Wednesday, 30 January 2013

Clinical Practice, Melody and Harmony

Clinical Practice, Melody and Harmony

Music is an art that is given form by its characteristics including melody, harmony, rhythm, texture, dynamics and pitch coming together.

There is evidence both the 7-note diatonic scale (melody) as well as harmony existed 3400 years ago as seen in the Syrian city Ugarit tablets. Though in earlier times there was probably no formatted succession as musical melody of any sort. In musical development, a sense for "melody" would not have occurred overnight as music often was the playing of single notes, assigned to various rituals, such as one gong for moon, another for sun, another for death, birth, etc.

Every piece of music has its own DNA, made up of three elements: melody, harmony and rhythm; present in every popular song from every genre. Melody is defined as the soul of music can stand alone; the addition of harmony gives music its beauty and adds detail thus catching the listeners' attention.

One of the music explorers of the 20th century, Alan Hovhaness, once said that the compose  joins Heaven and Earth with threads of sound which  combine the melodic lines and harmony. They are the two necessary elements to music.


Melody is defined as the primary sequence of notes or successive line of single tones or pitches perceived as a unity forming passages or phrases in various patterns leading to a song with the characteristics such as range, shape, pitch and movement. Movement of a melody or melody line is the direction or shape or the geometric line made when notes are joined together. When the melody moves stepwise and is connected, the movement is termed conjunct. Melody that leaps from pitch to pitch with no natural connection or flow is said to be disjunct.
In melodic music, normally there are one or two 'leads' who sing or play the melody. Music forms such as country, rock, Hindustani and Carnatic are examples of melodic forms of music. Hip-hop, rap, reciting verses, reciting slokas can also be considered a version of melodic music.
In melodic system of music there is a greater freedom to improvise and almost no two artistes are likely to perform the same song/music in a similar manner neither would they wish to do so.


Harmony is defined as the secondary series of a particular sequence of notes or chords (a group of 3 notes played together or in a separate manner one after another) which occur simultaneously with the melody. Harmony is the relation of notes to notes and chords to chords as they are played simultaneously.

The harmony of a song always has a different series of notes from the melody, although sometimes when the harmony is played simultaneously with the harmony the notes in both may be the same briefly.

In harmonic musical systems very frequently there are 'lead' instruments which play melodies but are at the same time accompanied often by a large group of other instrumental musicians playing something different from the 'lead' at the same time. The relationship between different notes played at the same time is what is called harmony. When two singers or instrumentalists are playing the same notes instead of harmonizing notes, they are no longer harmonizing but instead said to be playing "in unison" or together.

Western classical music is from the same script whenever and where ever it is played. Of course there is improvisation and indeed there are differences between various orchestras and it results in great music but one that matches the script/notes.

Melody and Harmony

Melody and harmony are considered as the body and soul of music. We do not forget the importance of  rhythm and tone that are built into the writing thus making music.

Melody is the linear aspect of music, in contrast to harmony, the chordal aspect, which results from the simultaneous sounding of tones. Harmony's function has evolved mostly to make the notes of melodies "connect" or to make their connection to each other melodically more apparent to the ear. It is a result of the joint contribution of melody and harmony in which the listener is “directed to a single melodic line, but this is conceived in relation to harmony”

While the melodic constraint is nearly universal, the harmonic constraint is more particularly Western.  Many non-Western styles either reject chords altogether, using only one note at a time or build entire pieces around a single unchanging harmony.

Doctors  in melodic form

It will be apparent by now that most doctors who are trained as 'individuals' with high knowledge to be able to deliver 'independent' care supported by a few other individuals in small teams (units, firms, etc) are probably in the melodic form. The 'attending' or the 'consultant' is the 'lead' and will deliver care 'tailored' to the patient (improvisation) and often no two individual clinicians would ever do or want to provide the exact same care even when faced with similar situations. They do deliver great care.

This has recognition with rock stars and rock bands. There is usually a lead singer and a lead guitarist often both are the same person, supported by a very small team of rhythm, base, keyboard and drums. They make great music. Those who are familiar with the Indian systems of Carnatic or Hindustani music will easily recognise the similarity with one (rarely two) lead expert singer/musician supported often by just two other musicians (an instrumentalist and a rhythm player). They make great music.

