Saturday, April 30, 2005

Patient Friendly billing

Patient friendly billing Often the only thing worse than the doctor's medical jargon is the hospital bill. It's much more complex, even more incomprehensible, and far more painful ! This site will help you to analyse the hospital bill and make sense of it, so you can protect yourself from overbilling !

Talking to patients

I enjoy talking to patients - and often learn a lot by doing so. I am an IVF specialist, and it's often quite a challenge to explain some of the treatments to some patients. Often, clever patients will come up with colourful terms and analogies, which I can then use when talking to other patients.
For example, I was talking to a patient who had already used clomid to grow more eggs , but still hadn't conceived. I told her the next step would be to use more powerful use injections for superovulation to help her grow more eggs, and that these were gonadotropin injections. She couldn't pronounce the word, so she said - "Oh, these are super-clomid injections." What a colourful term - and one which every infertile patient can relate to easily !
With another patint, I was discussing the fact that when we superovulate her for IVF, not all the eggs we grow are of good quality, and we need to be prepared for this, she said, " It's like playing oocyte roulette !" - and I added another word to my personal medical dictionary !

Thursday, April 28, 2005

Taking the path of least regret

With the many advances in IVF technology, there are now often many options available to infertile patients. Making a choice can be quite confusing, and they often don't know how to choose. This often leads to paralysis by analysis, and they are not sure what to do next. Do another IVF cycle ? Use donor eggs ? Adopt ? How do they decide ?
In such a situation, I advise my patients - Take the path of least regret. Make a list of all the possible options available, and pretend you are now 10 years in the future. If you then look back, what decision will give you peace of mind that you tried your best ? Select this option, so you have no regrets for the future.

Doctor , what would you do ?

As an IVF specialist, one of the commonest decisions we need to make is how many embryos to transfer. This remains one of the most difficult decisions, and we allow our patients to decide for themselves. Most patients ask me - "Doctor, what would you do ? " and are quite happy to leave the decision upto me - the medical expert.
However, even after 15 years of practise and having over 1500 IVF babies, this remains the most difficult question to answer.
I usually tell patients, "If the technology was perfect, I would not be asking you this question. If you wanted one baby, I would transfer one embryo; and if you wanted twins, I would transfer two. However, the technology is not perfect, and each embryo has about a 10% chance of becoming a baby. It's stil not possible for us to predict which embryo will become a baby, but we do know that the more the embryos we transfer, the better your chances of conceiving. However, as with other areas in life, there is a price you pay for everything. More is not always better, and there is a risk of having high-order multiples such as triplets and quadruplets if you transfer three or more embryos. It's a trade-off, and you need to weigh the risks and benefits before deciding."
A common response to this is - "Yes, doctor, we understand, but what would you do if you were in our place ? Can't you decide for us - we are confused ! You have so much more experience and expertise in this matter ! What do your other patients do ? Can't we do the same ? "
While it's very tempting for me to decide for my patients ( and very flattering to my ego), I try to resist this strongly. After all, it's my patients who have to live with the consequence of this decision for the rest of their lives, not me, which is why I feel they need to decide for themselves.
I remind them, " The very fact I am allowing you to decide means I need your input. I promise I will never let you make a wrong decision - but when there are options, you need to choose for yourself. If you are not sure, take the path of least regret, so you have peace of mind you tried your best. Every patient is different; everyone has a different perspective, which means given the same set of circumstances, 100 different patients may choose 100 different options. What I would do and what others do is all irrelevant - you need to do what's right for you !" Non-directive counselling means trying not to impose your viewpoint on the patient - after all, even doctors have biases, and we should not allow these to sway our patients.
While most patients appreciate why this is so important, others remain unhappy that the doctor is not helping them to decide.
The moral is simple - The buck stops with you. Learn to become well- informed, and to make your own decisions. It's hard to do so, and it's very tempting to abdicate the responsibility to your doctor, but this is not wise. You have made such hard decisions in your life before as well ( "whom should I marry " being an excellent example), so have faith in your abilities to decide for yourself !

