Wednesday, June 28, 2017

The law against giving cuts in the healthcare system


I'm very pleased that the Maharashtra government is passing a law which makes the payment of cuts, kickbacks, and commissions to doctors an offense for which they can be punished. I've always been vocal about the fact that kickbacks have corrupted the medical profession and damaged the doctor-patient relationship. These cuts impose a burden on the honest doctors who refuse to give kickbacks ; and helps bad doctors who are willing to take shortcuts to enrich themselves. In the long run, it hurts patients as well , because the cost is passed on to them, and they end up paying for these under the table bribes.
A practise which was started by a few bad apples has spread wildly like a cancer, and caused irreparable harm to the reputation of the entire medical profession. Kickbacks seem to have become institutionalized , and it's become very difficult for an honest doctor to survive in private practice without giving these.
It's because this has been going on so blatantly for so many years that the government has finally had to step in and take stern action against this practice - or should I say malpractice ?
However, sometimes the cure is worse than the disease. Government actions may be well-intentioned, but they usually end up back firing, because all they are able to do with their ham-handed laws is pass regulations which punish offenders when they are caught. However, this is doomed to fail in real life, because kickbacks are exchanged between two willing parties ! How does one document the kickback? Who will complain ? and why would they ? and how would they prove the cut was given? And does one punish the person giving the kickback ? or the person taking it?
This is a difficult and complicated situation, and part of the problem is that the government is being short sighted by only addressing  the symptom , rather than the underlying cause of the disease. We need to step back , and rather than think about punishing people because they've given or taken a kickback, we need to think about what we can  do to remove the need to give kickbacks ! This would be far more productive  approach, because this is a better question to ask , and a more useful problem to solve.
The government needs to take enabling positive steps, rather than pass punitive legislation , which only punishes people after the event. Why not stop the event from occurring in the first place?
Let's go back to first principles. The only reason people give kickbacks is to increase their business. Thus, specialists need referrals from GPs, which is they give kickbacks to a family physician ; a hospital gives a cut to a specialist, in order to fill their beds; and pharma companies and medical device manufacturers want doctors to prescribe their drugs and products , which is why they incentivise them with commissions.
The government needs to get rid of the middlemen in the healthcare system, if it wants to clean it up !
The best way of doing this is to enable patients to reach out to good doctors directly. Then there would be no need for these good doctors to either give a kickback, or to accept one !
It's possible to do this digitally today. The government should publish an online directory of all qualified doctors registered with the Maharashtra Medical Council , or order the MMC to do so.  This would enable doctor discovery, so that patients would be easily able to find the doctor who is right for them , from the comfort of their home.
Obviously, a bare bone listing is not enough ! The doctors would be mapped, so that patients can make a short list of doctors who are in their locality, and start contacting them.  Patients would be encouraged to rate the doctors they have seen, so that other patients can get information about how patient-friendly the doctor is. These comments and ratings would be moderated, so that they are of high quality; and doctors get a chance to respond to complaints. This simple step would be a great way of introducing openness and transparency into the system, and doctors would be then far more likely to treat their patients better, because they know they are being evaluated by them online.
The next step would be to encourage doctors to have their own websites , and the directory could link the doctor's name to his personal website. This would allow patients to learn a lot about each doctor, so they could compare them without having to go physically to their clinic.  We have a new generation of young doctors who are willing to connect digitally; and we have empowered internet savvy patients, who don't want to waste time travelling to a doctor's clinic. A doctor's personal website will help to kick out the middleman by enabling direct doctor-patient communication, and this will help to create trust. Doctors will not be able to lie on their website, and this will help to keep them honest !
The government needs to provide Information Therapy on their website, so that this becomes a trusted source of reliable information about health and illness. It should become  the port of first call whenever any patient has a health related query. The site should be in local languages, and will allow patients to learn about their symptoms, diseases and  treatment options even before going to their doctor ! The website could cover lots of things, such as the average cost of medical procedures , so that patients are better prepared. It could also act as a nucleus around which patients can create online communities and talk to each other, thus helping each other when they are ill.
This is the kind of positive proactive patient friendly step which a government should take , because it has the power, the responsibility and the duty to do so, in order to keep its citizens healthy. This step will help patients to find the best doctor ; and help doctors to get patients without having to give kickbacks.
A progressive government will use technology cleverly to heal the healthcare system , by helping both patients and doctors.  This platform will help to reduce costs for patients, because they will be able to connect with experts who can provide video consultations. It will assist patients in small towns , as they will not need to travel to cities to get second opinions from leading experts. Junior doctors who have free time can create patient educational materials, and share these on the platform . This will help them to  attract more   patients . Finally, this will  also improve the productivity and efficiency of the interns and resident doctors in government medical colleges, who will be able to serve the needs of villagers remotely, by using leveraging telehealth tools, thus reaching out to the poor and underserved.
The government needs to adopt technology to empower patients and good doctors, rather than waste time passing laws which look great on paper , but never actually achieve anything because they're toothless tigers. Unfortunately, today our whole attitude towards doctors has become so negative , that we refuse to try to help them, and this is such a shame !

