Friday, October 24, 2014

Corporate hospitals versus small nursing homes


In the past, when patients needed hospitalization, their family doctor would refer them to the neighborhood nursing home , which was managed by a specialist who would provide care which was cost effective and affordable . For more serious problems, he would refer patients to a government or municipal hospital. In those days, there were no large corporate hospitals, and the care which patients received was personalized.

Today, however, the  scenario has changed completely. There are lots of five-star super deluxe specialty care hospitals coming up all over the country . These are extremely profitable ventures, and lots of corporate are now pouring money into these. They are marketed and branded very cleverly and because they are large sprawling structures , with the latest medical technology and lab equipment, with large teams of medical specialists manning them 24/7.

This means that today patients are presented with a dilemma if they need hospitalization. Should they go to the spanking brand-new , state of the art hospital, or should they stick with the local nursing home.

The truth is that most common surgeries and medical problems are best treated much more cost-effectively and efficiently in a well-managed, well-equipped small nursing home . Not only are they much cheaper, it’s much easier for the patient to establish a relationship with the doctor. The care is more hands on and personalized, and more convenient as well, because family members and patients
don’t need to travel long distances . It’s also a lot cheaper, because they do not have to pay the overheads for the unnecessary trappings which super specialty hospitals are fitted with.

However, the problem is that nursing homes vary widely in quality. While some are excellent, others can be death traps, because they are so poorly equipped and badly staffed. This is why patients often prefer large hospitals , without understanding the hazards associated with these. While large hospitals look very impressive and imposing, the sad truth that the care they provide can be pathetic – something to which even the doctors who work in the hospital will testify to !

The truth is that while patients are awed by the dazzling equipment and technology available in the new hospitals, the truth is that most of them will never need these. The danger is that once this equipment has been bought, the hospital has to justify the expenditure, which means the doctors are often forced to refer patients for unnecessary scans and tests, to generate income for the hospital. Thus, just because the hospital has invested crores of rupees on a robotic surgery device, their surgeons are now forced to use these. While surgeons are happy to play with these new gee-whiz toys, the truth is that they only add to the expense of the operation – without adding any value whatsoever to healing and recovery. It’s the poor patient ( or his health insurer) who is forced to foot the bills. Sadly, patients aren’t even aware that they are being subjected to avoidable procedures and treatments, which only help the hospital’s bottom line – not their care. However, it’s become a very competitive game, and hospitals spends large amounts of money in a one-upmanship game, to try to convince patients why they are better than the others. Patients are not sophisticated enough to be able to separate the wheat from the chaff, and most just accept whatever their doctor tells them as being gospel truth, without knowing that their doctor is pressurized by the hospital management to bring a certain amount of moolah on a regular basis, in order to meet the targets they set.

While patients may feel very safe in  these hospitals , because they have so much equipment , the care they provide is often extremely impersonal . Patients are often treated as numbers , and there is little continuity of care . It’s very hard to get hold of the Doctor when they want to talk to him, as a result of which many patients are extremely dissatisfied with the services these hospitals provide. However, they are so worried that their local nursing home is not adequately equipped to handle complications, in case these arise, that they prefer the sense of security which large hospitals provide. They are willing to pay the additional premium these hospital charge, because of the trust and confidence which they inspire, thanks to their ambience and fa├žade. However, this trust is misplaced , and that a lot of medical care would be much better provided in small nursing homes , provided these are managed properly.

The trick is that you need to choose between a hospital or a nursing home based on what kind of problem you have . The best model is a blended one, where simple surgical and medical problems are handled in small nursing homes , because these are much more cost-effective . Only the more complicated problems needed to be referred to specialty hospitals . This is the way things would work in an ideal world. However, because both specialty hospitals and nursing homes compete for the same set of patients, and  because corporate hospitals have  so much more clout , the nursing homes are gradually being squeezed out of existence. This is bad for all of us, as medical care delivered in these corporate hospitals will continue becoming more expensive as time goes by.

Thursday, October 23, 2014

Please consult with the patient !

Conversation between doctor and patient/consumer.


When we talk about a doctor-patient consultation , we usually refer to the fact that when someone falls ill, they go to a doctor, who then tells them what to do. This is usually perceived as a one-way street,  where the doctor is the one in charge. He takes a history, does an examination, orders tests and makes a diagnosis and provides treatment .

However, a key component of the consultation needs to be the fact that doctors need to consult with the patient as well. Unfortunately , this is something which is often forgotten !

Thanks to advances in medicine, patients today have lots of choices . Each patient is different,   and depending upon their personality, world-view, religion and culture, each will select a different option. There is no single right answer, and doctors are not mind readers. They need to factor  in the patient’s personal preferences, and they can only find out what these are by talking to the patient.

Doctors cannot afford to guess – and they shouldn’t try to impose their choices on the patient either ! They need to be non-directive and non-judgmental, and allow the patient to decide. They need to ask the patient which treatment they would prefer. This is not a sign of weakness on the part of the doctor – it’s actually a sign of strength !

