Staying Alive (Both Sides Now)

This is an article I wrote way back when for a professional writing contest for MTIndia, Amit's wonderful community for medical transcriptionists in India which unfortunately has been made more use of by business owners than by transcriptionists.

In 1995, while the Internet was still for the quirky elite and cellphones were seen only in movies, and as fans mourned Jerry Garcia's death and Windows 3.1 was upgraded, small groups of people in cities like Bangalore, Delhi and Kolkata were busily laying down the foundations of the medical transcription industry in India. The next few years saw a boom of unimaginable proportions, with absolutely everybody deciding to jump on to the bandwagon. In the city where I live, there was an MT company or a training institute on every proverbial corner. Of course, this did no great good to the industry, firms shut shop with the same enthusiasm that they started out with, training institutes made hay while turning out ill-equipped MTs that nobody wanted, consultants with fancy offices ran Venezuela and even got beaten up on the streets where they no longer live, US MTs hired to proofread the Indian transcripts didn't have too many kind things to say and the BBS's still resound of that, but it did do one good thing. The novelty and the challenge of the work and the business attracted some of the finest minds. These people came to satisfy their curiosity and make some bucks, but stayed to prove a point.

Of these people there are two broad categories. The first is the business owner (BO), who came for the profit, struggled to survive, and having survived, stayed to build on. The second is the committed transcriptionist (CT), who came to learn and to earn, struggled to achieve standards of excellence, and pleased with their journey, stayed to reach greater heights of perfection.

The business owners have their share of frustration and worries, I am certain no one will rule that out. However, hanging out with people of the second category, the committed transcriptionist (not all of them committed to transcription necessarily, some to remand houses, some to 12 step groups, and some just to giving the world a hard time) for a few years now, I have come to realize that their frustrations and understanding it plays a key role in the growth not only of a service or firm but of the industry as a whole.

One of the nagging problems in the industry is that of attrition. People quit and most of them join other services. While what triggers it might be a fatter pay packet, the reason often is unhappiness with the workplace and the previous business owner. I am certain people wouldn't quit just for the money if their present place of work gave them a sense of fulfillment that money could not offset. I have been fortunate to have worked with a few of the better businesses in India. I count my employers, past and present, among my good friends. They are well meaning and sincere people. But, disclaimer done with, the general perception of these people is that they vacillate between the extremes of indecisiveness (to where they look like they don't care) and aggression (till you start wondering what really turns them on)!! Rare is the business owner or manager who stalks a consistent nurturing and caring path. Of course, of course, how true, how true, I can hear the applause resound, but is the true picture that simple?

The talk at the cooler (even in winter) very often has to do with how monstrous the BO is. Popular belief says they are uncaring and insensitive. They only care for how much they can get done paying how little and how fast and then, once the CTs are gone home, they count their dollars. I too would have agreed with this had I not known business owners as people first. I shall try share with you in the next couple of minutes how I have learnt to reconcile my frustrations as a CT with the ways of the BOs.

The first difference that all CTs need to keep in mind is that the BO is not a CT. Period. He or she does not understand what might be so exciting about following a patient through a difficult pregnancy, and then the successful cesarean. He or she does not know that the dictator is giving in to drug seeking behaviors of the patient. He or she doesn't know that you have been making sense out of the ESL dictator's fractured vocabulary all these years. He or she doesn't know what it means to be typing out daily labs on a 12-year-old girl for weeks on end, and then the death summary. The BO doesn't know and the BO doesn't care. That is a fact.

Let us look at what the CT doesn't know for a while too, in all fairness. The CT doesn't know where the money comes from, what interest is paid on the capital, or how the "lenders" extract their pound of flesh. The CT doesn't know of the many nice people who are willing to introduce you to potential clients for a slice of the pie now and forever, as long as the client is billed. The CT doesn't know what it means to lose a client who has been with the service for a length of time, what it translates to in terms of efficiency of production, in terms of lost income and in terms of investment required to recover that income. The CT doesn't know how it feels when your dear friend who came into transcription following your footsteps and whom you helped out by outsourcing work to, undercuts you to the very client you outsourced to his service. The CT doesn't know what it means when your employee goes and joins your competitor for a thousand bucks more.

There is also the widely held belief that a transcription service starts making money from the time the client starts paying for the lines. Let us take a scenario where a BO sets up shop. There is the cost of the basic infrastructure, the space, the hardware and the software, the leased lines and the dedicated secure servers. There is the cost of maintaining it. This done, the BO has to recruit staff. The choices are between setting up your own training division or recruiting experienced MTs. All of this has to be in place before he starts looking for business. To get business, the BO has to either set up operations in the US to market the service or he has to settle for middlemen who are a breed by themselves. The wise BO sets up his own front-end operation in the US, which again involves space, hardware, salaries, benefits, taxes. Now business can be looked for.

Getting a client to agree to "try" your service is a long process and unless you are an established brand, very, very difficult. Lower prices are not always sufficient motivation for a client to switch to your service. You have to establish the feasibility of shipping dictation out and getting it back to the client before he is convinced. Leads might come from the other coast and clients have to be serviced on site, leading to travel cost, and other overheads. Many clients insist on liability insurance, which the service has to provide. Let us assume our BO is a man with luck writ large on his forehead and he gets every client he approaches (the truth is about one in five).

