job. It was immediately our conclusion that it explained why the university she managed was in shambles. At times like this, in spite of our love for management books and management gurus, we get our very healthy dose of skepticism that they even help us at all in improving.
Margarita Lat-Luna, MD is an ophthalmologist and current deputy director for fiscal services of the University of the Philippines – Philippine General Hospital. She is treasurer of the Philippine Academy of Ophthalmology and board member of the Philippine Glaucoma Society. A lot has been said about the strengths and weakness of Philippine medical education, we decided to seek out a practicing clinician, educator, and administrator of what is certainly a great medical training institution. We also wanted to know how the premier training institution for medical doctors is doing financially. The former president of the University of the Philippines system, Dr. Francisco Nemenzo, has time and again said: in the ups and downs of the different departments and colleges of the whole University system, PGH is the rare cluster in the system that has remained true to its mandate, and has constantly been on par with the best in areas of service and academic excellence.
Tell us what has been keeping you busy.
Right now I am the deputy director for fiscal services of UP-PGH. I was appointed November 2011, so it has been over two years now that I have been occupying this position, and this has certainly kept me busy. I am also a clinical associate professor of the Department of Ophthalmology and Visual Sciences.
Sounds like a big responsibility to be a deputy. Do you have to be a doctor to occupy this position the way other positions in a university must come from the ranks of the faculty?
The scope of my work is just PGH, not UP Manila. For the fiscal office, you do not have to be a medical doctor to occupy the position. Several years ago there was an accountant who occupied this position. It has become the practice to appoint a medical doctor from the faculty because a doctor would have some understanding of the medicine, medical equipment, and medical supplies that we have to deal with daily in our purchasing and disbursement of funds.
It must be quite a sacrifice to occupy such a position. What made you accept it? What is the fulfillment?
When the position was offered to me, most of my friends and mentors and family were very supportive, but one of my mentors told me not to accept the appointment; as this is a position, he said, for someone just starting a practice, so you don’t give up much; or it is a position for someone who is retiring, so it is a legacy work for someone on the way out of the University. Even Director Jose Gonzales tells everyone, and he mentions in his speeches and lectures, that his deputies and coordinators are sacrificing a lot to serve UP.
There is really no attraction to the position, but in 2010 when I was offered to be coordinator for resource generation, I had to refuse outright because I did not know anything about fund raising. When this position became vacant, and it was offered to me, I felt compelled to accept it because I wanted to be supportive and positive, rather than just retreating and being negative to challenges given by the leadership.
As to fulfillment, there are a lot to do to improve the systems of the hospital, and we are working hard to make things run smoothly. We build on what was done by those before us. Our residents are trained well and are very eager to cure or diagnose the problems of their patients. But since most of our patients are indigents, our residents tend to want to shoulder the lack in financial resources of their patients, or they spend their time trying to find funds for their patients. We keep saying residents must be able to diagnose and do their work without being saddled with the financial challenges of patients, and the residents must have a place where they can point patients to where help is readily available. The process has of course been there for a long time, but I would like to think we have been able to help streamline and build on what has been there. The head nurse of the trauma ward had recently pointed out that the turnover of patients has become faster, meaning they come to PGH and are able to complete their processing and treatment a lot faster: the turn-around time has improved significantly.
Does this mean patients do not have to spend anything?
We get to absorb the bulk of Filipinos who are not covered by Philhealth. Social workers will interact with them and ask how them how social work, the hospital, and they themselves as patients can help the financial aspect of the process. We try to make the patients find in their network or resources the ability to help the healthcare system renew itself, and thankfully PGH has sponsors, and we also have a PGH Medical Foundation. The Central Bank, for example, celebrated a significant anniversary milestone, and they decided to donate an amount of money to the cancer ward to commemorate it.
PGH also gets a good part of the so-called pork barrel or PDAF of politicians.
Yes, no doubt that helps, but it could also be double edged. We also get pressured a lot by politicians. There are two keys to be able to access those funds: PGH has one key, but the politicians have the other key. They have to issue a guarantee letter for us to be able to release the funds for the patients they choose to release the funds to. How do we know they are not fake patients who just asked for a letter from the office of some congressman? How do we know they will not sell the medicine outside? PGH personnel, the doctors, the nurses, the social workers, are actually the best people to assess the patient: not the politicians. The Supreme Court decision on the PDAF is a clear improvement: it is a move away from patronage politics. We now have more control over the funds. When the funds are allocated to us, the PGH system now solely decides in the how and for whom the funds will be allocated to. It is not tied to patronage politics anymore.
