Thursday, March 30, 2006

Surrogacy in India

Surrogacy has always attracted a disproportionate amount of media attention, because the idea excites the public imagination. India seems to be in the news since it offers "wombs on hire" . Apparently, many infertile couples seem to be coming to India to have surrogacy treatment, because it's so much cheaper here than in the West. Some activists see red, because they feel this is a form of "reproductive prostitution" - they believe women are being marginalised and reprodution is being treated as a commodity , because money is changing hands.
While I feel surrogacy is a legitimate form of treatment, my major concern that there is no legal protection for the parents in India. The only legal recognition of the child's parentage today is the birth certificate - and it's only the birth mother's name which can appear on this. Today, genetic parentage is not recognised. What this means is that if the birth mother decides not to hand over the baby after birth, there is nothing the infertile couple ( intending parents) or the doctor can do, no matter what legal papers they may have signed, since these have no legal bearing - the contract is just not valid !
Normally, the infertile couple plans to adopt the baby after birth , so they can claim it legally. However, adoption in India is a long and complex procedure - and there is no mechanism for a "directed adoption", which means there is no way the parents can claim the child legally. This means that either they do a "black-market adoption"; or the doctor puts a false name ( not the birth mother's, but the surrogate's) on the birth certificate !
In order to correct this anomaly, the government is now planning to pass a law to regulate this. What worries me is that the law has many loopholes in it. The most worrisome is that effective a "legal blackmarket adoption" channel has now been opened up ! An unscrupulous doctor could handover an unwanted new born baby ( from an unmarried mother, for example) to a rich infertile couple, and claim that it was actually genetically theirs because they had undertaken surrogacy treatment ! Not only would this allow couples to bypass the regular legal adoption channels, it would create an avenue for some crooked doctors to make a lot of quick bucks !
Why isn't anyone else worried ?

Evaluating the Long-Term Impact of Patient Education

Evaluating the Long-Term Impact of Patient Education: "Health care costs have been shown to be reduced by education interventions that decrease the patient’s demands on the health care system. Two of the most frequently cited benefits of work-site health-promotion programs are reduced absenteeism and lost workdays. According to some estimates, approximately 80 percent of all health problems could be treated at home. Effective education programs can prevent minor illness or injury from progressing to the point of needing professional intervention. Increased patient awareness through education can also result in earlier detection of problems and more timely outpatient intervention, thus decreasing hospitalizations. Lastly, chronic-disease patients who have been empowered through patient education programs generally have better coping skills and are usually less reliant on health caregivers."
It makes business sense to spend on patient education ! We'll need to spend less on doctors !

Patient Knowledge Couplers

Patient Knowledge Couplers: "What do COUPLERS do? They match patient information…
Each Coupler leads users through a series of questions about themselves, their health, and their medical history. The questions collect relevant information about specific medical conditions.
…with an extensive medical database…
PKC’s staff of 25 full-time medical researchers combs through the latest medical literature to write Coupler questions and connect them to up-to-date medical information. That’s why Couplers are able to produce timely, personalized guidance.
…to provide guidance tailored to individuals.
Couplers do not simply spit out generic medical encyclopedia articles. They match patient information with the latest medical information to produce patient-specific advice, including potential causes, treatments, and management strategies.
Couplers are about you, not the “average patient.”"
Clever use of medical technology, to empower patients with the information they need ! You don't need to be so passively dependent on your doctor anymore. These clever tools will allow patients to take back control of their own healthcare decisions !

Curing Healthcare

Curing Healthcare: "Hello and welcome to my blog -- 'Curing Healthcare.' In 1981, while a practicing psychologist, I began developing a healthcare information system to help me deliver the best possible care by better understanding my patients' problems, determine the best courses of action, evaluate outcomes (the results/consequences of such actions), and continually learn from experience."
Dr Steve Beller has a very interesting blog - and he Puts Patients First !

NHS Blog Doctor: BMA News magazine article

NHS Blog Doctor: BMA News magazine article: "The internet is a truly international phenomenon and while medical blogs are dominated by doctors practising in the US, there are contributors across the world. Aniruddha Malpani is a consultant IVF specialist in Mumbai, India, who says his blog (www.doctorandpatient.blogspot.com) fulfils his need to communicate. ‘It breaks my heart when I see patients receive poor medical care,’ he says. ‘I feel the reason for this is because they do not take a proactive role in their treatment. I hope my blog will inspire and motivate them to do so.’"
Thanks !

Doctors as Bloggers

Doctors as Bloggers" The doctor is logged in.
What do physicians really think? A new wave of blogs gives the rest of us a glimpse into their
world."

10 Things To Know About Evaluating Medical Resources on the Web

10 Things To Know About Evaluating Medical Resources on the Web: "On this page

1. Who runs this site?
2. Who pays for the site?
3. What is the purpose of the site?
4. Where does the information come from?
5. What is the basis of the information?
6. How is the information selected?
7. How current is the information?
8. How does the site choose links to other sites?
9. What information about you does the site collect, and why?
10. How does the site manage interactions with visitors?"

Take Control of Your Period, The Well-Timed Period

Take Control of Your Period, The Well-Timed Period: "Take Control of Your Period was written to help women make an informed decision about managing their menstrual period. Reading it will let you in on the “best kept secret” about your period—you can choose whether and when to menstruate. Some women may prefer to have a period each month, but many others have lifestyles and health issues that favor having fewer periods each year."
Here's an excellent example of helping women to self-manage their bodies. Most women are still surprisingly clueless about their menstrual cycles, and this book educates them so that they can control their cycles to suit their desires.

