Thursday, September 29, 2016

Breaking the pharma doctor nexus by following the money

It's an open fact that many pharmaceutical companies spend a lot of money in bribing doctors to prescribe their particular brands. They have got a good return on their investment so far , because these gifts have been proven to influence the doctor's prescription behaviour ( even though many doctors continue to delude themselves that they are immune to these blandishments).

This nexus is harmful , because it increases medical costs. Doctors are tempted ( and many are blissfully unaware of the subtle influences which play on their unconscious mind ) prescribe needlessly expensive brands, and to over-prescribe.

There are three ways of solving this problem.

One is to get the medical councils involved , and to punish doctors who have taken bribes from pharmaceutical companies. This can serve as a powerful deterrent, but is a time-consuming and expensive process, because you have to go after a single doctor , one at a time.

The second option is to rely on pharma companies to regulate themselves. They have promised to mend their ways for many years, and the government has given them the liberty to do so. Unfortunately, voluntary regulation doesn't work well when some of the players refuses to abide by the guidelines laid down by the pharmaceutical association.  Game theory explains that even if one company defects, then  the other companies will also follow suit , because they feel that they are at an unfair disadvantage. This quickly becomes a race to the bottom, and they all end up breaking their own rules . Even worse, their behaviour becomes completely hypocritical. They pretend to abide by their rules, and higher management takes the moral high ground by turning a blind eye to what their field staff is doing at the ground level. After all, what you don't know can't hurt you !

Let's look at a more effective alternative.

The only reason pharma companies continue to bribe doctors is because they get a tangible financial return on their investment. They know that if they gift the doctor a foreign trip, the doctor is much more likely to prescribe their brand , because of the simple principle of reciprocity.  Sadly, doctors continue to justify these free jaunts by claiming that they go to medical  conferences only in order to educate themselves - and how does it hurt anyone if the conference happens to be in Paris ? They believe that they are upright medical professionals who prescribe a particular brand only because it's the best one. They continue to delude themselves that they are immune to the special treatment which is showered on them by the pharma companies. However, this is just a rationalization which doctors use to justify their behaviour. The truth is that all these favors given by pharmaceutical companies to doctors does change their behavior, and often in ways which are not in the patient's best interests.

This is why the most effective way of breaking the nexus is to make sure that pharma companies no longer get a good financial return on bribing doctors. Once this stops, then they will automatically stop wining and dining doctors, because it will no longer make business sense for them to do so .

Where does the money to bribe the doctors come from ? These expenses are disguised as marketing costs on the income statements of the pharma companies.  They are cleverly camouflaged  as payments to third parties who serve as conduits. The job of these marketing companies is to curry favor with the doctor by giving him whatever he demands.  Since these are business expenses, they are deducted from their total revenue,  which means that the government is subsidizing the bribes which the pharma companies are giving to the doctors. 

The IT  Dept has finally woken up , and is no longer going to allow companies to claim these as these business expenses, no matter how cleverly they're disguised. This has already happened in the case of Liva Healthcare, a small pharmaceutical company in Mumbai.  Pharma companies will realize that spending this money on doctors is going to turn out to be very expensive for them , because once the IT officer goes after them, not only will these expenses be disallowed, they will have to end up paying a hefty penalty as well . It wouldn't be very hard for a diligent officer to follow the paper trail from the company to the doctor , because these payments are done by cheque  - all they need to do is to follow the money to its source !

Once pharma management understands this, they will automatically stop engaging in this behaviour. 

The senior management of most pharma companies consist of ethical people , and they will be happy when they are no longer forced to pay off doctors just because their competitors are doing so. They will then be able to focus on ethically marketing their medicines. I am sure none of them likes paying money under the table - this is a dirty game, and the sooner we stop playing it, the better for everyone. 

This is a win-win situation for everyone. The company will be able to devote its income on research and development and ethical promotion, because it won't be wasted on bribing doctors; the government will earn more revenue ; doctors will no longer be tempted to prescribe drugs for the wrong reasons; and patients they will then have access to affordable drugs .

This is the option which the US government has adopted . They use a stick to make sure everyone plays by the rules , and have enforced these by passing a law ( the US Sunshine Act) and aggressively punishing  pharma companies who flout this.  It's time for the Indian government to follow suit !

Thursday, September 22, 2016

Non medical options for infertile patients

Whenever I counsel patients , I explain all their  possible options to them. I also include their non-medical choices, and emphasize that adoption and child free living are perfectly acceptable alternatives, which they should not reject out of hand.