Sunday, June 11, 2017

Why is overtreatment of infertility so rampant?


Lots of Indian IVF doctors put their patients on anti-TB medicines . While some of them will do tests to decide which patients to treat with these toxic medicines, others routinely put all their patients on the drugs, irrespective of whether they actually have TB or not.  Thus, in the Ashvini Hospital of the Indian Navy in Mumbai, all infertile patients are put on anti-TB treatment " empirically".

I have often wondered why medical treatments which are completely unproven have become so prevalent. In this case, it's obviously not driven by financial considerations - after all, it's not as if the Navy doctor makes more money by prescribing this treatment !

The truth is that overtreatment is rampant because of a common fallacy which it's very easy for doctors to fall prey to. They suffer from skilled ignorance and unawareness. This is the fallacy of expertise , where they don't know what they don't know

If you give unnecessary treatment to infertile women who don't need it, lots of them are going to get pregnant. The point of course, is they would have got pregnant whether you'd put them on the anti-TB medicines or not, but you have no way of judging that.

Since all human beings are biased , and because doctors don't carry out controlled clinical trials, they naturally start believing that it was the anti-TB treatment which they prescribed which caused the patient to get pregnant. Patients also contribute to this misconception, because when they get pregnant , they go back to the doctor with a box of chocolates. When they don't get pregnant, they drop out. This is  why over-treatment has become so prevalent.

In fact, the same principle applies for many ineffective treatments. Thus, if you do IVF only for patients who actually need it, which is, for example, women with blocked tubes, then your pregnancy rates are going to be average. But on the other hand, if you start doing IVF for everyone who comes to you, whether they need it not, then obviously your IVF pregnancy rates will go through the roof, because then you'll start doing it for young women with unexplained fertility, or for women who are just getting anxious and didn't need IVF in the first place . These are the women who had an excellent chances of getting pregnant on their own even without the IVF.

However, when they do get pregnant, they tell ten of their friends that they got pregnant thanks to the IVF, so that the doctor gets even more patients ! This sets up a positive virtuous cycle, where the doctor ends up doing lots of unnecessary IVF , and achieves a high pregnancy rate because of clever patient selection.

The doctor then starts believing that his IVF pregnancy rates are far better than anyone else , but is actually deluding himself , because he is doing it for lots of patients who didn't actually require it ! However, this ploy means he starts attracting lots of infertile patients from the community , all of whom end up getting overtreated, because they demand the same IVF treatment which helped their friend to have a baby !

This is why IVF has become so overused and misused in some IVF clinics.

Not sure why your doctor is advising IVF ?

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





Wednesday, May 17, 2017

The many hats I wear


For most of my patients, I am just their IVF specialist.

However, I do wear lots of other hats as well - and if you are interested in what I do, you can follow my LinkedIn posts at https://www.linkedin.com/in/aniruddhamalpani/recent-activity/posts/, where I try to share what I am learning with the rest of the world !

Reducing IVF anxiety



Lots of patients are very scared of doing IVF. This is partly because they've heard lots of horror stories about how IVF babies are abnormal, or that the hormones will make them fat, or that if they grow too many eggs, they will either get menopausal sooner, or start getting ovarian cancer as they grow older. And, they've heard lots of horror stories from some of their friends, who've done IVF, about how painful the injections can be, or how many mood swings it causes, or the fact that you need bed rest or that there are lots of complications, or that the risk of miscarriage is higher after IVF.

There are lots of myths and misconceptions, and these obviously add to the patient's anxiety, because of the fear of the unknown, that you end up spending so much time, money and energy, and even after doing all that, not only may you not end up getting a baby, you may actually be worse off because of all the side effects you've put yourself through.

Somehow a lot of IVF seems very artificial and unnatural today, because patients think that you're doing stuff in the laboratory, you're manipulating things, you're doing stuff, which nature wasn't designed to do, as a result of which there are likely to be problems. They often don't trust doctors, and we tell them there won't be problems because most doctors will always try to reassure patients and their concern is that we're not aware of some of these long term side effects, or that we're trying to sell our treatment just because it's more profitable for us.

I think the only way of getting over all this anxiety and fear of unknown, is what I call information therapy. Patients need to read up about IVF from reliable websites so they understand what the truth is, and they can separate the myths, which are so prevalent and they don't get carried away by old wives tales, because otherwise they will end up depriving themselves of the best chance of getting pregnant, and regret this once they get older, and time doesn't come back.