Wednesday, March 29, 2006

World Health Day 2006: Working together for health

WHO | World Health Day 2006: Working together for health: " Health workers - the people who provide health care to those who need it - are the heart of health systems. But around the world, the health workforce is in crisis - a crisis to which no country is entirely immune. The results are evident: clinics with no health workers, hospitals that cannot recruit or keep key staff."
I am glad that the WHO is using the World Health Day to focus on the important role played by health workers in delivering healthcare services. However, I was very disappointed that they have not realised the important role played by patients in delivering healthcare services ! Patients are the largest untapped healthcare resource - and if we can empower them with information, we can dramatically change the face of healthcare services.
One of the reasons the healthcare industry is sick is that it is still very doctor ( or healthcare worker)-centric. This is a tragedy. This is a service industry, which should revolve around the patient, so that he can take better care of himself, and does not need to depend upon "healthcare workers" to take care of every minor ache and pain he gets. Unfortunately, we have medicalised health to such a large extent, that not only are most patients incapable of taking care of themselves, most doctors can no longer even recognise a healthy individual, because they are so used to dealing with ill patients all the time !
I do hope the next World Health Day will be about Putting Patients First !

Monday, March 27, 2006

Dangerous drugs which have still not been banned in India !

Someone emailed me this disconcertingly large list of dangerous drugs , which are banned in the US, but are still available in India Don't use them !

*****ANALGIN:***

This is a pain-killer.* Reason for ban:* Bone marrow
depression.
***Brand name:* Novalgin

___________________________________________________________
*****CISAPRIDE:***
Acidity, constipation.* Reason for ban:* irregular
heartbeat
***Brand name:* Ciza, Syspride
____________________________________________________________
*****DROPERIDOL:***
Anti-depressant.* Reason for ban:* Irregular
heartbeat.
***Brand name: Droperol*
______________________________________________________________
*****FURAZOLIDONE:***
Antidiarrhoeal.* Reason for ban:* Cancer.
***Brand name:* Furoxone, Lomofen
_____________________________________________________________
*****NIMESULIDE:***
Painkiller, fever.* Reason for ban:* Liver failure.
***Brand name:* Nise, Nimulid
_______________________________________________________________________
*****NITROFURAZONE:***
Antibacterial cream.* Reason for ban:* Cancer.
***Brand name :* Furacin
____________________________________________________________

*****PHENOLPHTHALEIN:***
Laxative.* Reason for ban:* Cancer.
***Brand name:* Agarol
_______________________________________________________________________
*****PHENYLPROPANOLAMINE:***
cold and cough.* Reason for ban:* stroke.
***Brand name:* D'cold, Vicks Action-500
_______________________________________________________________________
*****OXYPHENBUTAZONE:***
Non-steroidal anti-inflammatory drug. * Reason for
ban:* Bone marrow
depression.
***Brand name:* Sioril
_______________________________________________________________________
*****PIPERAZINE:***
Anti-worms.* Reason for ban:* Nerve damage.
***Brand name:* Piperazine
_______________________________________________________________________
*****QUINIODOCHLOR:***
Anti-diarrhoeal.* Reason for ban:* Damage to sight

Thursday, March 23, 2006

The Quality Information Checklist for Health Websites

The Quality Information Checklist: "Here are eight ways of checking information on web sites."
Very useful when you need to check the quality of a health website. I love the way they have presented complex information so cleverly and simply !

Wednesday, March 22, 2006

What the ex-Chief Justice of India feels about the PNDT Act

I just read an eye-opening interview with the ex-Chief Justice of India, Justice Lahoti, in the Times of India ( 21 March, 2006, ‘A judgment can’t be a solution to all the problems’.

" In October 2004, a Supreme Court bench headed by Justice R C Lahoti upheld a Haryana government law prohibiting a person from contesting panchayat elections in the state if he/she had more than two children. There is now rethink about the effectiveness of the legislation.

Do you regret the judgment upholding the two-child norm?
No. It was in national interest.
But your own state of Madhya Pradesh is planning to reverse the two-child norm.
There are political considerations. Population control is needed in national interest.
But studies show that the two-child norm has led to an increase in female foeticide.
Activists have a one-track mind. I feel that anomalies in law can be corrected with amendments. Give tax benefits to fathers who have girl children. And if there is female foeticide, then amend the law so that only the male child is counted when enforcing the two-child norm. Don’t count the girls.
While female foeticide is on the rise, the PNDT Act has been flouted in all states and no one is being prosecuted.
What is this Act?
The law to stop sex determination in ultrasound clinics. It has come from the same apex court which upheld the two-child norm.
Solution in this case does not lie in enforcing the law but in educating the people. The PNDT Act is a shortterm solution. Ten years after the Act, there has been no further thinking on it. Can a law end crime? We need other solutions as well."

Hmm - interesting ! The TOI feels that the law which recommended a two-child norm needs to be reversed for two reasons . Because:
1. it is not effective;
and
2. it is coercive.