Why me ?

I recently saw a patient who was crying like a baby. She had just suffered her third miscarriage, and she felt that her heart was breaking. "Why me, doctor ? I am a good woman - I have not hurt anyone. I am a teacher, I take excellent care of my kids and love them so much. I would love to have a kid of my own, so why is God being so cruel to me ? "
Life is unfair , there is no doubt about that. If anyone deserved to have a baby, she did. She would make a great mother, and we had provided all the medical treatment we possibly could. She had been extremely careful, had stopped working and was religiously taking her medicines and resting in bed, but inspite of our best efforts, we could not save the pregnancy.
"Why me ? " remains one of the commonest questions everyone who is suffering asks, right from the time of Job. It's one of those questions no one can answer, but it's ironic that we only ask this when something goes wrong. Why don't we also remember to thank God for al that he has given us ? A blind Man will curse God for taking away his eyesight - but how many of us remember to thank him for giving us our vision ?
There is little one can do in such times - but going through this suffering can actually help to make us nicer and better people, if we allow ourselves to become more empathetic as a result of this pain.

What went wrong ?

As an IVF specialist, one of the commonest questions I am asked is by patients who do not conceive after their IVF cycle - Why went wrong ? It is very frustrating for both doctor and patient when a young patient does not get pregnant after a "perfect" IVF cycle, but the fact remains that Nature is not very efficient at producing babies; that the pregnancy rate after a perfect IVF cycle in the best of hands is about 50% per cycle; and that why good looking embryos do not become babies is still one of IVF unsolved mysteries ! This often means we really cannot provide a satisfactory answer the majority of times, which adds to the patient's misery. After spending so much time, money and energy, the least they can expect is a straight answer to the query - " What went wrong ? "
This is true for all of medicine. Medicine remains an imperfect science, and no matter how hard the doctor works, outcomes are not always good. It can be hard to come to terms with this, for doctors and patients, but the sooner we understand our limitations, the better for all of us. We can ensure that the treatment process and care is good - but the outcome is still not in our hands.
However, if we do our best, at least we have peace of mind we gave it our best shot - and what else can a human being do ?

Monday, April 25, 2005

When bad things happen to good patients

As a doctor, I try to do my best. I am an IVF specialist, and I would like all my patients to get pregnant in their first treatment cycle. Unfortunately, they don't, and this is a fact of life all IVF specialists have to learn to cope with. I recently had a young patient with unexplained infertility for whom we did an IVF cycle. She was an IVF specialist's dream - young; good ovarian response and excellent sperm. We collected 16 eggs, and confidently assured her that her chances of conceiving were excellent. However, when I did a "fertilisation check" the next day, I found that the sperm had managed to fertilsie only one egg of the 16 ! She had "total fertilisation failure" - an outcome which is every IVF specialist's nightmare because it is so unexpected - and so unpredictable. This meant that she had no embryos to transfer and was heart-broken - all that time, money and energy gone down the drain. While I know that we can get her pregnant the next time around by doing ICSI ( intracytoplasmic sperm injection) , where we inject a single sperm into the egg to make sure it fertilises, it's still hard to cope with the disppointment. I know you cannot count your chickens until they hatch, ( in IVF terms, I guess this means you cannot count your eggs until they become embryos ) , but there really was no reason for her eggs not to fertilise !
At such times, doctors always play the "what if" game. What if I had done ICSI in the first place ? However, this wouldn't have been correct either, because this would mean doing ICSI for all patients, and not doing IVF for anyone because of the risk of total fertilisation failure. In retrospect, on careful scientific analysis, we did to theright thing for her - and she happened to be one of the 5% of patients who fall into the category of " unexpected total fertilisation failure" which has been described in the medical literature - something which I could not influence. This is not the first patient this has happened to - and this will not be the last. I need to get over my grief and move on - and help her to do so as well !