You were a student here before: how would you compare UP-PGH then and UP-PGH now?
I think that it is like comparing apples and oranges. I am just guessing, but it must have been very different and difficult before, because of the budgetary challenges then. I would think funding was a bigger problem then. Now every year the budget for PGH goes up significantly, there is also increasing support from the private sector and the alumni. There is growing appreciation of what the UP-PGH is doing as an institution.
I have talked to different administrators and teachers of UP, and there is a constant theme of sadness on the subject of UP-PGH graduates who have migrated to other countries. Why so? Do you share that sadness?
Yes, of course I share in that sadness. I guess when you work in UP-PGH one realizes it is very difficult to spot people who deserve a UP-PGH education, and after getting them in the institution, the training is long and difficult. It took a lot of resources and talent to give them the quality education and training that they got from PGH. Aside from talent and resources utilized, in UP-PGH students are given the privilege to interact and handle patients directly, and that kind of experience is not quantifiable.
In our previous interviews, we have doctors who say UP-PGH needs to expose students to more public health subjects and issues. There are those who say it needs to have less exposure or handling of patients and for PGH to give more emphasis on basic science studies. What is your take on these?
I would like to think students who are able to see patients are able to absorb book-learning and theory more, at a much faster rate. A medical problem does not just remain at the level of theory. It is not just a theoretical case. PGH produces leaders in government and influence a lot of policy, so I tend to agree that we need more public health subjects and issues in the curriculum.
Former Chancellor Ramon Arcadio had a rule that medical students, trainees, had protected time, from 12 pm to 1 pm, for example, you cannot have rounds: the medical students need to eat lunch. By 5pm, you cannot extend your lecture, no bedside rounds as they need time for studies and extracurricular activities. A former medical student also led the fight for restrictions on the number of procedures a person in training is allowed to do. Intravenous line insertion, catheter, nasal tubes, the hospital cannot compel you to do more in a day than a certain agreed upon number. I think when you said there should be less stress on exposure to patients and more on other concerns in the development of the medical student is part of that motivation to have all these rules, limits, and safeguards. But there is also the unintended consequence, I think, in that there seems to be a lower tolerance for long hours, less ability to handle stressful work. Rigor, stress, and pressure are all parts of the being a medical doctor: an eight-hour surgery is part sometimes of an emergency. When do you train for that? When you are in medical practice already? Ironically the one who led among the medical students to set limits and restrictions on what can be assigned to them by the hospital did not pursue medicine as a career. Maybe she really wasn’t for the profession.
What would be in your wish list for your specialization?
For ophthalmology, but also for UP-PGH, I wish we could do more research. You can actually earn a living, support yourself and your family, as a researcher in other countries. We should have people paid by the government to just do research. There is no funding for research, certainly not the way they do it in Singapore, for example. In the Singapore Eye Research Institute, they have medical doctors and scientists who just do research. They do not see patients anymore, except for research. I was there for four months, but I was able to do research on glaucoma surgery, and my mentor conceptualized the research in my 2nd month. I gave the data to the statistician as I was about to end my four-month research, after a week I was asked to go back to answer some questions, and in two days she had an analysis of the data. One or two years later it was published in the Journal of Chromatography. The scientist we worked with had a way of measuring the chemical we used, wrote out the paper, and we got included in the publication.
We do not have the funding in the Philippines. All those into research who I know have a private practice on the side to support their research. There is no money in research. Research is supported by their private practice. Research for pharmaceuticals would have a different thrust. Dr. Mario Valenton was asking us when we were still students: where are your data about our incidence of angle closure and open-angle glaucoma? We could not give him the data. Now that I am already a member of the faculty and of the administration, we still do not have the data. We need a sort of a one-stop shop where research, data, measurements, people inclined towards research can be put in this one place, and research papers will come out of this place. New knowledge and new developments will come out this way.
UP-PGH is known for producing great doctors. Aside from Dr. Ricky Luna, the great OB oncologist, who are the great doctors in your generation of UP doctors? (Laughter at the mention of the name of her husband, Dr. Ricky Luna).