I agree with Justice Lahoti ! As he puts it - " The solution in this case does not lie in enforcing the law but in educating the people." Well-said ! Instead of wasting precious resources in trying to convict hapless doctors and painting them as villains , these could be much better utilised in promoting gender equality and offering better opportunities to girls, so that there is no longer any economic benefit to having a boy in India !

When patients are negligent

I just saw a memorable patient. The couple had been trying to conceive for over 7 years, and she was now 35. She had missed her period and had had a positive home urine pregnancy test. She wanted to confirm her pregnancy was healthy, which is why she came to me. Her blood test for beta HCG showed a level of 2000 mIU/ml, confirming she was pregnant, but I could not see a pregnancy sac inside the uterine cavity on vaginal ultrasound scanning. This meant she had an ectopic pregnancy, a condition in which the pregnancy lodges in the fallopian tube, instead of the uterus. This can be a life-threatening problem if the pregnancy is allowed to grow inside the tube, as it can rupture, and cause massive internal bleeding. I congratulated myself on making the diagnosis so early, and told her that we needed to kill the pregnancy; and that we could do it safely and easily with an injection of methotrexate, an anti-cancer drug which kills the rapidly dividing cells of the embryo, so that it gets reabsorbed by the body, without having to do any surgery. I thought they would be pleased that I had such an effective and simple solution to what could become a major problem - and which used to be one of the biggest killers of young women in the past. Much to my surprise, her husband flatly refused to believe me ! " But her home urine pregnancy test is positive, and I am sure she will have a baby !" was his refrain. He wanted a baby so badly that he was in denial mode - the last thing she wanted to hear was bad news. I suggested that they get a second opinion, and that she seek urgent medical attention before things got out of hand.
She left the clinic, and never followed up. I was very worried about her, since she was a "walking time bomb", and called her up 2 days later to find out what she had decided to do, but her husband was unwilling to take my call !
I learnt later from a colleague that her husband adamantly refused to take her to another doctor. 3 weeks later she had severe abdominal pain because of a ruptured ectopic pregnancy , and finally ended up having emergency surgery to save her life.
Everyone makes such a hue and cry when doctors are negligent. What happens when patients are negligent ? Who is responsible then ?

Saturday, March 18, 2006

The Patient's Journey

The Patient's Journey : "Referring to the patient's journey is a very appropriate start. Travellers have always needed help. How far must I travel? What route must I take? Are there signposts along the way? Is there a map, or must I find my way from landmark to landmark? Is there someone to act as a guide, or must I act as pilot and navigator, and who is in charge? Will it hurt if I 'bump' into something on this journey? What happens upon arrival - will I be a complete stranger in a strange land? Brian Hodges created h2cm to help with these questions. h2cm can act as a guide or prompt, not just for you to use, but for all who care for you. Rather than this being another thing that is done for you, or to you, the health carer model can be used by you alone. h2cm can help ideally when used together with your healthcare professional, or advocate should you have one."

Friday, March 17, 2006

Grand Unification Theory of Health Care

" Whenever you bring up the subject of health care today, whether to doctors or to patients, you immediately get an earful. You'll hear about the greedy, heartless HMOs; the growing difficulty in getting health insurance (whether you’re employed or not); the distracted, money-grubbing doctors; and the overly demanding and increasingly litigious patients.

Yet, despite this litany of grievances, you will find it strangely difficult to put your finger on what, exactly, the real problem is. For underlying these more concrete complaints you will perceive something else – the stirrings, expressed in vaguely wistful tones, of a more fundamental problem. And if you listen carefully, what you’ll hear is the expression of a deep, if poorly defined, sense of loss.

The sense of loss is genuine. Because something is being lost, and it’s something important, something vital, something necessary to the integrity of any health care system. It’s far more than just a patient’s freedom to choose his own physician, or to see a specialist when he wants to. And it’s far more than just a doctor’s freedom to practice medicine as she sees fit.

What we’re losing, we doctors and patients, is the sanctity of our relationship with one another.

Wait - don't go.

I promise I'm not going to get all warm and fuzzy about the importance of relationships. For, while the relationship between patients and their doctors can be warm and fuzzy, it usually isn’t, doesn’t need to be, and is often stronger if it’s not. It’s not a relationship based on feelings of affection, like those between friends or lovers. Instead, it’s a relationship more like that between allies fighting a war. It’s a relationship based on mutual dependence and trust – on mutual survival, in fact. We, doctors and patients, allow this relationship to weaken only at our own peril.

And that, it turns out, is the heart of the problem. The traditional doctor-patient relationship, so vitally important to all of us, is being systematically and methodically destroyed.

When you understand why and how this is so, then all the pieces of the health care puzzle instantly fall into place. Previously inexplicable events become not only logical, but predictable. And potential solutions to our health care crisis, both long term and short term, immediately begin to materialize.

This synthesis is laid out in what I humbly call the Grand Unification Theory of Health Care - the theory that explains everything.

The Grand Unification Theory rests on a simple, 5-step chain of logic:

1.The rationing of health care is an economic imperative, and cannot be avoided.
2.Since the very notion of rationing health care is taboo on our society, the necessary rationing must be done, and is being done, covertly - that is, without acknowledging that any rationing is occurring.
3.Covert rationing fundamentally works by applying coercive pressure to the focal point of all health care spending, namely, the physician-patient encounter. Thus, the final common pathway for all covert rationing must be - can only be - destruction of the doctor-patient relationship.
4.Loss of the doctor-patient relationship is fatal to the medical profession, life-threatening to patients, and debilitating to society.
5.The key to defeating covert rationing, and all the evils that flow from it, is to restore the doctor-patient relationship. "

Very well presented - please read this book. It's been written by an ex-doctor - and is full of wisdome !

