How to get an effective second opinion

Patients are often confused when exploring their treatment options. This is not surprising , because there are now so many choices ! When they are confused , they turn to their doctor for medical advice. Patients understand that doctors don’t have all the answers , which is why they will often get a second opinion to confirm that the advise which the first doctor gave was reliable or not. For example, if a patient has endometriosis, she goes to a gynecologist who advises her to do a laparoscopy to make the diagnosis and to treat the disease. She is understandably uncomfortable about subjecting herself to surgery, which is why she gets a second opinion from another gynecologist. When this doctors also says that a laparoscopy is the next step, since she has now been to two different doctors , both of whom arte advising the same surgery, she is comfortable that she is on the right track , and goes ahead with the laparoscopy. Unfortunately, this is flawed thinking. The trouble is that when you have a hammer, you end up seeing only  nails ! Lots of gynecologists respond in a reflexive manner when they hear the word endometriosis . Their standard advise is to do an operative laparoscopy , in order to remove the endometrial lesions. Their worldview seems to be that the endometrial deposits cause fertility problems;  and that whenever there is something abnormal, the best thing to do is to just take it out – just like all lumps in the breast need to be removed.

It’s quite easy to sell the patient on the idea of doing a laparoscopy. For one, it make logical sense. Isn’t it important that the doctor take a look inside the belly, so he can see exactly what’s going on ? Also, most doctor emphasise now easy laparoscopic surgery is today. It’s a simple procedure which does not leave a scar. It takes a few hours and the patient doesn't even need hospitalization because it’s”  minimally invasive surgery “.

This is why a lot of patients with endometriosis end up doing surgery – and the surgery actually reduces their fertility ! This is partly because the endometriosis is minor – it’s a red herring which wasn't really affecting her fertility and could have been safely left alone. However, once the doctor is in the OR, he has to complete what he started. Along with removing the chocolate cyst, he also removes normal ovarian tissue , thus reducing the patient's ovarian reserve and causing her to become infertile !

This is the biggest tragedy of going to two ( or more) doctors of the same specialty for a second opinion. They share the same world view – and their advise is likely to be very similar. This is why you should actively seeks out a second opinion from a doctor with a different perspective ! You will get a much more balanced viewpoint, so that you can understand both the pros and cons of a given option. Thus, you should seek out an IVF specialist , who will try to convince you why you should not be doing a laparoscopy , and why you’d be better off doing IVF instead.

It’s true that different points of view may end up leaving you a little confused , because it's hard to sort out what's right. Still, it's better to be confused because you know a lot, rather than make the wrong decision because you don't know any better. This ignorance can come back to haunt you afterwards !

Also, if a doctor says I think you should do surgery , one of the first questions you should ask him is - Can you give me good reasons as to why I should not do the surgery ! A good doctor will understand your question , and will answer this appropriately . He will be able to explain the pros and cons ; share his biases ; and will be able to justify his advise.  Unfortunately, there will be some doctors who will get affronted and upset about the fact that you are challenging their authority .

If your doctor gets angry because you ask questions, this just means that the doctors not very confident about his opinion - and you're actually be better off finding another doctor can give you a more thoughtful,  rational , and well reasoned opinion , which you can be comfortable . If you find you are scared to ask your doctor questions , this means that something wrong with your relationship with him – and you need to fix this before matters gets worse. If the doctors makes you feel uncomfortable when you ask questions, this means the chemistry between you and the doctor is not right, and you’d be better off finding someone else . A good doctor values a patient’s questions , and will do his best to answer them respectfully !

Bad doctors and worse patients

Patients enjoy complaining about doctors . Favourite complaints include:

how long they make them wait;

how much money they charge;

how many tests they order ;

how little time they spend;

and

how they never explain anything.

This is particularly true when the medical treatment does not go as planned. This is why when an IVF cycle fails , patients have a lot of complaints about their IVF doctor . No doubt some of these complaints are justified - but not all of them are !