Great doctors: what do you mean great? Different definitions of the word “great” would produce different answers. I have great respect for Tina Eusebio, ophthalmologist ; Michelli Gose, neurologist; Richie Yusay, urologist; Retz Gacutan, endocrinologist, Lulay Cabrera Tupas gynecologist-oncologist; Rems Elegado, dermatologist; Beth Riel, radiologist; and Ethel Tangarorang, pulmonologist. They are great for me because they are serving outside Metro Manila. Great for me is definitely defined by the sense of service and commitment to the community, the underprivileged, serving outside the metropolitan center; I think skills after a PGH training is assumed to be way above competent. JP and Anna Leung are in Baguio and Emmanuel Dela Paz is in Bataan. I am sure I missed many more names. Bufo Gatchalian in Ormoc, Nerd Khu in Cagayan de Oro, George Repique in Cavite, Mae Aguirre-De Guzman and George Tan in Cabanatuan, Ronnie Serrano in Davao, Hazel Gazmen in Dagupan, Joy Santos-De Leon in Bulacan, Leovic Dalmacio, Ching Arejola and Orville Ocampo in Laguna, Jasmin Batara in Marawi, Dina Sazon-Carlos in Pampanga.
What has changed in you now that you are part of administration?
What previous administrators say is true: people tend to blame the sitting administration for everything, for every problem. Now that I am here, I see administrators and the staff working hard, trying to make sure the University and the hospital are up and running every day. Sometimes people complain there is no equipment, only to find out no formal request has been made for us to acquire the equipment. What can we do in such a situation?
Do you still teach?
I still lecture on ocular pharmacology to 3rd year medical students.
What are you excited about in your field?
In glaucoma I am excited about the efforts to find ways to regenerate the optic nerve. With animals they seem to know how to do it, but they have not done it yet. March last year I was in UCLA and UC San Diego, and in San Diego one specialist said that during embryology, at a certain stage in our development in the womb, the development of the optic nerve switches off. He said they are trying to find ways to switch it back on again.
How do treatments here for eye diseases compare with treatments available outside the Philippines?
For ophthalmology, and specifically also for glaucoma, our treatments and doctors are at par with other countries. The treatments are the same. All the consultants in ophthalmology here in PGH also trained abroad.
Does training abroad help?
It gives you a different perspective: international exchange is important. Our country has an international presence in ophthalmology. Exchanging of ideas with different doctors from different countries is very important. We also want the Philippines in the global map in ophthalmology.
Do Filipino ophthalmologists have a strong presence globally?
Yes, definitely: Dr. Cesar Espiritu, for example, who was with our faculty, was the very first ophthalmologist to do live cataract surgery in front of an international audience
What have you learned in your years of practice as a doctor?
I have learned that we are all the same. Human nature is the same everywhere. As an ophthalmologist, what you hear from patients, in any class or race, is they want to take care of their eyes: they value their eyesight, sometimes more than their life.
How many kids do you have and are they going to become medical doctors?
I have four kids. The eldest is now in college, in UP Manila for BS Biology. We were surprised he took a pre-med course. We thought he wanted to be a chef. My husband has two doctor-siblings, his parents are doctors. All my siblings are doctors, and their spouses are all doctors. We never encouraged our kids to become doctors: they are free to choose what they want.
Are we supposed to believe you that you did not encourage them to study medicine? (Laughter)
Well, we never say this is what is good about being a doctor, or you should be a doctor. I was already telling Ricky my husband we have to save up for the tuition fees of our eldest as culinary school is very expensive, since I thought our eldest was going to aspire to be a chef.
Your parents are not doctors, yet all of their kids became doctors. Why? How did that happen?
My parents told us to be doctors, to be our own boss. I guess we liked that idea.
Please tell us of books or authors you like read.
My choice of books are mystery novels. I am now reading Michael Palmer. Dr. Robert Ritch, my mentor, introduced him to me. Palmer is a physician and his books are described as medical thrillers. When I was in grade school I went through Nancy Drew, in high school I went through Agatha Christie, while in Singapore for research I was reading Perry Mason. I am a mystery buff. I enjoy solving problems, the way I like doing Sudoku as a way of relaxing.