Healthcare delivery systems are harmonic

Most of us will also recognise that the days of individual clinical experts practising independently in their own premises is over in many countries such as UK when the NHS was created and on the way out in many countries such as USA (with HMOs and other attempts) and India (with corporate sector multi-specialty large hospitals). The practise of medicine has become too complex and sadly too costly for the continuation of the purely 'melodic' practice of individuals however brilliant they may be due to the need to avoid disjuncts.

What might be happening now is that we have put 'melodic' practitioners all together on a harmonic platform and expect harmony. What we get is occasional 'unison' and not harmony. The 'unison' can sound good too as when top musicians perform on the same stage as a tribute to someone or on some occasion. South Indians will recognise the Thyagaraja Aradhana where individual melodic monarchs sing in unison but that should not be mistaken or harmony. Similarly, we have individuals with the training and ability to practice independently all under one roof, occasionally there is unison, often there is cacophony. Hopefully this will be a transitional phenomenon.

This is where leadership comes in. Healthcare employers should be explicit in defining that healthcare delivery is now in overall harmonic mode with the melodic element as a vital element. Conductors (Chief Execs, Medical Directors, Nursing Directors, Clinical Directors, et al) should ensure that doctors and other clinicians work in an harmony mode where every individual within the team/orchestra follows a script (evidence, especially operational evidence that has prior local agreement) that is specific for that song/music and though it does not match with other musicians in an exact manner and though there is some degree of improvisation to cater to the situation (variation as a result of patient based differences). The resulting output will be greater care than we are able to offer today.  Hence our belief is that doctors and clinicians may be better working in a harmony mode.

Melody by itself (monophonic music) was the principal form of composition in western cultures before the year 1000. Together these constraints ensure a two-dimensional coherence in Western music analogous to that of a woven cloth. The classical western music has now moved on to harmony. It is time for healthcare to move from the melody of individual brilliance to the harmony of collective success.

Geetha Upadhyaya & M Hemadri
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Geetha Upadhyaya is CEO and Artistic Director at Kala Sangam. She was a Consultant Pathologist, with a particulat interest in the health benefits of practising arts. Having a postgraduate degree in classical Indian dance and music, her main interests are cross art collaborations, choreography and music. Geetha's aim is to establish Kala Sangam at St Peter's House as a national centre for South Asian arts, heritage and culture.

Geetha's thoughts expressed in this blog post are her own personal views and does not represent any organisation.


Melody with Clapton on vocal and lead guitar with improvisation et al; obviously it is wonderful tonight

Melodic Carnatic music with Unnikrishnan singing Ramadas' Palukae Bangaramayena  and note how Balamuralikrishna renders the same song so very differently

Singing in unison (individual singing in the melodic form but all together) from the famous annual Thyagaraja Aradahana

A classic harmony based music (where the melody is part of the harmony) Holst Planets Suite Mars

Melody leads & harmony blends to create the James Bond theme


Saturday, 26 January 2013

Swadeshi Healthcare

This was originally written for and posted at Healthradii ( now reposted here.

Swa =own, self, local
Desh = country/locality/region

Swadeshi = of one's own country/locality/region

Gadchiroli, Bangs and the wonder of low Infant Mortality Rates


Gadchiroli is a district in western Maharashtra. It is one of the most backward districts in India with a high level of tribal and deprived population. The terrain is tough with forests and floods; what ever little infrastructure suffers poor upkeep. In addition the area is infected with arms, ammunition, explosives with people willing to use these often; Naxalite related violence is a routine feature in the area. Currently there seems only two positive features to Gadchiroli, one of them is a general literacy rate of 74% which is far higher than the Indian national literacy rate of 59%.

The other is Gadchiroli's low Infant and Neonatal Mortality Rate. Clinicians could describe this as a a unique wonder, the faithful could describe it as a miracle. How is it, in an area with a difficult geography, backward population and extreme violence that the Infant Mortality Rate (IMR) is so low that it beats many 'developed' cities in India?