Now that the client is ready to use your services, let us see what goes into getting his reports back to him from when he dictates. You need sophisticated (and costly) equipment to dictate into and convert the dictation into the format of your choosing. Often, you have to walk the client through how to upload the files to your server. Some operations even place an employee at the client's site to help him or her out through the initial period. You need people to download the work and keep it ready for our morning. What happens after that is interesting because most people I know compare the 7-15 cpl that is offered by the dictator to what an Indian MT makes per line. You and I know that one person listening to the dictation here and transcribing it and sending the report back to the client is an exception rather than the norm. Most companies in India have only few such clients. The bulk of reports go through at least two or three levels, with inputs from as many as four or five people. The various terms that we have scattered in the industry is proof of this, we have MTs, proofreaders, editors, QA1s, QA2, and what have you. The final reports need to be checked for correctness in all areas, encrypted and delivered to the client on time. Add to this the support staff in the form of shipment folk, coordinators, administration, tech support, the list goes on, and though the nomenclature might change from service to service, the basic picture remains the same, especially so as the size of the service grows. So the 10 cpl that the client offers, once initial costs have been recovered, is really spread out among a large number of people.

Then there are the people who have invested in the company. The BO, by virtue of interacting daily with the crackpots that usually haunt effective production floors, softens a bit with time and tries to understand the situation on the production floor. But the other investors, the people who put in money thinking they would be sleeping on mattresses stuffed with dollars, want to see returns.

So down the line, maybe two years or maybe three, they cut into the cpl too. So does the middleman if there is one. This brings us back to the question, is it the CT then who is truly getting the thick end of the stick?

Let us look at our CT, albeit a representative sketch. He or she is a graduate or a post graduate, has a good grasp of the language, good communication skills, cares deeply for the "meaning" of the work he or she does, usually has interests outside of his field of work, is capable of doing independent research, feels strongly about things, has a big helping of pride in himself or herself. In most MT services in India, these are the people who get ahead of the rest and usually end up carrying the greater share of responsibilities within the service, often covering up for the lack of skills in others. Yes, I am talking about you.

What does lead to a lot of heartache is the fact that these people often feel unrecognized and exploited. As a member of such a group, I have often thought about what would make me feel recognized and not exploited. As removed as it might be from what I wish to believe about myself, the first thing that comes to my mind is monetary compensation. Does that mean that I would be happier in the same work conditions if I were paid more? Maybe not, but that is what my mind keeps telling me, and I have seen many a CT feel the same way. These are intelligent people who care for the ozone and human rights and things like that, but when it comes to feeling a sense of "worth" at their place of work, money seems to be able to fix it. Also, one need only look at it from an arithmetic point of view. The productive output of a person is what determines the compensation. One needs only to compute one's output, convert it to income and then deduct the overheads to arrive at a realistic paycheck. I am sure once a CT does that, this bug will not bother him or her any more. Of course, the possibility is there that once this math is done, the CT is going to get to see a side of the BO that was not obvious earlier. Best of luck to both in such a scenario. The other thing that people of our tribe look at is the position and the designation. From my limited experience, I know for a fact that nothing kills performance more than a designation. The only people I have seen who rise in the organization and still remain highly productive are people who have to think to remember what their "designation" is.

This business is one of teamwork, and the BOs have come to realize that too. The successful BOs are turning out to be those who know how to roll up their sleeves and get to typing stats if they have to. The third thing that CTs feel strongly about is the stress and the working hours. Of course that is not true with every service, but it is true of large services where large volumes of work have to ship before the sun sets. Compare this with the profile of the CT and the other career options available that would pay as much or more than medical transcription. Also, with the new commerce, the rules are slowly changing. People in fields like ours work hard and they play hard. They slog for months together and then they go splurge on vacations. Most of the transcription services in India are yet to be branded "large corporates." One would do well do find out how life is in the so-called large corporates.

Medical transcription is a human endeavor and, over time, nobody has come to understand that better than the BO, since at the end of the day, all the BO has to count as his assets are his people.

The ones who have hung on in there are people with a different view of things from the thousands who set the situation vacant columns on fire a few years ago. Both the BO and the CT have matured and have come a long way, not only on their personal journeys, but also on the journey toward understanding the needs and the compulsions and the limitations of each other. Satisfied workers are as crucial to this business as are satisfied customers.

Business owners have to do their bit in finding ways and means to enhance the quality of life of their committed transcriptionists (any other path would mean losing them to a rival service), they have to look at adding value to the compensation they offer to their people. They need to compensate for what the committed transcriptionist puts into the business. Often it is difficult to convert that into money, and therefore, the BO needs to consider things like offering vacations, gym or club memberships, sponsoring courses in personal development, encouraging involvement in other activities and causes, performance bonuses, offering services to take care of routine tasks of daily living that the CT might not find time to do, like day care for the children, setting up concierge desks to take care of paying bills, undertaking routine household maintenance tasks, etc.

The transcriptionist has to understand and come to terms with not only the highly demanding nature of the work that he or she does, but also the highly demanding nature of the business. The CT has to find ways of keeping alive and true the meaning of the work he or she does, in the face of high stress, crazy deadlines (often being called back from the open elevator doors), pay freeze, and the physical price exacted by the work on your body and mind. The choice to enter this field was yours, your business owners did not thrust it upon you. The responsibility to take care of yourself, your body, mind, and spirit, is also yours. You can always get up and walk away.

Activities like yoga, noncompetitive sports, dancing, etc., are of great help. Developing a hobby if one doesn't already have one is of crucial importance. Save a small amount regularly to spend on indulging yourself for the hard work that you do. Ask for recreational amenities at your place of work. Share your passion with others. Think about small ways that the workplace can be made nicer and more likeable. Take your ideas to the office manager. If you think it is a good idea, and nobody is listening, take it to the directors. Carry your music along with you and force your boss to listen to it (it is possible he or she will give you a payhike rather than have to listen to it again). Forward email about your pet causes to all at the workplace (preferably clicking on the send button multiple times, you can always blame a slow connection later). Tell everyone how much you like Thai food. Be a "pest."

That is the hallmark of a good transcriptionist. Ask any good business owner.

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