Sometimes patients get confused when the doctor asks them for their opinion . They believe that this means the doctor is confused and doesn’t know what to do , which is why he needs their advice ! In reality, this means that the doctor is a good professional, who is being respectful . He understands that it takes two to tango , and that patients need to provide inputs so that doctor can help them to make a decision which is right for them.

The only way to have a healthy doctor-patient relationship is when both contribute ! This will help the patient gets the best possible medical care . This might seem obvious , but it's amazing how rarely this advise is followed in real life.

The problem is that doctors are often so full of themselves , and have big egos - especially the big specialists in the big towns , who are brand names . They think they have all the answers and are happy to dish these out to everyone who comes to them. After all, when you have a hammer in your hand, all you see are nails !

In fact, this is a setup where problems are much more likely to occur . Specialists have a very limited perspective – and for a cardiologist, every chest pain originates in the heart, because he doesn’t understand anything about the stomach ! As long as everything is fine, patients have been socialized to meekly agreeing with everything the doctor says. They are passively compliant , but when things go wrong ( as they are bound to do in any complex biological system), they become angry and vengeful.

Medical decisions needs to be made on a shared basis, where both doctor and patient provide their inputs ; and take responsibility  for the outcomes. Sadly, many doctor’s still believe that shared decision making means -  Here's my decision, let me share it with you . Doctors need to respect their patients and their choices !

Tuesday, October 21, 2014

Why do you think you are not getting pregnant ?

Infertile couples who come to me for a consultation often bring fat files stuffed with their medical records. These contain copies of their earlier test results ; and summaries of the treatment cycles they have already been through. They pull these out , and then wait patiently , expecting me to study their records and then pronounce my verdict.

However, before I touch the file, I ask the patient, Why do you think you are not getting pregnant ? What have you learned from your earlier medical encounters ?

Many patients are puzzled when I ask them this basic question. Isn't it the doctor’s job to find out why they are not getting pregnant ? And isn’t the answer in their medical records ?

This is a very important question , because it allows me to assess how much they understand about their problem.  After all, if you need to teach someone, you have to start from their level of current understanding, and then take them to where they should be !

Some patients look confused, and I need to prompt them. I reassure them that this is an easy question to answer. After all, you only need 4 things to make a baby – eggs, sperm, uterus and tubes; and if they aren’t getting pregnant,  the problem  is either with the eggs; the sperm ; the uterus; the tubes; or we have not been able to identify it ( a condition we label as unexplained infertility).

If they cannot answer this simple question, this means they need a lot more counseling and time. I can judge how medically sophisticated the patient is from their answer, and I tailor my conversation accordingly. This is much more efficient and effective , and ensures that the patient and I are on the same page .

When I start going through the records, I ask the patient to explain key test results.  It’s not as if I am trying to test them  - it’s just to reassure them that they are smart enough to make sense of what seems to be complex medical gobbledygook ! If they get stuck, I clarify and help them to make progress. This approach reassures them that I will treat them as an intelligent adult; and that they don’t need to leave everything up to the doctor . This gives patients a lot of confidence that we can work together as a team.

Need help in making sense of your medical reports ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!




 

Monday, October 20, 2014

How to make better medical decisions - a guide for doctors



Physicians do get things wrong, remarkably often. Studies have shown that up to one in five patients are misdiagnosed. 

Yet people are very reluctant to challenge doctors, who are perceived as being experts.  Anxiety, stress and fear — emotions that are part and parcel of serious illness — can distort our choices. Stress makes us prone to tunnel vision, less likely to take in the information we need. Anxiety makes us more risk-averse than we would be regularly and more deferential.

If patients want to control their own destinies, they cannot afford to leave their brains ( and heart and spine) at home ! 

They need to go well-prepared for medical consultations, by arming themselves with Information Therapy.

http://www.nytimes.com/2013/10/20/opinion/sunday/why-we-make-bad-decisions.html?pagewanted=all&_r=0

Sunday, October 19, 2014

How patients can contribute to improving medical care


The NYTimes website has a great article called - Why Doctors Need Stories
http://opinionator.blogs.nytimes.com/2014/10/18/why-doctors-need-stories/?_php=true&_type=blogs&ref=opinion&assetType=opinion&_r=0

Narratives have always been important; and stories are great teaching tools. They are sticky and memorable, and medical students learn medicine by studying "around and about" their patients.

However, it's not only doctors who can contribute medical stories. Every patient has a story to tell, and patients can help to advance medical science by telling their own stories. A blog is a great way of doing so, which is why we encourage patients to keep a blog and share their experiences and their expertise, with other patients, and with doctors as well !

A great example of a superb patient blog is Manju's blog at www.myselfishgenes.blogspot.com

I hope her example will inspire other patients to keep a blog as well !
You can email Manju at manjupadmasekar@yahoo.com


Is Facebook exploiting young women by paying for their egg freezing ?