Thursday, March 16, 2006

CREDIBLE Criteria - Patient Decision Aids - Ottawa Health Research Institute

CREDIBLE Criteria - Patient Decision Aids : "CREDIBLE Criteria
What is the Purpose of the C.R.E.D.I.B.L.E. Criteria? The CREDIBLE Criteria were developed as part of the Cochrane Systematic Review of Patient Decision Aids. They provide a summary of some key indicators that provide confidence in the credibility of decision aid content."
What are the Criteria?

C - Competently developed:
* Are the essential components that promote quality decision-making included?
* Are the credentials of developers included in the decision aid or supporting materials?
* Is the development process adequate? A complete development process includes a needs assessment and review by a panel of experts and a panel of potential users.

R - Recently updated:
* Does the developer have an update policy or evidence review process that is continuous or at least every two years?

E - Evidence-based:
* Is there a link to an evidence review group or is the process that was used to identify and appraise evidence described?
* Are references to scientific studies or systematic overviews used to support statements describing benefits/harms?

DI - Disclosure of conflicts of Interest:
* Is there disclosure of sponsorship and conflict of interest?

BL - BaLanced presentation of options, benefits, and harms:
* Is there a balanced presentation of potential harms and benefits?
* Do the majority of users find it balanced?

E - decision aid is Efficacious at improving decision making:
* Do evaluations show that the decision aid improves knowledge?
* Do evaluations show that the decision aid is acceptable to users?
* Do evaluations show other benefits?
* Do evaluations show that it was free from adverse effects?
* Do evaluations include a randomized controlled trial?

This is an excellent format to use when you need to judge the reliability of a medical study or website !

Ottawa Personal Decision Guide - Patient Decision Aids -

Ottawa Personal Decision Guide - Patient Decision Aids : "Ottawa Personal Decision Guide. The Ottawa Personal Decision Guide (OPDG) is designed for any health-related and/or social decision.
It can help people assess their decision making needs, plan the next steps, and track their progress in decision making."
Very valuable tool in helping you decide what to do next when you are unsure or confused ! Print this out, fill it out, and discuss it with your doctor !

Shared Decision Making

Shared Decision Making:
"1. Patients need to understand their options thoroughly
2. Patients need to understand why it is in their interest to participate fully in decision making, rather than delegating decisions to their doctors
Since 1989, the Foundation has produced programs with the information that patients need in order to make an informed decision. These programs help patients clarify their values, understand the importance of their preferences in making good medical decisions and work in partnership with their physicians to make shared medical decisions.
No one medical answer is right for all people
The decision that will best serve a particular patient often depends critically on the patient's own preferences and values. The treatment that is best for one patient may not be what is best for another who is in exactly the same situation.
Informed, active decision makers
When patients get sick, they sometimes face treatment decisions that can be confusing and frightening. Should I choose surgery or something less invasive? Is this procedure right for me? Should I 'watch and wait' and defer a decision for now? Should I have this test? What are the chances that this treatment will work for me? How will it make me feel? How will it change my life?
Very often doctors make these decisions for patients, and many patients prefer that model. However, a growing body of research shows that when patients are well informed and play a significant role in deciding how they are going to treat or manage their health conditions, things work out better. Informed patients feel better about the decision process. Their decisions are more likely to match up with their preferences, values and concerns. These patients are more likely to stick with the regimens the treatment requires, and they often end up rating their health after treatment as better."
And this is why information therapy is such powerful medicine. Medicine is a science as well as an art - and the art consists of applying the science intelligently to each patient, where each patient has made their own decisions for themselves !

Why doctors should invest in patient education

Why doctors should invest in patient education : "Coached patients are typically more informed and better prepared, with realistic expectations regarding their conditions and the care they receive. Because coached individuals understand their own roles in managing their care, physicians can expect more productive and collaborative office visits."

Wednesday, March 15, 2006

TakeCareHealth.com

TakeCareHealth.com: "Take CareSM has developed an innovative approach to health care that puts the patient's priorities first." This is great news - finally, the healthcare industry is putting patient first. I wish doctors would lead this paradigm shift !

Decision Support

Decision Support: "Decision Support. Within the course of every illness or health problem, people are called upon to make decisions. Little decisions about whether to call a doctor and what self-care is best, and big decisions about medications, tests, and surgeries.
For consumers to make the best choices and decisions, they require two things:
• To fully understand the options
• To consider their own values and preferences

The best decisions are reached when both patients and their doctors understand the options and the patient's values before making their final choice. Decision guides provide the framework and information that patients and their doctors can use to make wise health decisions."
Here is an excellent set of decision guides about common medical problems , developed by Healthwise , and provided by Hill Health.

The California Patient's Guide

The California Patient's Guide: "How do I get copies of my medical records? What should I do if my health plan denies coverage for a particular treatment? How do I file a grievance against my health care plan? And, when can I sue my HMO? Can my health care plan exclude coverage for my pre-existing condition? If I don't have insurance, what are my rights to receive emergency medical treatment? What health care programs are available to me if I cannot afford private insurance?"

