Thursday, December 08, 2016

Patients with poor ovarian reserve: is there any point in flogging a dead horse?

Women with poor ovarian reserve who have regular cycles are extremely difficult to treat. Because they have regular cycles , they expect that they will have good quality eggs.  This belief is reinforced when they do IVF and their eggs fertilise and the doctor gets embryos.  They feel that these should implant, because this was their only problem. Since their uterus is normal , and since IVF has helped them to make embryos from their eggs, they think success is assured.

However, when their embryos fail to implant, they go to pieces. With repeated IVF failures, they start getting even more desperate , and are advised to explore options such as surrogacy.  This is bad advice.

The problem is that their major bottleneck remains their poor egg quality. Just because an egg forms an embryo doesn't meant that that embryo is good enough to become a baby . This is something patients with poor ovarian reserve need to understand .

However, because they are so desperate to transmit their own genes to their child, they often pursue treatment which is futile , and ends up wasting a lot of time as well as money. Sometimes it's better to cut your losses and accept that you need to move on to plan B, which is using donor eggs. Yes, this is a hard decision, but it's the one which gives them the highest chance of becoming a mother.


Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !





Monday, December 05, 2016

I will be speaking at HITCON 2017 in Ahmedabad


This is the third year I will be talking at HITCON in Ahmedabad.

I really enjoy these sessions, because the audience is enthusiastic and keen to learn. I think this is because the conference organisers charge doctors a fee to attend the sessions, which is why they take the conference seriously.

I especially like the fact that there are no pharmaceutical sponsors   for the conference. This is self-funded, and has been growing from strength to strength, year on year.

Plenary session at Hitcon: Dr.Aniruddha Malpani,a leading IVF Specialist from Mumbai,.

Avid medical articles writer,tech savvy and entrepreneur in HIT.

He will be taking on *How to make techno naive doctors-Tech Savvy*.

A must attend for all doctors who are interested in Healthcare Technology and start using newer things. Be there. Register Today. Hitcon- 2nd edition of Healthcare care technology conference for doctors by doctors.

This and much more. 21st January,Saturday in Ahmedabad

Pre conference,1pm to 5pm,Registration fees Rs. 250 & 22nd January Sunday,main conference 9am to 4pm,

Registration fees Rs.500.You can register online and pay by credit cards or cheque.Queries or Questions ?Want us to collect cheque ?  Hitcon helpline 8460656213.Book your seats log on to http://managementmedicos.com/hitcon-2017/

The movie Dangal will improve the sex ratio more than the PCPNDT Act


The falling sex ratio in India has been a matter of concern, which is why the government of India passed the PCPNDT Act , with the hope that this would help to increase the number of girls . The intention was that the Act would stop people from resorting to sex selective abortions.

Sadly, the act has had previous little impact . It has become a very punitive act , which focuses on punishing doctors who are allegedly performing sex selective abortions. 9 times out of 10, the doctors who've been hauled to court for flouting the Act is not because they have been caught performing sex selective abortions , but because they have committed clerical errors in filling in the infamous Form F. The Act is obsessed with regulating the misuse of ultrasound scanning, and just ends up criminalizing doctors whose records are not picture perfect, even though they may not be performing any sex selection. This is one of those draconian laws where the doctor is considered to be guilty, until he can prove that he is innocent !

This has become a huge tragedy, which has caused a lot of harm , because patients are being deprived of ultrasound scanning facilities . Also, because of the obsession with ultrasound scanning, the Government is failing to control the use of blood tests which are being misused to commit female feticide.

We are barking up the wrong tree , because we are more focused on measuring population-based numbers such as sex ratios, while we should be encouraging each individual couple not to discriminate between having a son or a daughter.

This is where movies like Dangal shine. For one thing , it's a story which is told very well . It strikes an emotional chord, and speaks to your heart . Most importantly , it talks to each individual viewer, and shows them that girls are as good as boys - that there's no advantage to prefer having a boy as compared to a girl.
Once this message gets across , and people internalize it and understand it, this is going to have a far more lasting impact as compared to any amount of laws we can pass , or sting operations we carry out. Even slogans like Beti Bachao, Desh Badhao are just empty platitudes.