When a patient who has failed an IVF cycle comes to me for a second opinion, the first thing I ask is - you please show me photos of your embryos. The standard response is a blank look, followed by - I didn't even know that you could ask for photos of your embryos ! When I reprimand them for not being better informed , they start getting defensive.“  I am not a doctor, so how am I supposed to know that you can take photos of embryos ! “

“ My doctor never gave me any, so what can I do ? “ When I ask why they did not do their homework before starting the IVF cycle, so they would know how critically important photos of the embryos are, because they document the quality of the IVF treatment , the response is – “ Isn’t that the doctor’s job ?”

Patients think I am criticizing them – and they start justifying their lack of information . When I question them , I'm not trying to be critical ; and I am definitely not trying to badmouth the earlier doctor; or make the patient feel bad about what happened in the past. I am simply trying to galvanise them into being more proactive, so that start to take more responsibility for the quality of care they receive ! Patients simply cannot afford to leave everything up to the doctor – they need to do their homework

proactively , before going for treatment.

During one of these Q and A sessions which I had with a patient recently , she got increasingly upset and frustrated . I went to a doctor because he was highly recommended , and I blindly obeyed everything he told me ! This doctor had a great bedside manner; and she trusted him. If he does not give photos to this patients , what do you expect me as a patient to do about this ? How can I question him ? Won’t he get upset because he thinks I am challenging his competence ? The patient then started blaming the doctor for not providing the photos.

Yes, it's true that any IVF doctor who does not proactively and routinely provide photos of the embryos to his patients is a bad IVF doctor . However, a patient who doesn't insist on photos of her embryos is an even worse patient – and perhaps deserves to get a bad doctor !

It’s fine for patients to make a mistake once – but if the patient keeps on going back to the same doctor and not insisting on photos , I think this reflects badly on the patient . After all, IVF is not a monopoly – there are lots of IVF doctors, and patients can take the time and trouble to find a better IVF doctor.

If you stop to think about it, it’s naïve to expect doctors to improve. After all , it's not always in their best interest to share information . While some are transparent and will provide photographs of embryos , many prefer taking advantage of the information asymmetry, so their authority as the “expert” is not challenged !

However, it’s definitely in the patient's best interest to ask for photos – and I am not willing to be charitable and forgive patients who refuse to take the time and effort to be proactive. There is a lot at stake when you are doing an IVF treatment – and it’s your duty and responsibility to be well-informed !

There’s no need to be aggressive , but you need to learn to be assertive.  And if your doctor takes offense, this is a red flag – and you should start searching for a second opinion.

If patients don’t start doing this, this is going to be harmful - not only for patients , but for good IVF doctors as well. If the cycle fails, and the patient learns that key information was not shared with them, she will start losing confidence in all IVF doctors , as a result of which the image of all IVF doctors takes a beating.

IVF/ICSI Success story for a man with globozoospermia

As a referral IVF clinic , we treat many patients who have failed IVF and ICSI cycles in other clinics. Here's a success story from such a couple.

Globozoospermia is a very rare condition , and most IVF clinics in the world will not be able to even properly diagnose this condition, leave alone manage such complex cases. While I am very proud of the fact that we helped our patient to achieve a pregnancy, I am even more proud of the fact that he has become an expert patient, who is very well-informed about his problem ! He now knows more about globozoospermia than most IVF specialists !


Here's his first person account.

We got married in August 2009, and  after marriage we were very happy and enjoying our new phase of life. After one year we thought of next stage of life - parenthood , which is very precious in every couple’s life. But our planning didn’t work. Then we approached the doctor. At that time we were in Kuwait we went to a famous clinic of Kuwait. The doctor suggested for complete diagnosis. The diagnosis resulted in identifying the reason for infertility is due to quality of sperm .However doctor said we can go for IUI treatment , and because of our lack of knowledge about infertility treatment , we underwent 2 cycles of IUI treatment in first half of 2011 with no success.