I always discuss these before I move on to explain their medical treatment options.

Sometimes patients get very upset when I do this. They believe that the fact I have started by discussing the worst case scenarios , means their chances of success are very poor. Some even accuse me of being negative and pessimistic , and feel that I am preparing them for failure.

This is not true.

The reason I discuss non-medical options is to emphasize the fact that they are in control of their life - that they have a choice.  After all, medical treatment for infertility is optional, and that if they choose to come to me for treatment , they should come with a smile, because they hope to get something from here.

Non-medical alternatives should be seen as empowering, because they allow the patient to pick and choose. They should not feel that they are forced into doing IVF - and they should not think of themselves as being helpless and powerless either !

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

Wednesday, September 21, 2016

Hallmarks of a bad IVF clinic

A patient just sent me this email
Now in September, I underwent IVF with donor eggs (frozen). Out of 7 donor eggs that were thawed, we got 2 embryos and 1 blastocyst (all A grade 8 cell embryos) which were transferred on day 3 and day 5 respectively. My endometrial lining was optimum when the transfer happened. My husband's sperm motility has always been very good according to the IUI and IVF doctors. However, bHCG is again negative and implantation did not occur. I have done HSG and Hysteroscopy tests prior to the IVF and everything were found to be normal. When we asked for ways to better our chances next time, my husband has been suggested the sperm DNA fragmentation and blood karyotyping tests while I have been suggested to undertake endometrium TB tests. We wanted to seek your opinion on undergoing these tests and your advice on other options to better our chances during the next IVF. Please feel free to ask further questions if any. Thanks in advance for your time and advice.

This patient is getting very poor medical care, and there are a number of red flags which suggest this.

1. Only 7 donor eggs were used. Good clinics will use at least 10 mature metaphase 2 donor eggs to maximise chances of a pregnancy

2. Her doctor did a sequential ( Day 3 plus Day 5) transfer. This suggests that the clinic did not have any confidence in the ability of their lab to consistently grow embryos to Day 5. Good clinics do only Day 5 transfer

3. When the cycle failed, they asked her to do a battery of tests. These are all useless, expensive tests which confirm that the doctor has no clue what he is doing. He is just mindlessly subjecting the poor patient to a lot of expensive and wasteful tests, which will not change her treatment options at all.  He is shooting in the dark, in the hope that he'll hit something.  The biggest danger is that one of the test results will come back as abnormal - and then the patient will be subjected to even more useless treatment, and will end up wasting even more time and money !

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

Tuesday, September 20, 2016

Do you trust your doctor ?

The heart of clinical medicine is the doctor-patient relationship. When we are ill, we want someone we can look up to - someone whom we can trust. We want a doctor who understands our problems - not just the medical disease we have, but someone who has insights into our personal fears  and worries as a human being as well. Being ill can be a lonely journey, and we want someone  to hold our hand and help us to get better. We need to be able to trust that our personal physician has our best interests at heart - that he will look after us, and will do whatever is needed in order to help us get better.

In the past, trust in the doctor was something which was taken for granted.

Doctors were respected professionals, and it was understood that a doctor could do whatever was needed in order to help you get better. The standard image of the family doctor was a hardworking professional who would get up at 2 am, or who would spend all night holding the patient's hand , in order to  keep a close eye on him to make sure he was getting better. People still have fond memories of what the doctor used to be like. Unfortunately, the only place we can see this kind of doctor today seems to be  in old movies.

Today, very few patients respect their doctor, and as far as the medical profession goes, it clearly doesn't command any respect at all.

We've lost faith in our doctors, and there are many reasons for this. It's true that some doctors are to blame, but the tragedy seems to be that whenever one doctor does something wrong, we extrapolate, from this aberration, and conclude that all doctors are crooked. This is the harm which the media does to the entire medical profession when it highlights the few black sheep in the profession. Sadly, good doctors also end up being tarred with the same brush.

The media loves to bash doctors. This is because we put so much faith in them, that when this trust is betrayed, we are angry and we want to punish these doctors with a vengeance.  This is quite ironic because we never seem to have that same degree of anger against crooked lawyers, or crooked engineers, for example.

Thus, the media will write about crooked bank managers, but this is not something which raises as many  hackles, or causes as much ire. Why is there so much disproportionate unhappiness with doctors?  After all, they are human too - why should we expect them to behave like angels ?