MAKING A KILLING - Chapter 1 - The End of Health Care

MAKING A KILLING - Chapter 1 - The End of Health Care: "Who Plays God in a System Bent on Profit? 'In the spring of 1987, as a physician, I caused the death of a man,' testified Dr. Linda Peeno, to Congress. 'Although this was known to many people,' she continued, 'I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was 'rewarded' for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the 'good' company doctor: I saved a half million dollars."
This is an eye-opening book - well worth reading if you are unhappy with your HMO and need to know what to do !

HMO Patient Self-Defense Kit

HMO Patient Self-Defense Kit: "HMO Patient Self-Defense Kit
Corporate medicine is, by self-admission, intent on shackling health care expenses by doctors and other medical professionals against the interests of patients. For the patient denied treatment, this is an adversarial system.
Unfortunately, a seriously ill patient in need of a medical treatment is disabled — by definition, least able or unable to advocate for themselves. The greatest mistake patients in need of critical care and their loved ones make is the assumption that the system is there to help them. Doctors and nurses may be there, but they do not control the corporate medical system. Often, it is a friend or family member who must lead the battle for a patient's care and they must remember that a likely response from the system will be delay and denial. How can patients or their allies help themselves in a system that is set up not to help them get treatment? Your tactics must be those of negotiation. "

Patient Advocate Primer: Persuade, Plan, Passion, Pin

The California Patient's Guide: "Patient Advocate Primer: Persuade, Plan, Passion, Pin. To be an effective advocate for yourself or someone else, there are a host of principles you can follow and many excellent books on the methods of advocacy. The most effective advocate is the most persuasive. Persuasion is the goal of all advocacy. Persuasion is the goal of the written word, the spoken word, unspoken messages. The right words or action from the right person or people to the key decision-makers at the appropriate time is the equation for success in advocating any position."

Monday, March 13, 2006

Treating patients as assets

The public healthcare system in India is collapsing. The standard reasons given for this sad state of affairs is: not enough doctors; too many patients; and not enough money.
I think we need to change our perspective. The large number of patients we have should not be seen to be a liability. In fact, we can treat this as an asset ! It's true that patients are at the "bottom of the pyramid", and if we can teach them how to take better care of their own health, they can dramatically improve their own health !
The catalyst in this equation is patient education - we just need to use it intelligently. Information can be Powerful Medicine !

Sunday, March 12, 2006

" Putting Patients First !" Seminar at HELP on World Health Day ( 7 April 2006)

Did you know that your doctor may be failing to prescribe one of the most powerful medicines known to man ? While your doctor may be an expert on the pharmacology of the latest drugs, it’s a sad fact that most doctors today are guilty of not dispensing one of the most powerful therapeutic tools they have at their disposal – information.

We all know that knowledge is power – and that information can be is powerful medicine. Much of what happens in health care is about information - information about your lab results, diagnoses, drugs, or referrals. Access to it gives you control over your own health and well-being. And the power of information grows when you and your doctor are able to share it. Unfortunately, patient education is a concept most doctors just pay lip service too , because they are often too busy and don’t have enough time.

Unfortunately, as a result of this, both doctors and patients lose in the bargain . Patients are often unhappy and dissatisfied when their doctor does not provide information. They then go to google to hunt for information on their own – and often get lost and confused. Doctors are also upset when they are confronted with patients who carry tons of internet printouts – most of which are garbage.

The best solution is Information Therapy – “ Prescribing the Right Information to the Right Person at the Right Time” . This is now routine in many clinics in USA. Don Kemper, CEO of Healthwise, USA (the world leader in this field) , will be presenting a seminar on Information Therapy, so that this becomes a routine part of medical practice in India too.

Patient education resource centers should be an integral part of all hospitals and clinics . Patients represent healthcare's largest resource - and they have been untapped so far. If we can help patients to make use intelligent use of their intelligence, everyone will benefit !
Speakers at this seminar include:
Don Kemper . Information Therapy – the US experience. Problems and Prospects;
Dr Aniruddha Malpani, Medical Director, HELP . How can we get doctors in India to prescribe information ?;
Mr Rajesh Jain, CEO, Netcore. Helping patients become better informed – the business opportunity for entrepreneurs in e-healthcare;
as well as patients who will be talking about how information therapy helped them get better.
This is a free seminar which will be held at HELP on World Health Day, 7 April 2006, from 11 am – 1 pm. Everyone is welcome to participate !
If you'd like to come, please send an email to helplib@vsnl.com

Saturday, March 11, 2006

Training patient assistants

I read a very interesting story in the newspaper today, which described how the Indian government is going to appoint unemployed graduates as tax return preparers. " Fees charged by chartered accountants for filing tax returns could soon crash with the finance ministry finalising a public-private partnership scheme to appoint, train and certify unemployed graduates for the job. The “tax return preparers” scheme is slated to begin from June 1 this year."
I guess the goverment is doing this is order to help people pay their taxes - as this will help them to earn more revenue.

Why can't they do the same thing to improve healthcare ?
The goverment should train people to become "patient assistants".
This person would be a CPA " Certified Patient Assistant" ( or "Patient Coach") . This is quite different from the model of the "village healthcare barefoot worker" who was always treated as a " second class doctor". This will be a person whose job is to serve the patient, so the patient has a better understanding of their medical problems.