In June 2011, we shifted to UAE and the first thing we hunted for was the best infertility clinic in UAE .We took all our earlier reports and explained everything about our problem and the treatments that we had undergone previously. Then doctor suggested for a repeat of semen test and the results shocked me . All my previous reports showed semen counts of 30 million and suddenly semen results showed  just 3 million with less than 5% motility with 98% abnormal morphology. He suggested us to go for an ICSI cycle. We went for our first cycle of ICSI in UAE in November 2011. 2 eggs were fertilized .However the doctor mentioned the quality of embryos  was not good and the growth was very slow , possibly because of slow sperms. We waited for 14 days and did the HCG test , but the result was negative. Then we were frustrated and we decided to take a break . I decided to try to improve quality of sperm and went through a nine months  course of homeopathic treatment.

After ten months of treatment we went for a sperm analysis at SRL diagnostics Dubai. The lab analysis showed an improvement in sperm count and motility but reported a new term - 80% Globozoospermia (which means the acrosome or cap on the head of my sperm was missing).

Then one day I searched for the best clinic in India who can give us new hope. We found out about Dr Malpani. We mailed him all the details and the treatments that we have undergone in the last two years. He responded almost immediately to my mail, and I was very happy. Then in my next mail I asked him for an appointment.

We planned for our first cycle of ICSI @ Malpani clinic in October 2012. In our first meeting with Doctor , he asked us what our Plan B was ( if treatment is not successful ).We were surprised and bit confused but later understood the importance of having plan B when he explained this to us. He educated us about our problem. Our ICSI cycle was not successful and none of the eggs got fertilized. Dr called us to the clinic and embryologist showed us the eggs and the video of complete process of ICSI. I was told this is not normal and that globozoospermia was a very rare diagnosis. It was suggested I repeat the semen test with special stains for checking the presence of acrosomes on the sperm @ Dr.Avinash Phalkde, SRL Diagnostics , Shivaji Park. 

I was diagnosed with 98% Globozoospermia. Dr said  I was the first patient he had come across with this diagnosis. He emailed me a few research articles on Globozoospermia and the articles mentioned that lack of acrosome can cause complete fertilization failure after ICSI . There were very few success stories in the world for treatment of globozoospermia. Then we decided to go for plan B (donor sperm) and met Dr in Feb 2013. At this time, Dr explained the option of doing ICSI with about Assisted Oocyte activation using a calcium ionophore . He told us that they would be doing it for the first time in their clinic . We took few days time to make up our mind and then decided to go with the treatment.

We had our 2nd ICSI cycle @ Malpani clinic in March 2013 but this time with AOA with Calcium Ionophore. This time 2 of 8 eggs got fertilized and the quality of embryos was very good. And after 14 days of waiting time it was a great feeling, because  the pregnancy test was positive. We had our first scan  after 7 weeks of pregnancy and we have a bonus because  it is a twin Pregnancy.

All kudos and all credits to Dr Malpani for suggesting AOA with Calcium Ionophore. We thank Dr Malpani from the bottom of our heart.
             

Internet reviews about doctors: threat or opportunity?

This is an article which I wrote for the Indian Journal of Medical Ethics. This was a comment on the paper, Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899

For most doctors (though perhaps not for the readers of this journal), the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

The introduction of the Internet has already changed the way most of us find information, make phone calls overseas, keep up with the news, stay in contact with our friends, book airline tickets, etc. It has already had a major impact on the doctor-patient relationship in the United States, and it is just a matter of time before it  plays an equally important role in the lives of Indian doctors and patients. While the technology has many benefits, it creates conflicts as well, because it gives patients a much bigger say in their own medical care – a concept most doctors feel threatened by, because it is so unfamiliar and new. One of the controversial areas is the sprouting of physician rating sites, which allow patients to rate, comment on, and discuss doctors' performance online, visible to everyone. This can be a mixed blessing, especially when patients are not happy with their doctors and use these rating sites as a platform to vent their frustrations.

