Monday, April 24, 2017

Do doctors charge too much ?

A doctor's income seems to have become an extremely sore issue in this day and age. Lots of people, right from the average citizen to the PM , feel that doctors charge way too much. Their belief is that medicine is supposed to be a noble profession,  and doctors should not allow their minds to be contaminated by base commercial considerations .  After all, doctors are highly educated professionals, and they should take delight in helping their patients to get better, rather than trying to maximize their income.
Lots of people believe that doctors have become too commercial and uncaring, and that their primary focus is on earning more, rather than providing good clinical care. This is why we are now seeing a backlash against doctors. They are getting beaten up by angry patients; the judiciary as well as the media are happy to criticise them; and  politicians are happy to pander to the masses by putting a price cap on procedures and medical equipment, so that they can make healthcare more affordable.
Doctors, on the other hand, feel very embittered that in spite of sacrificing the best years of their life burning the midnight oil in order to master medicine, they make a fraction of what corporate executives do. It burns them up that hot shot lawyers charge over 10 lakhs for making an appearance in court, irrespective of whether they open their mouth or not. They are knowledge workers, just as lawyers are, and yet people grudge them their fees. They can't understand why society uses such double standards when dealing with doctors. All a lawyer does is win a case, whereas a doctor can actually save your life - and how can anyone measure the worth of a life ? Doctors hare the fact that when a doctor messes up, judges are quick to  fine them crores of rupees, but when they perform life saving surgery, patients are reluctant to pay even a few thousand. Where's the justice in this ?
The problem is that we can't put a price on saving human life, which is why we expect doctors to be satisfied with compliments and gratitude. While these are great for enhancing a doctor's emotional income, how do they expect a doctor to survive on these ?
While an emotional income can be personally satisfying, how can the doctor use this to make a living ? He needs to pay money to buy a house to live in ; and send his children to school. Even if we wants to run a clinic to treat his patients, he still needs to buy the office space , the medical equipment, and pay the electricity bill.
The divide between doctors and patients is progressively widening. A doctor feels he gets grossly underpaid . No matter how many hours he may have spent in the middle of the night, struggling to save his patient's life, when the patient gets better, all he gets is gratitude. However, when the patient doesn't do well ( often for no fault of his) he becomes the patsy who is at the receiving end of the patient's ire.  This is why doctors feel they are getting an extremely raw deal.
There is no correlation between the amount of effort and time which he has invested in his career , and the return which he is now getting. This causes a lot of heartburn, and this is one of the reasons why doctors no longer want their children to become doctors anymore. They feel that all those years of hard work they have put in are never adequately compensated. Now it's not that doctors are greedy  - if they were, they would have become bankers - they are intelligent enough to have got into any profession of their choice ! They don't expect to roll in wealth , but they do want to make enough to be able to live comfortably.
I think we need to stop grudging them their fees. I agree there are a few greedy doctors, but by being miserly and by underpaying doctors, we're harming everyone in the healthcare system. It's because doctors are not paid well that they to resort to all kinds of underhand means in order to increase their income levels.
I think this is one of the problems we are seeing an epidemic of medical corruption today. It would be far healthier if doctors were paid freely and fairly for their professional services, and were given the value and the respect which they deserve.  Unfortunately, in India , we don't seem to value advice.  Thus, while patients are willing to pay surgeons a fat fee for doing an operation, they are not willing to pay family physicians for the advice they give , even though the advice may be far more valuable because it helps to save them from unnecessary surgery. Underpaying doctors just increases medical corruption because doctors can't live  on love and fresh air.

Saturday, April 22, 2017

All doctors need to become patientologists

Doctors take pride in mastering the scientific minutiae of medicine . On the top of the medical hierarchy are the super specialists - the ones who have a lot of technical expertise in a very narrow slice of medicine. They're usually looked up to by other doctors because they're the doctor's doctors. They know practically everything there is to know about their personal area of interest, and because they attract a lot of referrals, their depth of knowledge in their domain is enormous.

However, all this super specialization comes with a price. Because they are so focused on the little segment of medicine  which is of special interest to them, they sometimes fail to see the big picture. This is something which makes a lot of their patients extremely unhappy because they feel that these specialists have lost the human touch.

Doctors need to remember that while it's great to specialize - to be an interventional  cardiologist or a pediatric pulmonologist, they all need to be patientologists as well. They all need to specialize in learning how to take care of their patient's emotional needs.

Unfortunately, this key skill is often lacking. It's not as it doctors are not empathetic, it's just that this valuable trait is not emphasized during their training. In fact, residency can be very dehumanising, because the poor junior doctor is often made to work under conditions where he feels he is being treated like an animal. He is often sleep deprived, hungry, stressed, and subject to bullying by his seniors. It's high time we brought humanity back into the medical profession, and the first step in this direction is to handle young doctors more kindly, so that in turn, they also learn to treat their patients with tender loving care!