A well told film can have a powerful impact, especially given the fact that it's in a setting like Punjab, which has always had a fascination for boys. Aamir Khan is a great actor, and has a lot charisma. The trailers suggest that it's a compelling story , which is full of action, which means people will enjoy watching it !
Aamir's show called Satymev Jayate was disappointing because his team didn't do its research properly, and oversimplified matters. I think he has learned from his mistakes, and will hopefully stick to his core focus - acting - which is where he shines !

This movie is the kind of positive intervention which will reduce gender discrimination in India. We may not be able to judge the impact until a few more years go by, because it takes time for people to change their behavior , and their attitudes, but I am very hopeful !

My guess would be that the sex ratio at birth in India would definitely improve over the next four years, and while the PCPNDT activists may want to take credit for this, my guess is that it will movies like this which would have a far greater impact, and the tragedy is we'll never be able to give them the credit they deserve.

Saturday, December 03, 2016

How the media can stop unnecessary doctor bashing


Today, wherever something goes wrong in a  private hospital, the doctor is blamed. He is called negligent , and is often beaten up. There's a lot of unnecessary violence, and doctors get a lot of bad press.  This is why the image of the medical profession suffers.

The aggrieved family approaches a reporter with an emotionally charged story. This if often biased, incomplete and factually wrong. The reporter is happy to carry it, because any story which features negligent doctors gets a lot of attention, and they want to be the first to "break" the story - " if it bleeds, it leads. Sadly,  medical accuracy becomes the  first casualty of this slip shod approach.  A good reporter will try to contact the concerned doctor to get his side of the story. However, doctors are scared of the press, and are usually advised by their lawyer to clam up, as a result of which they are very reluctant to talk to journalists. This is why the reporting is so one-sided and incorrect.

Here's a solution if editors want to make sure that their stories are factually correct.

Each medical college should set up a Press Advisory Board which consists of senior medical teachers. Journalists should be able to reach out to these medical college professors 24/7, who are trusted and respected sources of medical expertise. They would provide them with the medical background they need to be able to make sense of the facts , rather than be swayed by an emotionally upset patient.  This would help to provide a more sympathetic and balanced understanding of  medical complications - the vast majority of which are not due to errors or negligence ! Armed with the right context, doctors would then no longer be painted as villains, and the medical profession would be able to do a better job taking care of patients.

Friday, December 02, 2016

How medical colleges can improve healthcare in India



There is no doubt that the municipal corporation teaching hospitals such as KEM, Nair and Sion are brilliant medical institutions. I've been trained at them , and the clinical training is excellent because there are so many patients who throng to these hospitals for their treatment. They do an outstanding job, especially when you consider the constraints which they have to operate under. Thus even though their bed capacity may be 2000, they will often have a far larger number of inpatients ( many of whom are nursed on a mattress on the floor ) because they don't turn any patients away.

While they are doing a great job, there's plenty of scope for them to do even more.

The biggest strength of a teaching hospital is its human capital - their medical staff . At present , this is being underutilised, because they are only being used within the hospital .They have so many renowned leading medical teachers and professors , who should be producing Indian language patient education materials, which should be shared online. This will allow them to reach out to people in their homes, through their mobile. By providing them with accurate, reliable, local language information, we can help patients to get better medical care. Sadly, the opportunities for reaching beyond the four walls of the hospital are being overlooked.

It's not just the medical professors - it's the medical students and residents as well. These junior doctors are hard working, but all they seem to be forced to do is cram for their exams, so that they can pass these. Why can't they be used to create clever apps to help doctors to reach out to patients in their homes. If we can go to there the patient is, we don't inconvenience patients ; and we don't overload hospital facilities by forcing patients to come to hospitals. We can use telehealth to amplify the expertise and experience of the hospital's medical staff. This is good for the students as well, because it will increase their clinical exposure , and they will be able to learn a lot more "real life" medicine, rather than stuff their heads with the exotic illness and rare diseases which hospitals attract. It will also help them to become more empathetic, because they are reaching out to patients, rather than limit themselves to the comfort zone of the hospital.