This is a timely paper, because there are now many physician rating sites. Some have been created by private agencies, while others have the blessings of government organisations and health insurance companies. Although these have attracted a lot of attention from patients as well as the popular press, there has been very little discussion about these sites in medical journals, even though they are likely to have a significant impact on the way we practise medicine. While government and health insurance company representatives are vocal in their support for these sites because they believe they encourage transparency, many physician representatives argue against them because they are worried that they could compromise physicians.
This paper purports to have two aims. First, it offers a structural framework which can be used to debate the ethical principles behind these sites, thus providing a useful starting point for further decision-making and discussion: what should physicians and policy decision-makers take into account when discussing the sites and their impact on the doctor-patient relationship?

Because there is very little direct evidence of the harms and benefits of these sites, this paper also discusses how evidence from the related area of public reporting of physician performance can help to guide research in this new field.

The paper uses the three basic ethical principles of patient (and physician) welfare, patient autonomy and social justice.

In theory, the availability of information about the quality and competence of physicians (as assessed subjectively by their patients) can help patients stay away from bad doctors, thus helping them to get better medical care and enhancing patient welfare. The provision of online doctors' report cards encourages transparency of medical performance, and this could also result in greater public trust in the healthcare system.

While discussing the principle of welfare, the authors remind us that we also need to consider the impact of these sites on physicians' well-being. While the majority of reviews of these sites appear to be positive, negative reviews can cause both psychological and financial harm to the doctors concerned.
Physician rating sites also encourage patient autonomy, because they empower patients with information. The authors look at this benefit through the interesting prism of improving the patient's health literacy at three different levels: functional, interactive and critical.

As regards the third principle of social justice, the fact that these sites are online means that only patients with access to the Internet can use these services. This means they can actually worsen the digital divide between the haves and have-nots.

The most interesting question these sites raise is: do they provide reliable and useful information? Or is it possible to game these sites, as a result of which the ratings can no longer be trusted? Can doctors manipulate them by requesting their happy patients to provide positive reviews? Or can disgruntled patients ruin a doctor's online digital reputation by posting negative, biased and dishonest reviews about him/her on multiple sites? How can patients trust the information that these rating sites provide? And what can doctors do when they encounter negative ratings which they feel are unfair and biased?

The most useful nugget of information I found in this paper is tucked away in a table, which describes the five basic conditions which need to be met in order for a physician rating site to be useful. These include: transparency, justification, participation, minimum conflicts of interest, and openness to revision. Most sites have not been able to meet these conditions. Indeed, there is a lot of scope for improvement in how these sites are created and maintained, and paying attention to these basic principles will help to ensure that the next generation of physician rating sites provides value for all stakeholders in the healthcare ecosystem.
I enjoyed reading this paper because it discusses an issue which is very close to my heart. However, I feel the author has done his readers a disservice by unnecessarily complicating the issue. He has used a rather formal, heavy style so that making sense of the article is an uphill task. Just because this article is written for an academic journal does not mean it should be hard to understand. Perhaps the fact that the author is from a non-English speaking country may explain why the language is not lucid.

After reading this article I encourage physician readers to google their own names to see what their patients are saying about them. It is going to be increasingly important for doctors to manage their online digital reputation, because whether we like it or not, our patients are going to talk about us. We must learn what our patients feel about us. Ignorance is not bliss; in fact it can actually be harmful.

Patients have always had opinions about their doctors; after all, this is how a doctor's reputation develops. Traditionally, this was by word of mouth, a slow process, and it could take a doctor a lifetime to build a reputation. Physician rating sites have accelerated this process dramatically.  However, while many patients will swear by their doctor, there will be others who will swear at them.

While it is all very well to take the moral high ground when talking about the right of patients to freely express their opinion about a doctor, I can vouch from personal experience for the fact that negative reviews can raise one's hackles quickly. While some such reviews may be well-deserved, others are unfair because they have obviously been penned by disgruntled patients, venting their bile. Others may even be planted by the competition.