Why I am a doctor

"Birth of a Baby": Being a doctor can be hard work - long hours, lots of stress, never-ending paperwork, and poor outcomes because of biological variables which you cannot control. In fact, many patients wonder why sane, intelligent people choose to become doctors in the first place ! The answer is simple - while the financial income is good, the over-riding reason most doctors choose to remain doctors is the fact that their emotional income is unbeatable ! I am an IVF specialist, and when patients express their gratitude like Rajesh Jain has done, it makes all the hard work and sleepless nights worth it !

Sunday, April 17, 2005

What a brilliant idea !

I recently attended the mourning ceremony of my uncle, who had passed away 14 days ago. The traditional rituals and religious ceremonies were performed to mark his death , and friends and family members came to pay their condolences. I was very impressed that at this time his son had organised a blood donation camp, so that whoever wished to could donate a bottle of blood in his memory ! They collected over 150 units of blood in a few hours - what a great way of paying your respects ! I wish more people would do something like this at social occasions such as weddings and funerals !

Monday, April 11, 2005

From Healer to Coach – A paradigm shift for the 21st century.

From Healer to Coach – A paradigm shift for the 21st century. " Most physicians who have opted for their challenging and interesting professions are motivated by a desire to impact positively the health of their patients. It is time to recognize that the days of traditional medical authority and persuasion are numbered. In order to provide real value to patients and produce improved health behavior outcomes, physicians need to learn and adopt coaching techniques that honor patients' agendas and their motivation to change, and support them through a process that is designed to help them succeed."

Friday, April 08, 2005

How You Can Help the ER Doctor Save Your Life

Chest pain is one of the commonest reasons patients visit the ER. It's been estimated that between 2% and 5% of those cases are misdiagnosed - sometimes with fatal consequences.

Here's what Kevin Helliker, writing in The Wall Street Journal , suggests you can do to make sure this doesn't happen to you:

1. Don't act tough and understate the seriousness of the discomfort you're feeling.

2. Be forthcoming about your personal history - diabetes, hypertension, bad cholesterol, or heart disease in your family. Don't hide anything. If you smoke, admit it. (Medical history is a key component of good diagnostics.)

3. Make sure you tell both the triage nurse and the doctor everything. If one misses an important detail about your condition, the other might pick it up.

4. Ask for an ECG (electrocardiogram) if you are concerned - but recognize that this test only picks up on about half of all heart attacks. So don't let anyone in the emergency room tell you that if your ECG is good, your heart is good.

5. Make sure your doctor reads the ECG itself and not a computerized analysis of it. The computerized reports are even less accurate than the actual ECGs.

6. If you've had a previous ECG, let your doctor know and ask him to compare the two. This makes a correct diagnosis much more likely.

7. Sometimes, a doctor may give you a gastrointestinal "cocktail" if he thinks your chest pain is related to a digestion problem. But just because the pain abates after taking the cocktail doesn't mean you didn't have a heart attack.

8. Even if symptoms disappear, consider a follow-up with your doctor.

Thursday, April 07, 2005

Help improve doctor-patient relationships - a guide for doctors

Help improve doctor-patient relationships - a guide for doctors : "Patients want a doctor who:
* Shows warmth and concern.
* Gives them enough time to say what they want to say.
* Demonstrates that he or she understands what the patient has said.
* Speaks simply to them.
* Tells them what is wrong and what to do in an unhurried manner."

You might want to print out this article and share this with your doctor - it may help him improve his bedside manner !

Waiting at the doctor's clinic

The one thing patients hate universally is waiting at the doctor's clinic. Often these waits seem interminable - and to add insult to injury, they are considered to be "routine" - and no one even bothers to apologise for making you wait ! Making you wait makes a lot of sense from the doctor's point of view. The more the patients he sees, the more the money he makes. Also, many doctors take pride in having a full-house of patients. This flatters their ego - and is also an excellent marketing tool, because patients feel reassured that such a busy doctor must be good ! However, why do patients put up with this waiting ? After all, you are paying good money to see the doctor, and your time is valuable too ! I think the only reason doctors make patients wait is that they can get away with it. If patients started walking out if they were made to wait excessively, doctors would improve their efficiency dramatically ! I know one patient who actually sent the doctor a bill for the time he was made to wait in the office without an explanation or apology. Till then, the best you can do is carry a paperback to pass the time...