Come explore with me.

The Numbers

Around the year 2003 the whole of India Infant Mortality Rate was about 60 and India ranked 150 (out of 194 countries), Gadchiroli Infant Mortality Rate was 26.5 (which would equal a world ranking of about 100). That means the whole India IMR was a 100% more than Gadchiroli.

What is really interesting is in 2010 Indian Urban IMR was 31 with Delhi Urban IMR at 29. This means that the remote Gadchiroli had a better IMR in 2003 than Indian cities including India's capital have in 2010.

The neonatal mortality rate (NMR) in Gadchiroli in 2003 was 25. The neonatal mortality rate in 2010 for the whole of India is 33 (for urban India the 2010 NMR is 19).

Those are the basic facts highlighted.

How was this achieved?

Localism and operational research

By long persistent and consistent effort. It may be still be a wonder but it is certainly not a miracle. The research was detailed, hypothesis was based on local data and its analysis. The action that ensued was closely followed by continuous operational research and there was sequential building of hypothesis relevant to the local situation.

This means there was no direct transplantation of clinical pathways, technology or treatment from any so called best practice. Principles of public health research were rigorously followed to create locally optimum methods. The principles are universal but the data, analysis, hypothesis, action, pathways, care delivery methods were all local and specific to Gadchiroli.

Who did it?

Abhay Bang and Rani Bang; a husband and wife team both physicians with public health qualifications from Johns Hopkins decided to test and put theory into practice. Both have long family histories of concerning themselves in the matters of improving the lives of others. Just Google their names and be inspired.

What was the approach?

A holistic bundled approach. It is important to remember that these bundles were created on the basis of local data analysis. To put it precisely the Bangs for example found that local data showed sepsis/pneumonia, prematurity and hypothermia as the top causes of death. After a further analysis found in order of priority dealing with sepsis, asphyxia, hypothermia and feeding problems will reduce mortality with management of sepsis alone is likely to contribute to reduction of neonatal mortality by 50%. Tools for management was created after consulting with local population and delivered by village healthcare workers. The village healthcare workers were local resident literate women who were provided with a total of 12 months on the job training.

A 16 item Home Neonatal Care intervention package including management of asphyxia by bag and mask ventilation, injection of vitamin K, thermal care, early diagnosis and treatment of sepsis with two antibiotics (injected gentamicin and oral co-trimoxazole) were implemented. You can see the mind blowing results in the charts above. Over 15000 injections administered by these village healthcare workers and there have been no complications.

Every shred of evidence was local, every intervention was agreed with and co-designed by the local users, care was delivered by local people. No imported best practices, no national guidelines, no experts, no experienced care providers, no external or governmental monitors, to working to imaginary targets/predictions, no high technology, no huge amounts of money.................

The bundle approach did not stop with care delivery for neonates. Women's health was a closely inter-knit issue with child health and that was part of a bundle. Public education especially on healthcare issues was a part of another wider bundle. There have been equally immense successes in those areas.

A good quality of life is enabled by good personal habits and Gadchiroli happens to be one of the few areas in India where the public have recognised alcohol as not conducive to healthy living and hence demanded prohibition and help to keep the prohibition going. This is part of the public health bundle championed by the Bangs. I am positive if there was any way that they could reduce the violence in the area, if they had any power or influence on it they would have, I suspect they might have already explored it.

The Importance of the Bangs, SEARCH and Gadchiroli to the world of healthcare

When we think of healthcare in India most of us will be aware of Apollo in the corporate sector, Aravind Eye Care for brilliant innovation in ophthalmology, some pharmaceutical companies who produce affordable drugs for India and Africa, recently we think of Dr Devi Shetty's volume based quality improvement models; there are many more commercial names we could think of. We may think of medical tourism, we may even think of some traditional Indian healthcare systems such as Ayurveda and general health system such as yoga. While those are examples at the better end of the spectrum, we would probably avoid thinking of a greater cohort of diverse providers and their dubious ways.