He ( though I feel women may be better at this, because they are usually more empathetic) can be taught these basic skills ( anatomy, physiology, drugs, illnesses,
counselling) through instructional modules, which can be delivered on CDs or on websites. This " mini-medical school " will also teach them to teach patients how to organise medical records; learn what questions to ask their doctor; how to research the medical literature; how to decide amongst treatment options).

They could be charged for this training; and when certified, they could then charge patients for their services. Smart doctors could also employ them in their clinics, to help them take better care of their patients.

A large number of these empowered patient assistants would go a long way towards improving healthcare in the community, which means this project represents an excellent return on investment !

Friday, March 10, 2006

Health Information Translations

Health Information Translations : "Welcome to Health Information Translations, a collaborative initiative to improve health education for limited English proficiency patients. This site is intended to be a valuable resource for helping health care professionals teach health education to those patients with limited English skills. By leveraging the combined skills and experience of 3 of Central Ohio's largest health care organizations, this project will produce some of the most valuable resources for health care education in diverse communities. "
Shouldn't the Indian goverment be doing this for its citizens ? The amount of patient educational materials available in Indian regional languages is amazingly small. This is a shame - a small investment would pay such huge returns !

Why Most Published Research Findings Are False

Why Most Published Research Findings Are False: "The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true."
" The hotter a scientific field (with more scientific teams involved), the less likely the research findings are to be true".
Fascinating insights - and perhaps this explains all the hype we recently saw in the field of stem-cell research.

Medical Journals Are an Extension of the Marketing Arm of Pharmaceutical Companies

Medical Journals Are an Extension of the Marketing Arm of Pharmaceutical Companies: "Examples of Methods for Pharmaceutical Companies to Get the Results They Want from Clinical Trials.
Conduct a trial of your drug against a treatment known to be inferior.
Trial your drugs against too low a dose of a competitor drug.
Conduct a trial of your drug against too high a dose of a competitor drug (making your drug seem less toxic).
Conduct trials that are too small to show differences from competitor drugs.
Use multiple endpoints in the trial and select for publication those that give favourable results.
Do multicentre trials and select for publication results from centres that are favourable.
Conduct subgroup analyses and select for publication those that are favourable.
Present results that are most likely to impress—for example, reduction in relative rather than absolute risk."

Telemedicine in Rural India

Telemedicine in Rural India: "With the aid of HealthSAT, India's telemedicine initiative has the potential to provide specialized health care to millions of poor Indians. This potential was well summed up by Dr. Devi Shetty: “In terms of disease management, there is [a] 99% possibility that the person who is unwell does not require [an] operation. If you don't operate you don't need to touch the patient. And if you don't need to touch the patient, you don't need to be there. You can be anywhere, since the decision on healthcare management is based on history and interpretation of images and chemistry … so technically speaking, 99% of health-care problems can be managed by the doctors staying at a remote place—linked by telemedicine.”"

Wednesday, March 08, 2006

Patient Narrative Videos: Learning from the illness experience

Patient Narrative Videos: Learning from the illness experience "A series of “patient narrative videos” were designed to foster insight into patient perspectives on the illness experience. People become involved with this project through word-of-mouth or referral. In general, we give patients a small video camera, tapes, and a tripod, show them how to use the equipment, and ask them to take it home in order to share their thoughts and feelings over time. Patients come back with four to six hours of video, which we view and log. We ask patients what they consider to be the most important aspects of their stories, and use these key points as the framework for editing the footage into a coherent “rough draft.” We review this version with the patients to ensure that we have not distorted their perspectives and then produce the final copy. We have completed several patient narrative videos since 1996, including patients living with chronic pain, diabetes, severe eczema, fibromyalgia, manic-depression, pancreatic cancer, and Parkinson’s disease. We do not pay patients for their participation, in part because we want to reduce the incentive for “performance.” The patients offered their narratives because they thought the videos would help people better understand “the world of the sick.” Thus far, it appears they were correct: These videos have been shown to medical students, residents, academic and community physicians, medical educators, communication scholars, and film festival audiences in a variety of contexts, each time proving a powerful trigger for reflection and discussion. This approach complements the use of written narrative in medical education and provides a compelling expression of the disease experience. Patients participating in this project have found the process of creating the narratives therapeutic."
This is a great way of overcoming the physician patient communication gap !

Tuesday, March 07, 2006

Meritocratic Jesus refused to heal the sick

The Students' Notebook: "Meritocratic Jesus refused to heal the sick... his justification is that this would snatch away the businesses of those who are good enough to find a cure. Again there is an emphasis on 'merit'. According to Meritocratic Jesus, the world is full of opportunities where those with the capability can take advantage of, he sees the terminally ill as an opportunity for the doctors to get richer. Those with merit will always benefit from helping the less fortunate. This does not always happen in real life, sometimes acts of altruism are just needed to end suffering."
Interesting viewpoint !
Most people believe that doctor will go to heaven because they do so much good in their lifetime. I remember reading a book which said that all doctors will go to hell, because they derive their livelihood from the sufferings of others !

Why don't unhappy patients speak up ?

I still cannot understand why patients put up with terrible customer service in the healthcare industry. If you had to wait 70 minutes at a restaurant without an apology or explanation, would you stew in silence ? If not, then why do you put up with such atrocious behaviour when the doctor does it ? And if you do put up with it, then it seems to me that you deserve it ! Doctors make patients wait because patients are willing to wait !