These apps can be used for triage; combined with the ability to talk to a doctor live, as needed. This will be much more convenient for the patient , who will then not have to wait for hours , waiting to be see in the hospital OPD. This will be much more cost effective as well, because the corporation won't have to spend so much on each patient. The truth is that lots of the problems which cause patients to seek medical attention are simple problems , which can be solved in the comfort of the patient's home, without the patient actually having to come to the hospital.

This is a great opportunity, and the numbers which you're talking about are mind boggling. Technology can be used to connect hundreds of medical students, residents and doctors with the millions of citizens who live in Mumbai.

The problem is that we still are stuck with an archaic top heavy model , where everything seems to revolve around the hospital , and the tertiary care facilities it provides. We need to flip this model around, and think about what we can do to make sure that patients don't need to come to the hospital in the first place.

These hospital should partner with the IITs and IIMs to create medical entrepreneurs, where the next generation of doctors can cope up with clever out of the box solutions , adapted to Indian needs.
Health insurance companies should be happy to fund these efforts, as they can use these to improve their outreach activities.

4G is now easily available, and most people have mobile phones. Why can't we make use of these new options so that we can provide care in a new format which is much more patient friendly ?

Thursday, December 01, 2016

Improving healthcare by using the human capital in our medical colleges

Indian doctors have a great reputation globally for being excellent clinicians, and the government teaching hospitals do a great job at providing cost-effective medical care to poor patients . They take pride in the fact that they don't turn any patient away, no matter how poor he is. They make excellent use of their resources, and  treat patients at a tenth of the cost which a private hospital levies.


However, one of the things which they are not making the best use of is their human capital. These teaching hospitals have medical colleges, which means they have teaching staff; medical professors; lecturers ; as well as medical students. We are not utilising their skills optimally, and this is a shame.

Why aren't these medical professors creating MOOCS ( massive online learning courses ) to teach doctors all over the country? They are all experts in their own field, but why are they restricting their teaching only to the medical students within the four wall of their campus? Why can't they reach out to all medical doctors all over the country? Not only would this be great for medical students from other medical colleges, it will be very helpful for practicing doctors as well, because then they would have access to authentic information which is relevant to Indian conditions. This would be provided by a local authority , and in a local language, which means it would have a much greater impact.

These hospitals should be using digital technology to amplify their outreach activity. This will allow them to improve their efficiency and effectiveness , so they can do far more than what they've been able to do in the past.

The students areall digital natives - and there are so many opportunities waiting to be explored ! We need to make better use of the young blood in our medical colleges, and allow them to use their brains to think out of the box.

These hospitals could become world leaders  in creating models on how cost-effective medical care could be provided frugally to the poor. At present, the medical skills , experience and expertise of their doctors is not being utilized adequately.

We can learn to use telehealth, and just like the IITs and IIMs have become world leaders by applying entrepreneurship to the IT field, why shouldn't these teaching hospitals also aspire to become thought leaders in health care?

Sadly, rather than stimulating them with exciting challenges, all we end up doing is getting them to cram tons of stuff , and then exporting our brightest and best doctors to the West. Why not create opportunities for them within India itself which will allow them to improve the health of millions of Indians ?  The social impact and personal fulfillment would be so much more ! We already have the people, the skills and the tools - we just need to marry them together.

We're not utilizing our next generation of doctors well at all. This is because no one is really answerable or accountable. The seniors have become so used to doing things in the old-fashioned way , that they are not able to innovate . We need to think out of the box , so that we can create models which are tailored to what the Indian patient needs, rather than blindly imitating what the West does.


Wednesday, November 30, 2016

Why is the Government turning a blind eye to the misuse of new technology for female feticide ?


Ultrasound scanning can be life saving . However, because it was being misused for gender determination and female feticide, the Government introduced the PCPNDT Act and started  monitoring ultrasound scanning more closely, to prevent this abuse.