We never think of Gadchiroli or the Bangs who have taken on a whole district with the poorest population and produced amazing results with meagre resources in an clinical area where everyone else in the whole of India finds it daunting. They are a triumph of public health, they are a victory of scientific principles of operational research, they are a beacon of localism.

Yet when I speak to many doctors in paediatrics, public health and operational management they are blissfully ignorant of this leading example. When I speak to paediatricians in India and paediatricians of Indian origin in UK, most of them are totally unaware of this.

It will be essential for every doctor in India and in every developing country to be fully aware of the Bang's Gadchiroli experience. When we talk of developing or delivering alternative models of successful healthcare that are specific to local needs there is no other learning resource better than Dr Abhay Bang's published material which clearly describes the principles of how to do it. These should be taught very seriously as a part of the public health curriculum in medical schools in India.

Aping the west, urban Indian healthcare providers should eliminate their mental block against anything local; they must develop some discipline in following the scientific principles of improvement and vision to own and deal with population health rather than client/customer health; that might help them improve the quality of healthcare in India. If you are Indian you have certainly heard the Gandhian word called 'swadeshi'; Abhay and Rani Bang are probably the greatest proponents of Swadeshi in healthcare, being Gandhians themselves that is hardly surprising what is relevant is that swadeshi has given India some top class results and lessons worth emulating in every area of Indian healthcare.

This is the Indian rural version of what Intermountain Healthcare does at Utah. I recommend the Bang method for India's healthcare improvement. I also recommend a Bharat Ratna for the Bangs.

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Dr Abhay and Rani Bang's SEARCH website:

India Infant Mortality Rate graph generated from the longitudinal data at

Monday, 14 January 2013

NHS in India - be aware of what it means

This blog post was originally published as a guest editorial at Soumyadeep Bhaumik's Caffeinated Works & Random Musings which is one of the largest healthcare blogs in India
Reposted here.

I follow Indian healthcare with some interest.

I have wondered about 'why do doctors who work in India and want to continue to work in India take up exams such as FRCS, MRCS, etc?' Many of these exams are conducted in India. I suppose I should give those doctors the benefit of the doubt and think that they do it as a part of knowledge improvement and knowledge validation with an international perspective. Many though may have commercial marketing motives. I ask myself if the content and the style of these exams are suitable for non-western practice? I think not, but that is purely my view.

Now the news of NHS wanting to go to India. The NHS in UK is a government funded public service healthcare system. Is that the model the NHS will follow in India? The NHS in UK is increasingly outsourcing its activity to the private sector and inviting private sector in to the NHS. However, the NHS in its new wisdom may be choosing to go to India to provide services as a private provider. Which is the exact opposite of what the NHS does here in UK. The policy and strategy confusion seems to be immense and contradictory. The NHS currently does not have any great operational experience of purely private provision.

Why would the Indians allow the NHS to do the exact opposite of what they do in UK in terms of business model, inside India? It is a question that should be asked in the Indian parliament; I am sure it will be asked if and when trouble arose.

More relevantly, why would the NHS itself want to do this? The reasons are not that difficult to fathom. India is a growing market in general, healthcare is a really high growth market, there is a clear need for more high quality providers. The non-commercial UK NHS wants to take commercial advantage of these factors to make money for UK. It is nothing else apart from money making. Money making in itself is not such a bad thing, only to couch it in the language of healthcare improvement, helping populations, transferring expertise, spreading knowledge and other obviously superficial euphemisms reflects poor intentions. I am a believer in the primacy of intentions.

I wonder if the NHS would still go to India if it was required to provide 72% of its Indian services in rural India (that is the percentage of population that lives in rural India) to the same standard and more or less the same price that they provide in urban India? I ask because that is exactly what the NHS prides itself in UK; providing more or less the same standard of service at more or less equivalent costs all over UK. Well, if you want to be an international business thats how you begin to think; Coke and Pepsi do that, produce soft drinks, distribute it to all corners of India at almost the same price; which is exactly what they do anywhere in the world. Will the NHS do in India what their business model does in UK? Would the NHS in India treat the rich and the poor equally as they are required to do in UK?