Thursday, April 20, 2017

Generic drugs vs branded debate

The recent move by the Modi government to make prescribing of generics compulsory has raised a lot of hackles. The objections have been pretty predictable. Obviously, the pharma companies are up in arms because they make most of their money from selling branded drugs. If this option is taken away from them, they're going to have to look for alternative means of generating revenue, and having to change a highly profitable business model is not easy for large corporates. Once the law gets teeth, it will no longer be business as usual, which is why they're upset. They are worried that their business will get commoditised and their margins will shrink. Since pharma CEOs are powerful , lots of observers are understandably cynical about the prospects of these new rules being implemented . Their belief is that they will be diluted so much that they will remain a toothless tiger.

Since the pharma companies guys can't complain directly that they are upset because this is going to eat into their profits, they are using doctors as their puppets. Doctors are upset with this move because they see this as an encroachment on their professional autonomy. They've been writing brand names for many years, and they don't see what they need to change an engrained habit. Yes, brand names are easier to remember, but the truth is that many of them get incentivized to prescribe a particular brand. They are obviously reluctant to say goodbye to this easy money. Also, they are worried that the locus of power has now shifted to the chemist, who will end up deciding which generic to dispense.

The general perception today seems to be that brands are of higher quality than generics. This is not true, since the active molecule in the drug remains the same - it's only the label which is slapped on it which changes. Yes, the government needs to make sure that the drugs are manufactured in a quality factory , and this is true for all drugs , whether or not they are generic or branded ! If you have a poor quality manufacturer, then whether he's marketing a generic molecule or a branded drug, its quality will remain equally poor . The FDA will have to become far more proactive , and as long as the medicines meet quality control standards, what the name on the box says makes no different at all to its therapeutic efficacy ! This is why private labels have become so popular in the FMCG industry - consumers are realizing that there is no point in spending extra on branding . This is as true for drugs as it is for FMCG products.

All pharmacology textbooks teach students and medical residents to prescribe generics. It's the active molecule which makes the drug effective, and this is what is drilled into the doctor's head during his training. The problem is that once a doctor starts practice, he forgets what his professors taught him, and gets influenced by the friendly medical representative, who is always welcomed because he comes bearing gifts.

There are many extraneous factors which come into play when a particular doctor chooses to prescribe a particular brand, but he never talks about this openly , because he's ashamed about the fact that he's not necessarily doing what's in the patients best interest. He needs to justify his actions, and the most convenient excuse is that brands are better than generics, even though he has no proof that this is true. He needs to salve his guilty conscience by bad-mouthing generics.

The healthcare industry needs to get back to basics . Pharma should focus on producing high-quality drugs at a reasonable cost, and stop wasting money on " marketing ". Once generics become mainstream, they will no longer need to employ an army of medical representatives to cajole and induce doctors to prescribe their brand - most of which are just "me-too" variants. This will help to reduce their marketing spends, because companies will not have to waste money on competing with other pharma companies for which particular brand the doctor chooses to prescribe. This is a step in the right direction , and we should all be pleased , because it'll make quality drugs more easily available to patients at an affordable cost. As with anything else, any time you change the status quo, some people are going to get upset, but over time this move will help to make sure that medicine is practiced more rationally and ethically in this country.

Pharmaceutical companies will now focus on improving the quality in their manufacturing plants, rather than wasting money on branding and marketing. Also, since they will no longer have to spend on cajoling doctors to prescribe their brands, they will be able to deploy this towards educating patients, so that patients are better informed about what medicines they are taking, and why.

Tuesday, April 18, 2017

How digital patient profiles can help doctors to understand their patients better

Service industries such as hotels use customer relationship management ( CRM ) systems extensively  in order to track the personal preferences of their clients , so they can provide them with high-quality services, tailored to their  individual tastes . Guest Experience  Management Systems allow them to delight their customers, allowing them to create guest loyalty. In order to do this efficiently, they need to capture a lot of  data about their customers, so they can learn more about their customer's needs and wants.  This is true even for websites like Amazon, who collect a lot of data about the past purchases of their customers, so they can customize what they display to each individual.
Why can't we apply these same lessons to medicine ? After all, patients are the healthcare industry's customers, and the more we know about our patients, the better the services we're going to be able to provide for them. Isn't it logical that we should have all this information about our patients at our fingertips whenever we do a consultation?
Ideally, whenever a patient signs up for an appointment, the EMR should be able to scrape online publicly-accessible databases and provide a summary about what her likes and dislikes are, so that the doctor is better prepared for the visit . Not only will the doctor be armed with the medical details about her illness, but will also have a better idea about what kind of  individual she is, and what her personality is.
Today, a good nurse or clinical assistant provides this information to the doctor just prior to the consultation , and this helps the doctor to create a personal connection with the patient. Over time, as we establish a relationship with our patient, we are able to understand our patients as unique individuals, and this allows us to create trust. Patients are comfortable with their doctor because they feel that he knows and understand them.
Why should it take multiple visits to create this bond?  We need to use technology intelligently  to help doctors to connect better with their patients , by helping them to understand their personal desires, wants and needs. This can help to strengthen the doctor-patient relationship, because the doctor will be able to see his patients as more than just someone who has a medical problem which needs treatment - he will see them as a fellow-human.  Wouldn't you be delighted if your doctor asked you about how your son was doing in school, because his EMR informed him that you had recently posted a photo of him winning the Math Olympiad on your Facebook page ?
Doctors today are often seen as impersonal and uncaring. Additional personal details about the patient will  make the doctor-patient interaction much richer, because it will help the doctor to connect better with the patient. It will encourage small talk and this kind of social lubrication can reduce the barriers  which impede doctor-patient communication. Most patients want to try to create a personal connection with their doctor, so that he will be more empathetic - let's help doctors to do this as well.  This is what made the family doctor of the past so special - he knew a lot about the family, and was often considered to be a part of it. We can use technology to create this same kind of magic again.
Interestingly, this kind of background information can help the doctor to provide better medical care. He can explore whether there is family support available at home; and who the caregiver is, so he can involve them in the treatment plan as well.
Perhaps when we ask patients to take an appointment, we should encourage them to fill in some of their personal details in the intake form, so we have a better sense of what their interests are. For example, they could add a link to their Facebook page, and this would help  doctors to improve their bedside manner by helping them to break the ice with their patients , since they now have some background information about their patient.
As William Osler  “The good physician treats the disease; the great physician treats the patient who has the disease.” Technology can help doctors to learn more about their patients !

