Sunday, July 24, 2016

What keeps doctors up at night - the human side of medicine

The panel discussion on " First, Do No Harm: featured the medical legends, Dr Farokh Udwadia, Dr Yeshwant Amdekar and Dr Sunil Pandya.

It gives a rare glimpse into the heart and soul of a doctor - and you can see what makes them keep awake at night worrying about their patients.

The book, Patient Safety - Protect yourself from Medical Errors is now online at

You can also download it free at

Wednesday, July 20, 2016

Dr Farokh Udwadia on the increasing tension between doctors and patients

Why startups run such a rocky unpredictable course

It would be great if investors could develop a formula to be able to determine which startups will be successful. We'd become rich extremely quickly , and wouldn't have to waste so much money on those which fail. One would expect that over so many years, after investing so many billions of dollars in startups, the super-smart people who run venture capital firms  would have been able to come up with a formula for success , so that we could determine which startups we should be investing in.

However, the fact is that we still don't know which startups will do well. A lot of it is still hit-and-miss, and most investors will accept that there is a major element of relying on gut-feeling when they decide which startups to back. This is not because investors are stupid - it's just that startups are complex adaptive systems ( CAS) , which means they are unpredictable and unknowable.

Two of the most prominent properties of complex systems are self-organization and emergence. This means that no individual agent in the system ( either the founder or the VC) is able to control the outcomes in the system , as these are a consequence of interactions within the system . Complex systems by nature are unpredictable and generate surprises, which is why investing in them can be such a roller-coaster ride.

The startup ecosystem has lots of players -  employees,  customers, other startups, investors, large companies, established competitors, government policies and regulation . The complexity relates to the unexpected emergent behaviour of the overall svstem which can not be predicted from the behaviour of an individual player, nor understood by decomposition of the system. In a complex system,  cause and effect follow a non-linear relationship where small changes  can potentially have a big impact . This is why complexity has been dubbed the “science of surprisc”  and startups have surprised lots of established players in a variety of markets - for example, the Apple iPhone disrupted the incumbent mobile phone players ; and Google transformed the advertising industry.

Paradoxically, a startup has no command and control structure, so that even though it may seem that the founder is in charge, in reality it is the initial core group of early employees who are forced to  create rules and make things up as they to run the business on the fly. Execution as learning becomes the DNA of successful startup cultures, because there are no readymade processes which they can follow. This is why startups follow a chaotic process of discontinuous growth, and the glue which holds them together is the vision and passion of the founder, which guides the activities of the employees during their early journey.

Complex adaptive systems are dynamic self-organsing systems which are able to adapt in and evolve with a changing environment. This is one of the strengths of a startup , which gives it the agility, resilience and flexibility it needs so that it can be far more innovative than a traditional large company .

Complex systems seem to be always teetering on the edge of chaos  - and this is a feeling I am sure lots of entrepreneurs can identify with  !  The dynamics of a complex adaptive system combines both order and chaos, which means there is bounded instability that is characterized by a state of paradox: stability and instability, competition and cooperation, order and disorder.

Complexity theory provides a new perspective through which we can observe the development of new business startups because they do not follow the standard linear life cycle theory of the growth of a mature company.  This is why startup founders need to embrace chaos, encourage experiments, and tolerate mistakes. Given that no one is in charge of a complex adaptive system, the management approach should emphasize collaboration and agility to create desired outcomes.

Atul Gawande  points out that complexity theory divides problems into three general categories: simple, complicated and complex. Simple problems are ones in which the inputs and the outputs are known , and you simply need to follow a set of rules - for example, you use a checklist to make sure your tax returns are filed properly. Complicated decisions involve significant uncertainty. In these situations, the solutions may not be known, but they are potentially knowable, but it can take time and money to find them. Some startups will get tripped up by these because they run out of cash when they get to this stage. Finally, complex situations are those in which the formula for success is unknowable. While you may use rules of thumb to try to improve your chances of success, you do not know what will work, and cannot predict the outcome .  Being a parent is a good example. You can raise children using the best evidence-based rules, but you can never be sure how they will turn out !