I was very impressed by the recent news that Facebook and Apple  have agreed to pay for egg freezing for their employees. I thought this was a very positive step, as it allowed young women more reproductive autonomy. By feezing their eggs , they now have more control over planning their life, and could choose to postpone childbearing, without compromising their fertility or increasing their risk of having a baby with a birth defect. I felt this was a very enlightened move, which would help to create employee loyalty.

I was therefore very surprised to read that some health activists felt that this was a retrogressive step. They were painting it as being anti-feminist, because they believed these companies were interfering  with their employees plans to start a family. These people felt that companies wanted to manipulate young women so as to extract the most of their productive working years, by asking them to postpone child-bearing . It was being positioned as a " artificial reproductive technology to boost capitalistic productivity" versus " natural reproduction  " debate. They claimed that the move was ethically wrong, as children needed mothers who were young; and that  asking women to bear children at a later age would lead to more medical complications as well.

I believe this is a very good move , and is very ethical as it allows women more control over their reproductive options. Egg freezing allows women to ensure that biology is no longer destiny ! Just like birth control allows women more control over when to have babies and how many to have , egg freezing allows women more options as to when to have a baby. It allows them more flexibility in having both a career and a baby, so that they can have their cake , and eat it too.

In fact, not allowing them this option is unethical in my opinion. Why should women be forced to have babies at a particular age ?  Our poor grandmothers were forced to have baby after baby , because she did not have the option of using birth control ! Just like contraception allows women more control over their life, so does assisted reproductive technology.

Also, older mothers are often better mothers because they are more mature; more stable; financially better off; and settled in life. The organisation is not interfering - it is simply allowing women the freedom to choose for themselves. After all, they aren't forcing them to freeze their eggs !

Since the eggs are young, the risk of pregnancy complications are not increased, as long as the woman is healthy. Her calendar age is not an issue - it's her physical health

I think these critics are falling into the trap of underestimating these women. They are very smart
( after all, they are working at Apple and Facebook ! ). They are very capable of making up their own mind and this is an empowering move in my opinion ! These are very personal decisions which are best made by the women involved themselves - and we should respect their right to do so !

Saturday, October 18, 2014

The embryo scope as a marketing gimmick




 Most doctors unfortunately are quite happy to take advantage of the fact that patients are dazzled by medical technology. They are easily lured by claims of the “newest and latest” advance, and lots of doctors take pride in the being the first to offer the newest IVF toy, claiming that using this will improve success rates dramatically. Patients have short memories, and there is a new technology being promoted every few years, depending upon what is fashionable.

The flavour of the month seems to embryoscopy, and many IVF clinics are proudly promoting this, saying that this is now the “state-of-the-art” technology which will improve IVF pregnancy rates.

So what is the embryoscope ? It’s a type of incubator that has a built-in camera, which is capable of taking pictures of your embryo several times an hour. These pictures are then combined to create a time-lapse video showing the embryo’s development at every stage, so that the embryologist can assess embryo development more precisely and select the best embryos for transfer.

An embryoscope is expensive, and in order to recover the cost, IVF clinics feature their latest buy prominently in their advertising materials and on their website. They use this in order to differentiate themselves from the competition, by offering technology which is “more advanced” than the others. Patients are quite clueless, and are easily swayed by these claims because they are not sophisticated enough to separate the wheat from the chaff. They happily cough up Rs 30000 more , so that the doctor can use the embryoscope for their embryos, with the hope that this will improve their chances of success.

The dirty secret is that these clinics cheat patients by claiming to use the embryoscope for them, but never do so in reality. Let me explain.

Each EmbryoScope has the capacity to culture only up to 72 eggs or embryos from a maximum of 6 patients at a time. These need to be observed over a period of 5 days ( for a blastocyst transfer) which means that one embryoscope can typically be used for only one patient every 5 days.  Thus, if there are 3 egg collections daily, the embryoscope will be fully blocked in a 2 day period for a total of 5 days. This means that the embryoscope cannot be used for another patient who is cycling at the same time.  Embryoscopes are expensive, and most clinics have only one.  This means that if a busy clinic is telling all the patients who are cycling at the same time that they are using an embryoscope for each of them, they are clearly lying !

How can you make sure you are not being taken for a ride ? Remember that the purpose of an embryoscope is to take a video of your embryos as they develop in vitro. If the clinic tells you that it is using an embryoscope for you ( and charging you extra for this), then you need to insist that they give you a video of your embryos, so you can verify this. The embryoscope automatically provides a video output, and you should ask for a copy of this, so at least you have documentation that an embryoscope was actually used for your care ( even though using this does not improve your pregnancy rates). This  is a simple method by which you can ensure your doctor is not charging you extra for a procedure they are not using for you.

Want to make sure you are not being taken for a ride by your IVF doctor ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!






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