Monday, April 17, 2017

When more is not better in IVF - IVF "add-ons" can harm patients

Finally, Dr Raj Mathur, consultant gynaecologist at Manchester Fertility and St Mary's Hospital, started by acknowledging that there does indeed appear to be a problem. Clinics advertise their use of add-ons as markers of quality or innovation, he said. With this comes a duty, however, to advertise responsibly, for example by placing the technique in its context and offering full information about it. Dr Mathur said that clinicians have a responsibility to protect their patients, who are at a heightened sensitivity and may be overly receptive to the claims linked to add-ons, and should take great care not to exploit unproven treatments for profit. - 


Sunday, April 16, 2017

Is this a good quality embryo ?

We routinely show patients  their embryos before the transfer, and this can be quite an emotional moment for them. The commonest question they ask is - "Is this a good quality embryo?"
Of course, what they really want to know is if that embryo will become a baby, but they do realise that doctors aren't very good at predicting the fate of an embryo once we transfer it.
As a scientist , it's easy to explain to what a top quality blastocyst looks like; and that a eight-cell embryo with no fragments on Day 3 is a good quality embryo. However, from the patient's perspective , the only good embryo is one which becomes a baby !

The problem is we just cannot determine with today's technology which embryo will implant successfully and become a baby.

IVF technology has limitations , and both patients and doctors need to accept this gracefully. Thus, sometimes great looking embryos on day three will arrest on Day 4 and not form blastocysts on Day 5 in the laboratory. Conversely , we have embryos which look terrible on day three , and yet form good quality blastocysts.

The problem is that when we grade an embryo in the IVF lab, we have to depend upon eyeballing it - what does it look like ( the scientific word for which is morphology) .  How many cells does it have ? Are these cells equal and regular ? Does it have  fragments ? How fast does it divide ?  This grading allows us to select better looking embryos as compared to the ones which don't look so good, because we know the ones with better morphology have a higher chance of implanting. However, we still can't predict the fate of an individual embryo as yet. The problem is that implantation is a complex multifactorial biological process, which is affect by many variables which we can't tease apart. This is hardly surprising, given the fact that we are trying to follow the fate of a living ball of cells which we have put back in the uterus.

This is not for lack of trying. Thus , scientists have developed  additional technological tools such as PGS and CCS, where we biopsy the embryo to check its chromosomal constitution, because we know that aneuploid embryos ( those with chromosomal abnormalities ) have a lower chance of implanting.  Similarly, some labs use time-lapse technology in order to get a real-time video of how the embryo develops in vitro. However, while these tools provide additional data, none of them is clinically helpful , because it still doesn't answer the patient's million-dollar question  - will this embryo become a baby or not.

This can be frustrating not just for patients, but for doctors as well. Thus, we can say, "Okay, this particular embryo looks the best on day five." However , after we transfer it in the uterus, we can't track its fate, so that if doesn't implant , we can't pinpoint why it failed to do so . Did it stop dividing on Day 7 ? Or was the endometrium not receptive ?

This is what I call the " T plus 1" problem. While we can grade the embryo on that day, we don't know what will happen to it on the next day. Will it continue to grow well ? Or will it arrest ? Will the cells start fragmenting ? In the IVF lab, we have to live one day at a time, and there is no getting around this limitation as yet. In a perfect world, we would be able to grow the embryo to a baby in the lab, and then hand this over to the mother - a process called ectogenesis. However, we have not reached this level of sophistication as yet , except in science fiction

Having said this, it's still important that you have photographs of your embryos for documentation , so you can judge their quality. Other doctors can also look at your embryo photos and grade their quality. However, you do need to understand that not all good quality embryos will become a baby. Conversely, just because an embryo is of poor quality doesn't mean that it won't become a baby - and if it does, these babies are perfectly healthy and normal.

Need help in assessing the quality of your embryo ? Please send me your medical details by filling in the form at so that I can guide you !


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