However , technology moves on, and it is now possible to determine fetal gender at 9 weeks of pregnancy with a simple blood test on the mother, using NIPT technology ( non-invasive prenatal testing) .

According to a new research report by RNCOS entitled, “Indian NIPT Market Outlook 2022, the Indian NIPT market represents a market with remarkable potential for growth.

The UK Govt has already expressed concern that this test is being misused for sex-selective abortions.

However, the Govt of India is not doing anything to prevent the misuse of this technology to prevent female feticide. Blood testing is much easier than ultrasound scanning, and if these blood tests are not carefully monitored, female fetuses will continue being aborted, because the Govt of India is focusing purely on checking ultrasound scanning. The sex ratio will keep on dropping  because government officials are not being proactive.

We cannot afford to miss the forest by getting bogged down in the trees !

Public Private Partnerships to heal Healthcare.


We all know that the healthcare system in India is creaking.  The situation is going to become progressively worse , because we cannot keep up with the demand for medical attention. Epidemics of infectious diseases such as dengue and malaria have become increasingly common, because of poor infrastructure. The rise in non-communicable diseases because of poor life style has created a double whammy, and we are reaching a breaking point.

The government is supposed to provide healthcare services to citizens, but the problem is that the public sector doesn't trust the private sector. We know that there's a shortage of hospital beds, but still the government is hell-bent on passing rules and regulations which are forcing nursing home owners to shut down. That means the shortage of hospital beds is going to become much worse in the future.

We've tried the PPP ( Public Private Partnerships) models, but these have been plagued by political problems.  They've not delivered the results which were promised , because of vested interests.

This is a shame. We should use a blend of both private healthcare facilities along with public hospitals, by combining the strengths of both.  The public hospitals are great at providing cost effective care to seriously ill people. The private small nursing homes have the major advantage of being able to provide care locally , so that it's much more convenient for patients. We need to marry the best of both worlds, but we often end up extracting the worst of both. Poor patients are forced to run to public hospitals for minor problems, which could be much better tackled locally.

We need to set up partnerships as well as linkages , so that there is no unnecessary duplication of services. Both private and public hospitals need to trust and respect each other, so that they can do what's right for the patient. There are many opportunities to create unique models for success , but these are being frittered away. We need to create a robust referral system, to make sure patients get the right care in the facility which is correct for them.  It's high time we learned to develop medical processes and protocols so both the private and public sector can work together and complement each other.

Thus, simple elective surgical procedures such as hernia repair could be done in the nursing homes, so that there's no need for these patients to block up an expensive tertiary hospital bed, which could then be used only for the critically ill patient. If a poor patient goes to a public hospital , and the diagnosis of hernia is made, he could then be referred to the private nursing home nearest to him, which could provide him care at a subsidised rate.

Similarly, public hospitals could outsource lab services to reputed private players  who provide high quality diagnostic reports because they are so well-equipped. This way patients would benefit, because they would get reliable reports, rather than have to depend upon the poorly equipped public hospital lab. Everyone benefits. The public hospital doctors now have results they can trust;  the private lab processes more samples, which helps them to improve their revenue; and the public hospital does not need to invest in extremely expensive lab equipment, saving them a lot of capital expenditure, which could be used to upgrade their ambience.