This is because the heart of healthcare is the patient's personal relationship with the doctor. When a doctor takes advantage of that relationship, he betrays the trust which the patient places in him, and we want to punish him for this . In our heads and hearts, medicine is thought to be a noble profession. When we find that we can't trust doctors anymore, it shakes our faith and belief in all of humanity, not just the medical profession. After all, if you can't trust your doctor, whom can you trust?

The good news is that there are lots of trust worthy doctors - but you do need to spend some time and energy in order to find them. Look for a doctor who respects you, and whom you respect. This is a two way relationship, and you need to find someone who is open and transparent, and is willing to share information with you -  a doctor who has both a head and a heart. A good doctor does not try to cover up when he does not know what's happening, and will share both medical knowledge as well as medical ignorance with you. He  will not abandon you, no matter how serious your illness, and even if he cannot cure or treat you, he will be there to hold your hand.

Monday, September 19, 2016

I'll be talking about Startup Failures at the Vibrant Gujarat Startup Summit

The Vibrant Gujarat Startup Summit will be held in Ahmedabad  on 21 Oct 2016

Am looking forward to this - lots of  great topics !

The website is

Saturday, September 17, 2016

Please don't mess with your doctor's mind

Doctors do their best in order to take good care of their patients because they want their patients to get well. It's in his best interests to do so, because a happy patient will refer lots of others to the doctor, and thus help his practice to grow.

However , in this day and age , unfortunately the trust which patients used to have in their doctor has taken a big beating . This is why patients spend a lot of time on Dr Google , trying to get his second opinions. Now while I am a big believer in the Information Therapy which Dr Google provides, patients need to understand that this is a double edged sword , and they need to be sophisticated users to benefit from this.

One of the worst things you can do to a doctor is to keep on challenging his authority or questioning his advice . He feels disrespected , and he's not going to take as good care of you as he would have if he had felt that you trusted and respected him. The doctor patient relationship is a delicate one and you need to nurture it.

Now this doesn't mean you that you leave your brains at home and do everything your doctor tells you to, just because he is the medical expert. However, you do need to respect the fact that he's a trained professional.

The problem is that trust is intangible. It's not something which you should give away easily , and therefore it's quite reasonable to expect your doctor to work in order to earn your trust. But once he's done that , then you shouldn't keep on playing doctor yourself . You should allow him the autonomy to help you to make the right decisions . This becomes a positive virtuous cycle.

If the doctor senses that you trust him, he respects you as well , and will go out of his way to make sure that you get the best care possible . This is why it's best to follow the middle  path - after you've verified your doctor's advice, let him be the captain of the ship. This means that you should let him know that you accept him as  being the leader of the medical team , but that you are still an important part of the team . He will also reciprocate , and this will help the two of you to craft a win win partnership where everyone benefits.

Thursday, September 15, 2016

Why PGS does not work as advertised - the difference between genes and chromosomes

Lots of patients know that the commonest cause for IVF failure is a failure of the embryo to implant. We also know that the commonest reason for implantation failure is a genetic defect in the embryo. This is why it seems very tempting to do pre-implantation genetic screening ( PGS) for all IVF patients, so that you can select the genetically normal embryos . This should increase the chances of implantation and reduce IVF failure. After all, what's the point of transferring a genetically abnormal embryo back into the uterus ? It will just fail to implant, or even worse , end up in a miscarriage.

This makes logical sense, but unfortunately , in real life , biology is far more complicated. I think we need to remember that when we're doing PGS , we're really not doing genetic screening; we're really just doing chromosomal screening, so that a better name really would have been pre-implantation chromosome screening or PCS.

Why is this important ? All these tests ( for example, CCS and NGS) only allow us to make sure that the cell has a normal number of chromosomes. This means we can make sure it is euploid, so that we can screen out which embryos are aneuploid ( they have an abnormal number of chromosomes) .  Aneuploidy is an important cause for failure of implantation as well as miscarriages, but we also need to remember that counting the number of chromosomes is not enough if we want to identify genetically normal embryos. After all, there are over 30,000 genes , and there are only 23 pairs of chromosomes. This means that even though an embryo may appear to be normal on a PGS, this does not mean that it is genetically normal. Thus, a lot of PGS normal embryos will have a normal chromosomal complement, but they will still have lethal genetic defects will which prevent them from implanting.

Unfortunately , most patients don't understand this difference. When they end up spending a lot of money in order to transfer a PGS-normal embryo , and then still end up with a failed IVF cycle or with a miscarriage, they're obviously very bitter and angry and feel they've been misled. This can create a lot of dissatisfaction.

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


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