You will find the free resources , which include an e-learning course at www.ivfindia.com very helpful !

You can download our IVF Comic Book free at www.slideshare.net/malpani/ivf-comic-book

Need more information about IVF 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, May 15, 2017

हिन्दी में आईवीएफ जानकारी


भारत में स्मार्ट फोन सस्ता हो गए हैं, और 4 जी व्यापक और सस्ती हो गई है। आधे से अधिक भारतीय आबादी अब ऑनलाइन है, और जब उनमें से ज्यादातर मनोरंजन के लिए स्मार्टफोन का उपयोग, वे भी जानकारी के लिए शिकार के लिए उपयोग शुरू कर दिया है। जबकि आम कारण सस्ते दामों पर और सौदों के लिए देखने के लिए है, उनमें से बहुत कुछ इंटरनेट का उपयोग कर रहे चिकित्सा समस्याओं के बारे में जानकारी खोजने के लिए। 

बांझपन आम चिकित्सा समस्या है जो 25 और 45 की उम्र के बीच लोग बुरा असर है - और इस समूह जो ऑनलाइन अपने समय के सबसे खर्च कर रहा है अब है। वे सख्त बांझपन और आईवीएफ के बारे में जानकारी के लिए देख रहे हैं। 

अच्छी खबर यह है कि हम कम से समझने के लिए हमारी वेबसाइट पर विभिन्न भारतीय क्षेत्रीय भाषाओं में, विश्वसनीय जानकारी आसान के 500 से अधिक पृष्ठों प्रदान करना है www.drmalpani.com , गूगल ट्रांसलेट का शुक्रिया। जबकि अनुवाद की गुणवत्ता अभी भी एक बहुत होना बाकी है, इस बांझ दंपतियों के लिए खुद को हिंदी में सूचना थेरेपी के साथ सशक्त बनाने शुरू करने के लिए के लिए एक महान शुरुआती बिंदु है, तो वे खुद के लिए सबसे अच्छा आईवीएफ क्लिनिक पा सकते हैं!

IVF information in Hindi


Smart phones in India have become cheaper, and 4G has become pervasive and affordable. More than half the Indian population is now online, and while most of them use the smartphone for entertainment, they have also started using it for hunting for information. While the commonest reason is to look for bargains and deals, lot of them are using the internet to find information about medical problems.

Infertility is the commonest medical problem which afflicts people between the ages of 25 and 45 - and this is the group which is spending most of its time online now. They are desperately looking for information on infertility and IVF .

The good news is that we provide over 500 pages of easy to understand, reliable information in various Indian regional languages on our website at www.drmalpani.com,  thanks to Google translate. While the quality of the translation still  leaves a lot to be desired, this is a great starting point for infertile couples to start empowering themselves with Information Therapy in Hindi, so they can find the best IVF clinic for themselves !

Why do IVF doctors abandon their patients?


Most IVF patients are mature enough to realize that the success rate in an IVF cycle is never going to be a 100%. No matter how perfect your embryos are; how good your doctor is; and how easy the transfer is , we still have no control over implantation, and cannot predict which embryos will become  a babies.  Patients come to terms with the risk of failure, because they know that doctors are not gods. 
However, they find that while the doctor can be extremely persuasive and charming when they go for their first consultation  ( because they are in sell mode and want the patient to sign up for the IVF treatment), when their IVF treatment fails, they often feel abandoned . They are desperately seeking answers, but they find no one is willing to provide them. 

When they reach out to the clinic, often the doctor's simply not available . When they try to meet him, they find  it's very difficult to get an appointment . Even when they finally get a chance to talk to him, they find he's very evasive, and refuses to provide any clear answers as to why the IVF cycle failed.  Even though patients understand that we can't always answer all their questions, they want to hear the truth from the doctor's mouth. The trouble is that doctors start equivocating, and come up with all kinds of flimsy answers which patients know are not truthful. 

The doctor who was very optimistic and hopeful at the time of the embryo transfer because he told you that they had created perfect top quality embryos for you, starts singing  a completely different tune when your cycle fails . He now claims that the reason for your failure is that " Your embryos weren't very good because your eggs weren't very good" and "Perhaps we should consider doing donor egg IVF for you, or surrogacy in your next cycle". Sadly, you don't have any photos of your embryos, and this advice comes as a bolt out of the blue . Patients are understandably upset, because the doctor is not being consistent and congruent.

This is why they start losing confidence in the doctor , and feel that they've been cheated .
When an IVF cycle fails, a good doctor realises you are hurting, and will proactively reach out to support you. He will invite you back , so you can analyse the cycle together, and  create a  plan of action for the future, based on what went right, and what needs to be tweaked.

Can't understand what your doctor is saying ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion and I will be happy to help you !