I suspect that is not what the NHS in India will be about. I sincerely hope the NHS in India will make me eat my words as that will be a win-win for everyone.

The principles of care, content of education, models of care delivery that are needed in India are different. India is perhaps already suffering from a techno-centric, finance driven, western oriented, urban focussed, doctor obsessed healthcare system. As long as we are clear in our minds that whether it is examinations such as MRCP/FRCS/MRCOG/MRCGP which are conducted in India or a possible NHS as a provider in India are simply commercial businesses operating in India for profit making; as long as we recognise and be constantly aware of this its fine. Once we start assigning higher value, philosophical or operational, we will be doing a disservice to the Indian public by deliberately misleading them. Those of you who are highly sensitive amongst the Indians should also reflect on whether this is a form of cultural and knowledge colonialism.

I am British and work in the NHS. I am an admirer of the NHS system and I believe the NHS in UK does a great job in terms of many clinical, operational and cost parameters. It is my vested personal interest that NHS in India is successful commercially. I am of Indian origin and have family in India, hence creating awareness of potential sub-optimisations is probably my broader duty.

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Tuesday, 1 January 2013

Human Error: Does not exist

Human Error. Does it really exist?

We have discussed wrong site surgery/procedure (

The equivalent for this in histopathology would probably be labeling errors. Labeling errors could at the best lead to rework/reprocess and at the worst result in wrong report with potentially catastrophic effects on patients which can be as grim as wrong site surgery. In most laboratories there are multiple checking steps within the process to detect errors and prevent them leading to errors in reports that could harm patients. In a busy pathology laboratory in England in 2007 there were 113 slide and block labeling errors. By 2009 after a series of Kaizen events it dropped down to just 2 labeling errors which would be a 98% improvement giving a short term six sigma score of 5.8.

 What is interesting are the results of the root cause analysis of the 113 pre-Kaizen. Most of them showed that human error as one of the root causes. What is remarkable was the post-Kaizen improvement was achieved with the same people. The root cause analysis of the 2 post-Kaizen errors showed further opportunities for system improvement.

If system improvement can reduce or eliminate (well, nearly eliminate in this example) human errors, the immediate logical obvious question to ask is 'Does human error exist?'

Deming says that 80% of quality problems are caused by management and 20% by employees. It is further thought that since the employees are essentially a part of a system for which the management is responsible, almost all quality problems are caused by management. Deming seems to have taken the view that the focus and emphasis on quality has to be top down and the creation and delivery of quality should be bottom up.

There are a number of areas where zero errors or quality problems (or virtually zero errors) are possible. In the same pathology lab the number of endoscopic biopsy request clarifications (which used to happen due to doctors illegible handwriting) are now down to zero since the lab started asking for a copy of the printed endoscopy report to accompany the specimen. Previously it was thought that poor handwriting and not putting enough information was a part of human error due to human fallibility, in practice it caused arguments, distress and wasted time.

We are now beginning to question whether there is anything called human error at all. As realists and practical professionals we realise that there will be some areas where perhaps human error does exist and possibly cannot be avoided but we believe that for people working within well organised systems this should be a rare thing. We wonder if people with poor training and no experience in quality methods who nonetheless think they are capable of understanding quality improvement are unable to analyse with an aim of system improvement and hence blame human error as a reason by default. After all everyone has recognition and sympathy for the phrase 'to err is human'

We are having an emerging view that 'Human Error' as an attribution for quality problems is a cop out clause used by poor managers and weak leadership. It need not be so. However it requires managers and leaders to shoulder the responsibility for building continuous quality improvement into their work and the way their teams function. CQI systems are already available and they have to be applied with patience and persistence - those who do that will find  the path of continuous improvement and will eventually share this view of ours that 'Human Errors does not exist in organised systems' though it may sound very radical right now.

M Hemadri & David Clark

David Clark is a Consultant Pathologist and National Clinical Lead, NHS Improvement. David's thoughts expressed in this blog post are his own personal views.

PS: Regular readers of this blog would have read a previous post about how we find designs which set us up for failure (not deliberately) and we then blame it on 'human error'

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