Can we censor these sites? Let us not fool ourselves; the horse has left the stable. It is a fact that we will need to learn to live with patient complaints – including the ones posted online on doctor rating sites, for all to see.

The good news is that these doctor rating sites can actually help doctors to become more patient-centric. Hopefully, we will start treating our patients better, because we know they can harm our reputation by going online and posting negative reviews. Doctors should read the patient feedback stories at doctor rating sites to educate themselves as to what patients want from their doctors. The good news is that what patients want from their physicians is not all that different from what good physicians want to offer their patients. Patients are generally not unreasonable, high-maintenance consumers; they simply want doctors who care, listen, and know what they are doing. By reading the positive ratings, doctors will have role models of good physicians to emulate, and by reading the negative ratings, they will learn what to avoid. Smart people learn from the mistakes of others, and we can learn a lot about what a medical encounter feels like from the patient's perspective by browsing through these websites. They will help us become more empathetic doctors if we are mature enough not to take the negative ratings too personally.

In the big picture, these rating sites are a great opportunity for the medical profession to be open and transparent with patients. Medical associations should set up doctor rating sites to ensure that the basic information which patients need about a doctor (clinic location, credentials, professional qualifications and so on) is available. Also, these sites will be comprehensive because they will provide information on all doctors. If these are seen to be fair and frank, patients will be happy to refer to them as an authoritative source of information on doctors, rather than waste hours scouring dozens of unreliable and incomplete sites. It is also a good way of identifying the bad eggs in our profession, those who end up giving all of us a bad name. Even though we know who these are, we often prefer to participate in a conspiracy of silence and to turn a blind eye to their antics. Rating systems will allow the truth to come out in the open more quickly, helping with self-regulation of the profession.  The Medical Council could take cognisance of repeated complaints about a doctor, and take action to prevent problems from flaring up.

Infertility and Mother's Day

This is a guest post from our expert patient, Manju.

Many infertile women who are struggling to become mothers view Mother’s Day as a curse, because it cruelly reminds them of their inability to become a mother. While the rest of the world celebrates motherhood, they suffer from Mother's day blues.

Just stop and think about this picture - did the lady ever carry a baby in her womb ? No – but even though she never gave birth, she will always be fondly remembered as Mother Teresa. When we think of Mother Teresa, we remember :

her caring ways;
the selfless service she rendered to the poor and needy;
the love and compassion she showered on suffering souls;
the dedication she showed in the work she did;
and
the sacrifices she made did to make this world a better place.

It’s these qualities which prompted people to call her "MOTHER" affectionately , and not the fact that she had undergone the biological process of giving birth !

Mother's day is a celebration of all the sterling qualities that exist in a human being - LOVE, AFFECTION, DEDICATION, SACRIFICE, COMPASSION, and EMPATHY.

Being infertile actually brings out these latent qualities which lie within all us. Can you show me an infertile women who doesn't love children ? Being infertile teaches you empathy – and all of us learn a lot from adversity.

Infertile women are usually much more caring – and can reach out to a fellow soul in pain because they are suffering themselves.  The truth is that carrying a baby for 9 months doesn't make anyone a mother - caring does !

Is there anyone else who knows how precious motherhood is than we do :)

So, my dear friends, have a very Happy Mother's Day ! Every one of us deserves as many Mother's day wishes as any other women !



You can email Manju at manjupadmasekar@yahoo.com

Her blog is at www.myselfishgenes.blogspot.com

Video Guide to PCOS ( Polycystic Ovarian Syndrome)

Reaching out to patients directly

Hospital CEOs are smart and understand that in order to fill their beds and to maximize their revenue, they need to reach out to patients directly. This is after all what marketing, advertising and branding is all about . However, these are expensive propositions – and though these traditional methods have been used for many years , they don't work well for multiple reasons. This is why lots of hospitals incentivize doctors to refer patients to them. This can be in the a form of kickbacks , cuts, “referral fees”, “assistant charges” “ medical consultant fees” or commissions . This works initially,  but is a broken model for multiple reasons .