Sunday, April 30, 2017

Surrogacy ? or donor egg ?

I just received this email from a patient

My date of birth : 24/7/73 (43 years old)
My partner date of birth : 11/3/76 (41 years old)
Trying to conceive 4 years, since May 2013
One previous pregnancy in June 2013, first month of trying, ended in early miscarriage at 5.5 weeks.

Started IVF in September 2014 and have had 7 failed cycles to date.  Details below:

Cycle 1: October 2014

Gonal F - 600 units
4 eggs retrieved
1 fertilised with icsi
1 top grade 8 cell embryo (no fragmentation) was transferred on Day 3
No pregnancy

Cycle 2: April 2015

Fostimon - 600 units
Early ovulation before egg collection meant I lost at least 1 mature egg, but they still managed to collect 2 eggs
Both fertilised with IVF (we dropped ICSI on Dr's advice as sperm was good quality)
2 top grade embryos were frozen on Day 2 due to my progesterone levels being too high for fresh transfer as a result of early ovulation

FET Cycle: July 2015
The 2 embryos from the above cycle were transferred, both survived the thaw
No pregnancy

Cycle 3: August 2015

Due to early ovulation last time and poor response to stimulation, we opted for a mild/natural cycle
Fostimon/Merional - varied between 75-300 units daily
2 eggs retrieved, fertilised with IVF
2 top grade embryos transferred on Day 2
No pregnancy

Cycle 4: October 2015

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
1 egg retrieved, fertilised with IVF
1 top grade embryo transferred on Day 2
No pregnancy

Cycle 5: February 2016

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
2 eggs retrieved, fertilised with IVF
Both were frozen on day 2 as I wanted to try another cycle in order to batch together 3 or 4 embryos

Cycle 6: August 2016

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
1 egg retrieved, fertilised with IVF
Top grade embryo, was transferred along with the 2 frozen embryos from the previous cycle (1 of these looked very weak after the thaw, but the other looked good, but they still transferred all 3)
No pregnancy

Cycle 7: December 2016

Fostimon/Merional - 600 units
4 eggs retrieved
1 fertilised normally with IVF
1 top grade embryo transferred on Day 3
No pregnancy

I then embarked on a 3-cycle package with a view to freezing and batching any embryos

Cycle 8 : March 2017

Fostimon/Merional - 450/600 units
4 eggs retrieved
3 fertilised with IVF
2, top quality embryos made it to Day 3 and were frozen 
(SO I now have one 7 and one 9 cell Day 3 embryos in the freezer)

Cycle 9: April 2017

Fostimon/Merional - 600 units
6 eggs retrieved
5 fertilised with IVF
5 made it to Day 3 (4 top quality, one lower as it has 50% + fragmentation) and we have for the first time ever decided to try to take them to Day 5 and see if I can produce any blastocysts.
As of today, these embryos are :  3 x 6 cells and 2 x 8 cells (one of the 8 cells is the one with the fragmentation which she thinks is likely to stop growing, and one of the 6 cells is a little elongated in shape but she said it still looks normal)

This brings you up to date as this last cycle is still active - we will know whether they make it to Day 5 by Tuesday.

Over laying all of the above I have had various immune work as I have ulcerative colitis, an auto immune disease, and so have been tested for NK cells/cytokines.

I have tried : Humira, Prednisolone, Intralipids, LIT treatment and also take clexane and aspirin in addition to the progesterone post transfer.

I hope this gives you a lot more information.  As you can see, we have few eggs/embryos per cycle but a very high fertilisation rate, with high grade embryos, but still none of them have led to a pregnancy. 

I am baffled as to whether this is an egg quality issue (I have been told this is probably the case due to my age - but I have been trying since age 39 and am a very fit and healthy person), or if it is a receptivity issue.  That's what makes it difficult to decide whether it's donor eggs (we are not keen on this) or surrogacy with my own eggs that we should be exploring or keep going with my own eggs/womb...any advice you can give is very much appreciated as we are desperate to have a family.
-------------------------------------------------------------------------------------------------------------------------

This is a very common dilemma many patients face, and they are very confused if they should change the uterus ( surrogacy) or change the eggs ( donor egg)

This was my answer.

 I am worried about your advanced age. This suggests you have diminished ovarian reserve, and this would explain your early miscarriage; as well as your repeated failed IVF cycles. Being fit or healthy does not translate into  having genetically fit eggs . As a woman grows older , her eggs accumulate genetic defects, because she does not produce any new eggs.

You can read more about this at http://www.drmalpani.com/knowledge-center/the-infertile-woman/oopause

Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus, or whose uterus has been irreparably damaged. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem. The soil is passive - it is the seed which is active and is responsible for growth


I agree donor egg IVF is a very hard option to come to terms with, but this would maximise your chances of having a baby

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, 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.

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