Patient's Bill of Rights

In view of the ongoing strike of medical residents in Bombay, Karmayog, an organisation in Bombay, is proposing a Patients’ Bill of Rights , which should be displayed on every floor of every public and private medical care facility.

" To have a list of exact services available and corresponding fees (for supplies and bandages, etc.)
. To have a visible map of the hospital (in Marathi, Hindi, English, and other languages)
· To know and understand the procedures involved
· To be given a reasonable time frame for the treatment
. To know all the costs associated with seeking medical care
· To receive prompt and courteous care
· To be informed about the documentation needed for treatment.
· To have minimal documentation for emergency cases.
· To get Reproductive and Child Health Services free of cost at Public Health facilities.
· To receive medications and vaccinations from the local Public Health post or dispensary.
· To get medical services which are within the capability of the medical facility.
· To obtain from the doctor complete information concerning the diagnosis, treatment, and prognosis in language the patient can understand.
· To receive necessary information from the doctor such as long-term effects, side-effects, etc. before giving any prior consent to a medical procedure and/or treatment.
· To refuse the suggested treatment and be informed of the medical consequences thereof.
·To receive medical care in well-equipped and sanitised conditions.
·To receive quality care from competent medical professionals.
· To be able to select doctors of one’s choice when possible.
· To privacy during medical check-ups.
· To be assured that all communication and records will be kept confidential
· To educational information about medical problems eg. via a library, IEC materials, etc.
· To be enabled to pay hospital fees on a payment plan
· To have access to a non-hospital staff member appointed to address complaints as soon as possible.
· To have the contact information of responsible person (both at hospital and BMC office) to register a complaint or give feedback.
·To have adequate waiting space.

I applaud this initiative - these are reasonable requests.

However, there should also be a list of Patient's Responsibilities and Duties !

- You should provide your doctor with accurate and complete information about your medical history, past illnesses, allergies, hospitalizations and medications.
- You should report changes in your condition (however minor they may seem to you) to your doctor - don't keep him in the dark!
- If you do not understand what your doctor says or wants you to do, you should let him know without any hesitation!
- You should follow your doctor's treatment plan.
- You should keep your appointments on schedule, and if you cannot do so for any reason, let your doctor know well in advance.
- You should pay your medical bills promptly!
- You should follow hospital rules and regulations without fail.
- You should have realistic expectations of what the doctor can do for you. Everyone would like to get well completely, but one should always bear in mind that the doctor is not a miracle worker.
- You should help your doctor to help you! If you cannot stick to a particular treatment plan, let your doctor know, so that he can formulate an alternative plan.
- You should maintain good health habits.
- You should participate actively in your medical care. Patients who are highly motivated get better faster: in other words, help your body to heal itself!
- You should ask questions to clarify any doubts or dispel any misconceptions in your mind. A doctor or nurse may not know when you're confused, uncertain or just want more information. Therefore, do not refrain from asking questions.
- You should respect the doctors and the nurses. The medical staff deserve your respect and courtesy: treat them the way you would like to be treated by them!
- You should not ask for false medical certificates or padded medical bills (in order to get additional reimbursement).

Medical tourism growing worldwide

Medical tourism growing worldwide: "Inferior medical care would not be worth having at any price, and some skeptics warn that Third World surgery cannot possibly be as good as that available in the United States. In fact, there have been cases of botched plastic surgery, particularly from Mexican clinics in the days before anyone figured out what a gold mine cheap, high-quality care could be for the developing countries.
Yet, the hospitals and clinics that cater to the tourist market often are among the best in the world, and many are staffed by physicians trained at major medical centers in the United States and Europe." Sometimes cheaper can be better - it just needs to be marketed properly !

Can a little ( medical ) knowledge can be dangerous ?

I received the following email from Dr Athreya.

" Hello Dr Anirudha and Dr Anjali, I was greatly fascinated after reading the article on HELP in Sunday Magazine of 'The Hindu' newspaper. I Congratulate you on this innovative mission and vision you have ahead. Wish you all the success. My only concern, may be not valid, is that it should not lead to partial knowledge which could be dangerous. Since I am in science stream I am also worried about the confusion which may prevail in the minds of a layman, like me who do not have any knowledge of medicine, while encounter with agnostic views and interpretations of scientific theories and findings in medical field. As we are immensely bombarded with facts in medical findings we may be unable decide on legitamacy of findings, which only experts can handle."

Here's my reply.

" I understand your concern that " a little knowledge may be dangerous".However, in my opinion, ignorance is far more dangerous !
It's true that there is often a difference of opinion amongst doctors - after all, medicine is a complex, inexact science. It just means that patients need to be aware of these differences - not get intimidated by them. It's better to be confused because you know too much - rather than to live in ignorant bliss ! Armed with this knowledge, patients can then make the right decision for themselves ( with a little help from their doctors !)

Monday, March 06, 2006

Information Therapy Seminar at HELP

Don Kemper, CEO of Healthwise, is coming to India to talk about Information Therapy. US and UK health insurers have increasingly invested in ways to support their member's health and health care decisions. Kaiser, United Health Care, AETNA, CIGNA, WELLPOINT all have developed member Websites and disease management programs to provide the information and decision-support that their members need. Don Kemper is the founder and chief executive of Healthwise, the leading source of consumer health information in North America. Healthwise content is used on the Websites of 9 of the 10 largest US Websites as well as on such consumer portals as WebMD, YAHOO and MSN.com.