The problem is that most investors think of a startup as being a complicated system,  while it is really a complex system. This is why they expect that the entrepreneus should be able to deliver controllable and predictable outcomes if the proper processes are put in place properly and the founder runs a tight ship .   They assume that an intelligent analysis of past events improves their capacity to predict future events. The truth is that in  complex environments that change all the time, we cannot anticipate all situations and we cannot pre-design a system that is always guaranteed to work - all we can do is experiment and correct course intelligently, by trying to fail as quickly and  cheaply as possible , until  we stumble across what works.

Startups are complex systems, and we need to learn to be humble, and not assume that we have all the answers, just because we are domain experts or have tons of money . The best approach to supporting a startup is to accept that everyone is equally clueless but well-meaning , and allow the founder to try something that seems to make sense , based on his knowledge , your instincts , and the available data. You must then jointly measure the results and often repeat the cycle many times in search of the best possible outcome.

Now I am not advocating that investors take a nihilistic " chalta hai ", " anything goes " attitude . After all, as  parents,  even though we know that we cannot control how well our children will do in life, we  do our best to provide them with a high quality education ; and do set boundaries until they are mature enough to make their own decisions.

Complex adaptive systems produce novel, creative, and emergent outcomes, which we cannot predict or control.  Investors who understand  how complex systems work drop the burden of trying to control the founder and instead focus on the small actions they can take to influence patterns of interaction. If we understand our limits, we will be able to do a better job  !

Lokmat newspaper covers the book launch of Patient Safety

Panel discussion on First Do No Harm at Seth G S Medical College and KEM Hospital

The book release was followed by a panel discussion on " First Do No Harm" .  Dr Farokh Udwadia, Dr Sunil Pandya , Dr Yeshwant Amdekar and Dr Urmila Thatte shared many useful pearls mined from their years of clinical experience on what doctors can do to improve patient safety.

It was a great feeling to be back in my alma mater. We had a full house and the Seth G S Medical College and KEM Hospital team did a great job with organising the book launch and the panel discussion !

You can read the book at  or download it at !

Free book on Patient Safety - Protect yourself from Medical Errors

Tuesday, July 19, 2016

Why startups fail - and the real reason may surprise you !

Along with being an IVF specialist, I am also an angel investor who funds startups. Failures are common in both IVF and angel investing, which is why it's a topic which fascinates me.

One of the major risks any startup faces is that of failure. In fact, this possibility  is built into the very definition of a startup, because a startup is an experiment in order to find out what works in the real world and what doesn't. If it does work, the payoff is enormous, but the reality is that about 90% of startups will fail, because we cannot predict the future . Since failure is expensive, a lot of time and effort is invested in trying to reduce the risk of failure.

Unfortunately, we seem to be going about it the wrong way.  When a startups fails , we want to find a scapegoat to blame, and this is usually the founder. There's a lot of finger-pointing , and people create stories as to what went wrong , and why. How could the founder burn through so many millions so quickly with nothing to show for this ? Surely he must have become too egocentric and refused to listen to reason, which is why he drove his company into the ground.

Whenever a startup succeeds , we look for a hero , and the founder is painted as someone who's super-human.  However, the flip side to idolising  extremely successful founders  such as Steve Jobs is that we also paint founders as being villains when the startup fails.  We forget that success or failure doesn't depend on an individual  -  it depends on the system. We need to analyse the failure dispassionately by doing a post-mortem, so that we can learn from it and move on.

Unfortunately , humans prefer reading emotionally-charged stories rather than taking the time and trouble to understand complex alternative histories and counter-factuals.  This short-cut means we end up doing a disservice  to the ecosystem . We gift all the glory to the successful founder , and punish the one who fails by dumping all the blame on him.

In order to reduce failures,  smart VCs  implement systems and processes to make sure that the startup is on the right track.  The founder is required to report reams of data, and they analyze this data to try to pick up patterns and early warning signs of failure.  However, rather than use this data to help the startup to succeed , it is often mid- used for pulling up the founder when the company is not growing as planned.  Because investors are very busy and have lots of startups to track and monitor, they focus only on a few numbers, and use these metrics to judge the performance of the founder. These will decide whether the startup gets the next round of funding, or whether the investor pulls the plug and allows the startup to die.