Tuesday, November 29, 2016

'POINTLESS' IVF TREATMENTS THAT CAN WASTE THOUSANDS

'POINTLESS' TREATMENTS THAT CAN COST THOUSANDS

Endometrial scratch (up to £350)
Scratching the womb is said to release hormones that make it more adhesive, but studies found it does not help women with fewer than two failed implants.
Assisted hatching (£615)
May help repeatedly unsuccessful couples by softening the embryo’s outer shell so it can ‘hatch’ more easily, but no evidence this works for older women.
Time-lapse monitoring (£775)
Camera shows up abnormalities by taking pictures as embryos develop, but no good quality evidence for routine use.
Embryo glue (£320)
Chemical with added hyaluronic acid developed to help the embryo ‘stick’ to the womb lining. May increase birth rates, but can also cause unplanned multiple births.
Intra-cytoplasmic sperm injection (up to £1,390)
Sperm injected directly into egg is said to help fertilisation, but experts argue this is not necessary if a man’s sperm is normal.
Intra-cytoplasmic morphological selected sperm injection (up to £600)
Uses a microscope almost 6,000 times more powerful than usual to identify any defects, but creates no more pregnancies than a basic sperm injection.
Immune therapy (£1,500)
Based on claim a woman may fail to become pregnant because her immune system rejects the embryo. A review found blood level of ‘natural killer’ cells, which fight infection, has no effect on implantation.
Pre-implantation genetic screening (£3,100)
Identifies abnormalities, screening out embryos unlikely to implant. May cut miscarriages, but has not been found to raise birth rates in women with a good prognosis.


Read more: http://www.dailymail.co.uk/news/article-3972968/The-great-IVF-swindle-Couples-desperate-baby-sold-treatments-not-need-8-000.html#ixzz4RPm8N1kM

Fixing healthcare in Mumbai


I just attended a meeting at Freedom for A Billion, where senior medical experts such as Dr. Sanjay Oak , CEO of Aga Khan Health Services, and Dr. Avinash Supe , Dean of KEM Hospital, spoke about their vision for improving healthcare for Mumbai.

Healthcare represents what economists call a wicked problem. There are many moving parts, and there's no one person who is in charge of everything. Thus, doctors will treat an ill child with diarrhea, but how do they make sure that the child does not get diarrhea again ? When he goes back to his house in the slum , how can the doctor ensure she gets clean drinking water ? Another problem is that healthcare is always a very emotionally charged issue, because it is so personal . When someone in the family falls sick, we are willing to move heaven and earth to help them get better, and it's very frustrating when we encounter road blocks because of high costs, red tape , a shortage of doctors, or poorly equipped healthcare facilities .
The truth is that while doctors can treat illness, our health is impacted by many factors which are completely beyond our control - for example, the quality of air we breathe. The big problem is that growth in Mumbai has been completely unplanned , and healthcare facilities have not been able to keep up with the needs of the exploding population.

There were lots of eye openers during the presentation. It's interesting that the problem isn't a lack of money, because the Mumbai Corporation has tons of money - it's a very rich corporation, thanks to the taxes we pay. For example, the Dean of KEM Hospital, a 2250 bed teaching hospital run by the Municipal Corporation has a budget which authorises him to spend Rs 100 Crores every year on upgrading facilities and buying state of the art medical equipment in KEM Hospital.   The problem is political interference. Even though the money is lying in the bank, politicians with vested interests will block him from spending this, because they want him to buy the equipment from their buddy. It's hard for a Dean to stick his neck out, because a few disgruntled corporators will allege that you're corrupt because you are favouring a particular vendor, when all you're trying to do is to buy the best CT scanner to be able to provide better care to your patients.

One way of fixing the problem would be to insist that all municipal corporators ( who control the corporation budget ) should be forced to take treatment only in municipal hospitals. Only when they understand the problems which a patient in a corporation hospital has to suffer through , will they become a little more empathetic . They will then be more willing to give the Dean more autonomy by treating him as a respected senior expert doctor. He needs to be able to exercise his discretionary power so he has the freedom to purchase the best equipment, using his best judgment, so that he can do his job properly.

The problem with the public health system today is that there is no accountability nor transparency . This is why no one is responsive, and the buck keeps on getting passed around from one person to another. It's much easier to do nothing, rather than try to fight politically motivated rivals, who want to take a cut of every transaction. This is why the medical equipment in these hospitals is outdated and poorly maintained , because the money lies unspent. This is one of the reasons why patients are so unhappy with public healthcare facilities . Even though the quality of medical care is very good, the level of hygiene and the ambience - the hotel facility and hospitality care provided in these hospitals - leaves a lot to be desired.

The problem is that we take a top-down approach. We need to take a bottom-up approach and think about what we can do to put patients first . The good news is that there are lots of opportunities to do so, and I'll discuss these in my next post.

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