For one thing the hospital is effectively signing away 10 percent of their profit to the doctor . Even worse, he's not likely to be loyal at all , because if another competing hospital offers 15 percent, the doctor will then start sending his patients to the other hospital !

CEOs realize that they need to establish a direct one-on-one relationship with their patients, rather than go through a middleman. This is a challenge,  and he needs to know how to do this cost effectively. After all , his priorities are to provide high quality medical care , and he has a limited budget . He has to chose how much money to spend on marketing, branding and advertising – and which channels to use . There are multiple opportunities , but because one of them is right under his nose, he often fails to see this !

When a patient is admitted, the focus is on providing good medical care. Unfortunately very little attention is paid to the needs, wants and desires of the people accompanying the patient – the patient's friends, relatives and neighbors who come to visit the patient in hospital . All these visitors are potential future customers and clients , because they're all going to fall sick at some point ! If they have a good experience when they come to the hospital as visitors, this will create a positive experience, so that when they fall sick at some point in the future, they're much more likely to choose this hospital , rather than go somewhere else.

What can the CEO do to make sure that all the visitors have a wow experience , so that they are happy to talk about how great the hospital is ? If we assume that the technical care which is provided by the medical staff is good , then you only need to do so basic simple stuff so that visitors feel like valued guests, rather than as barely tolerated pests !

However, because hospital CEOs are so focused on things like maximizing bed occupancy , keeping their doctors happy, and buying new equipment , that they don’t spend enough time thinking about what they can do to provide a better experience to the visitors who come to his hospital !

Healthwise awards Dr Malpani the Patient Champion Medal

The most neglected person in the hospital

Hospitals are designed for doctors. They have been created so that the doctor can collect all his patients under one roof , and provide medical care to them in a setting which maximizes his productivity and efficiency. They provide the doctor with easy access to medical equipment, labs, technology, consultants , specialists, nurses and assistants. Unfortunately , hospitals are not very friendly places for patients , who will often feel lost and uncomfortable , because they are scary places ! The good news is that a lot of work is being done on improving the patient experience within the hospital. Studies prove that improving patient experiences is good, both for the patient and for the hospital and for the medical staff.

However, even more neglected than the poor patient is the hospital visitor. Most hospital will allow visitors only during specific visiting hours , at which time the hospital overflows because there are so many other visitors who are forced to come to visit the same time. Most visitors are treated as a necessary evil . There are lots of do's and don'ts as to what they are allowed to do and what they are not. They are usually treated as dirt by the staff, which is why most visitors are quite intimidated about going to the hospital.

Actually this is such a huge opportunity which hospital management is neglecting , by not focusing on the needs of the patient’s visitors ! Visitors need to be treated as a valued guest in a hospital setting , because all visitors are going to be potential patients at some point . Hospital visitors are very aware of their own mortality , and are much more likely to be receptive about their health and illness prevention . It always amazes me why hospital managements don't recognize this ; and why they don't spend a little bit of time , energy and effort in making visitors feel welcome. This is an extremely worthwhile investment,  because when these visitors fall ill (as all of us will some day ), they are likely to remember the hospital which treated them with respect and care , and are far more likely to select this hospital for their healthcare needs. Hospitals have a captive population of visitors, but instead of capitalizing on this , they often neglected and ignore – or even worse, ill treat them !. This is a huge opportunity which is waiting to be exploited - and the good news is it's very easy to engage this population. Thus , while they are waiting, they can be given educational materials to read; and patient education videos could provide information about the medical services the hospital provides. Smart hospitals could give all visitors a free health education DVD – or a book on how to take care of common medical problems. This is a great branding exercise – and is a very cost effective way of acquiring new patients for the future !