Now there are three ways to get better numbers:
● The first is to improve the system. To do this, the founder needs to change processes in order to add value at the front line - a difficult and time consuming task, which needs patient capital .
● The second is to suboptimize.  Here the founder focuses exclusively on improving the area being measured, often at the expense of other areas.
● The third is to game the numbers. The founder manipulates the data to make the numbers look better.

Thus, if the major focus of the investor is on tracking GMV (Gross Merchandise Value) , the founder will focus on inflating that number, often at the expense of neglecting more important metrics , and this is what leads to disaster in the long-run. It's easy for a founder to dress up the numbers in order to make them look better - which is why so many e-commerce companies continue to behave in ways which make no sense to an outsider. They sell products at  a loss  in order to get their GMV up, because this is what keeps their investors happy. Similarly, if an investor wants to see growth, they are happy to buy customers, no matter what the cost, so that they can raise their next round of funds from a bigger fool.

Startups are complex adaptive systems which have to tackle unknown unknowns. Investors need to understand that the success or failure of a startup depends on providing them a supportive ecosystem. We need to focus on collect useful metrics which can be used to support the growth of  the company, rather than using them as a stick to blame the founder when things aren't going as planned.

Monday, July 18, 2016

Bouncing back after a failed IVF cycle.

While being an IVF specialist is a lot of fun because we're helping people to have deeply loved babies, the one part of my job which I hate is having to tell patients their hCG is negative and the cycle has failed. This is specially true when the cycle was perfect, we got good quality blasts, the transfer went well, the endometrium was perfect. Because no matter how much we explain to patients that an embryo is not a baby and that IVF doesn't have a 100% pregnancy rate, when the cycle fails their heart breaks. Quite frankly, mine does too. I'd be very happy if we could give them a baby , so that they could move on with their lives, and send lots of their friends to us !

    It's very difficult to counsel these patients sometimes, because they're emotionally very upset, and even if their brain understands that we've given them good quality care, their heart still hurts. Often, they don't know how to cope with this. They either end up blaming themselves, or they blame God, or they blame the doctor. I tell them, "For heaven's sake, don't blame yourself. This is a biological process which no one can control, and you need to learn to be kind to yourself." Blaming the victim is a destructive way of coping with IVF failure.

    Blaming God doesn't help either. I believe in a kind God who wants good things for us. I think it's helpful to have faith in a higher power who we feel is looking out for us. Whether you're religious or not, this belief can help you cope with dark times, even when you cannot make sense of his actions.

    As far as blaming the doctor goes, I don't like being blamed of course, specially when  we have put in a lot of effort , and given patients the best possible medical care. We spend a lot of time counselling patients, and explaining to them what we're doing and why, so they know exactly what's happening. However, I'd much rather that they blame me , rather than themselves, because I have a clear conscience, and I know we've done a good job. Since I know no one could have done anything more, blaming me does not hurt me, and if using me as a punching bag helps to relieve my patient's distress, than I am happy for them to do this . I can deal with that blame, because I know it is mis-directed. I feel that giving them a target to get angry with helps them to vent their anger , so they can move on.

When an IVF cycle fails, the predominant emotions are one of depression and sadness, and this can be hard to deal with. When you feel sorry for yourself , you feel powerless and alone, and get paralysed into inactivity. Compared to this, anger is a better emotion, because you can channel it into doing something else - and I believe this is better than not doing anything at all.

    I tell patients that they need to find the strength to cope with this blow within themselves. While growing up, all of us have dealt with disappointments in our life, and we have sources of solace we can tap into. This could be a spouse; family members; friends; relatives, or a spiritual authority , such as a guru. While I can help them analyze what went right in the cycle and what went wrong , there are still lots of grey areas we can't figure out - what we call the unknown unknowns, because IVF is still not an exact science.  However, no amount of analysis can provide comfort when the cycle fails, and healing finally has to come from their heart.

Need help in getting pregnant ? Please send me your medical details by filling in the form at so that I can guide you !

Sunday, July 17, 2016

Freezing time: What career women need to know about preserving their fertility

In the 1950s, contraception allowed women to plan their families, so they could decide how many babies to have and when to have them. Now, reproductive technology empowers them even further, so they can make the right life decisions for themselves. Biology is no longer destiny, and women can compete with men on equal terms, without having to worry about their biological clocks!



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