Saturday, April 02, 2005

The Insurance Industry and how they misuse medical tests

A patient of mine recently decided to go in for a life insurance policy. Because this was a large value policy, the insurance company wanted her to go in for various tests, including an exercise stress test. The rationale for this testing is to allow them to identify clients who are at increased risk for dying, so that they can distribute the risk, and increase the premium they charge these clients. She was a healthy 42 year old woman; and her stress test had some ST segment depression in the inferior leads. The doctor who did the stress test then chose to report this as a "mildly positive" stress test. Based on this report, the company then refused to issue her a policy ! Unfortunately, as with most companies which are bureaucratic and autocratic, trying to explain to them that the medical literature proves that ST segment changes during exercise in women do not reflect an increased risk of dying , was like banging your head against a brick wall. They just refused to listen ! The solutions they offered in order to allow the client to prove that she had a clean bill of health were mind-boggling. The client could do a thallium stress test or a CT angio to prove that she did not have coronary artery disease ! They told her of another client who had even gone ahead and done a coronary angio to prove his arteries were healthy, in order to qualify for the policy ! This is a travesty of all medical testing, and I feel doctors should put their foot down, and prevent insurance companies from misusing medical technology.
An excellent article offers much better alternatives.
"The biggest problems posed by our continuing “love affair” with stress testing relate to the enormous delays and tremendous expense we must bear to indulge these misallocated “affections!”

Will insurance companies wake up and listen ?

Patient Advocacy

The Center for Patient Partnerships - Patient Advocacy:The Center provides advocacy services, at no charge, to patients with serious life-threatening or chronic illnesses, their family members, friends, health care or other professionals. there are no geographic limits to our service area - - we have served patients from Texas to Thailand and Portage to Portugal!

Patient Experiences of health and illness

Patient Experiences of health and illness: " Being told you have an illness can be confusing and frightening and finding reliable information can be frustrating. DIPEx shows you a wide variety of personal experiences of health and illness. You can watch, listen to or read their interviews, find reliable information on treatment choices and where to find support. "

Helping doctors to enhance patient participation

Doc.com An excellent teaching module for doctors, showing them how to " enhance patient participation in the clinical encounter by facilitating the development of a mutually agreed upon agenda that includes both the patient’s and the doctor's priorities." If you are willing to overlook the medical gobbledygook, this is an excellent presentation for doctors on how to talk to their patients. Patients can learn from it as well !

"Doc, tell me what I need to know"--a doctor's perspective

"Doc, tell me what I need to know"--a doctor's perspective " The amount and complexity of information must be tailored to the perceived needs of a patient. Access to further information should be facilitated, and patients helped in interpreting the data."

Patients as experts

Patients as experts : Informed and shared decision-making: the crux of patient-centred care : A thought-provoking article by a doctor. "Often, our approach to involving the patient, although well-intentioned, is flawed by a failure to accept the patient as an equal partner. A consultation should be seen as a meeting between experts, that is, physicians are experts in disease and patients are experts in their own experience of disease and in their preferences."

Parents' Common Sense Encylopedia

Parents' Common Sense Encylopedia: Every once in a while I come across a gem of a website. "The purpose of this project is to give short, easily understood answers to common questions that come up in my everyday pediatric practise".

Healthcare consumerism - more power to the patient !

Healthcare Consumerism A marketing newsleter for doctors, telling them how to benefit from the emerging trend of healthcare consumerism. It’s based on the idea that patients themselves make their own healthcare choices based on cost and quality, rather than simply accepting the care provided through a traditional healthcare plan.
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