Mr. Kemper will be in Mumbai on Friday and Saturday, 7 and 8 April to present at an invitational workshop on "the business case for consumer health information within health plans. Kemper's talk will describe the patient education trends among health insurers in the US and the business case for their contribution to health insurance success. The presentation is sponsored by HELP, the Health Education Library for People, located in Mumbai.

We will be having presentations for a diverse group, including: health insurance companies; doctors; hospitals; journalists and the public.

Everyone is welcome - we hope Information Therapy will help put patients back at the center of the healthcare system !

HELP stars in India's leading newspaper - The Hindu

HELP stars in India's leading newspaper - The Hindu: "I first read about Aniruddha and Anjali Malpani — the two Mumbai-based young doctors who specialised in fertility treatment — when they set up the first ever sperm bank in the country in 1992. They were subsequently mentioned once again when they popularised the concept of post-operative day care by setting up their own centre.But their most remarkable achievement in the field of health and well-being is the establishment of the Health Education Library for People (HELP), the first consumer health education resource centre in the country. Set up in 1997, HELP aims to help the layman by providing them with the information they need to promote their health, prevent illness as far as possible and learn about any medical problem they may be already suffering from. It also enables patients to work in tandem with their doctors. As Aniruddha puts it, 'We believe that Information is the best prescription!' Incidentally, HELP is a charitable trust and a non-profit organisation." HELP is proud to have been featured in India's leading newspaper.

Making money from the wellness craze

Making money from the wellness craze" This course is designed to provide the theoretical basis and practical application of lifestyle medicine within your existing practice. By participating in this ground breaking seminar you will gain the knowledge, insights, and skills to efficiently and effectively guide your patients towards improved lifestyle choices and consequently better health. Specifically you will learn to:

* Incorporate Lifestyle Medicine within your existing practice
* Understand and use coaching psychology to initiate behavioral change
* Prescribe exercise and physical activity
* Understand stress and psychosomatic risk factors
* Develop smoking cessation strategies with your patients
* Address weight management and obesity issues
* Improve your personal health habits"

Wellness is the new craze today ! After all, only about 1% of the population is ill at any given time, which means doctors have a lot of spare time. So they are now targetting everyone - after all, everyone wants to be well, and aren't doctors the experts on wellness ? ( Actually, they aren't - they are just illness experts, but this is another story).
To capitalise on this demand, and to satisfy the craze for " diplomas" from "abroad", Apollo has cleverly tied up with Harvard , to issue doctors who attend this seminar with certificates ( " directly from Harvard Medical School, Boston,
USA !)which they can frame and put on their walls ! Why go to Harvard if Harvard can come to you ?

Hats off to their clever marketing - something we all can learn from !

Beginning medical practise – get off to a flying start !

The starting point of all achievement is desire. Keep this constantly in mind. Weak desires bring weak results, just as a small amount of fire makes a small amount of heat. Napoleon Hill

Starting practice can be difficult , because so many things need to be done at exactly the right time, and it’s easy to get overwhelmed. Often, it’s difficult to know what to do and when to do it, because this is the first time in your life that you will be handling a job of such complexity entirely by yourself. A little advance planning can go a long way toward giving you confidence when your clinic actually starts. It’s helpful to have a timeline and use basic project planning techniques to ensure that everything goes off smoothly. A good start will boost your chances of long-term success considerably !

When to start ?

When should you cut the umbilical cord of training and start practice ? How do you know when you are ready to start off on your own ? This depends upon lots of factors, such as your career goals and your field of specialization. Thus, while a family physician may be comfortable starting within a few months of graduating, many specialists will want to work with a senior specialist for some years before starting out on their own. Other factors such as marriage and bearing children can also play an important role in this decision.

Where to start ?

Deciding where to practise is one of the most important decisions you will need to make. Sometimes you may not have much choice in the matter - for example, married women may have to settle down where their husband chooses to locate. But if you do have a choice, then how should you go about selecting the best location for your practise ? Most new doctors mindlessly choose to settle down in large cities, because this is where the “glamour” and “action” is. However, often the competition here is intense, and you may be much better off looking for alternatives. Remember that the place where you eventually practise will, to a certain extent, determine the pattern of the practice. It may take months of research and effort before you find a town, which is not only suitable for your practice, but also optimal for your personal life and bringing up a family.

There is an axiom in business that there are three keys to success: location, location, and location. The best location for your practice is in a convenient, highly visible, and easily accessible office. The easier you make it for potential patients to find and use your services, the more quickly you will achieve the level of success you desire. After all, if you want to deliver a service to the public, then you will be most successful if you are located where the public is willing to go. Selecting a location should be done with the same care as selecting a spouse - you want a long, healthy, prosperous and happy lifetime together, so treat the decision with an eye toward the long term. Chances are that you will spend many years building and growing your practice in the location you choose, so it's important for you to consider where you would like to work and live for the long term.

You should pay attention to the following points:

* The community's need for a doctor.
How many other doctors are there in the area ? What are their specialties? Will the area support another doctor ? What is the density of the population ? Is there anticipated growth or decline in the population ?
* Your needs and those of your family
Are buildings or office premises available for purchase? Will you lease or rent? Has the property plenty of car parking space? Is there good access to public transport? What are the recreational facilities and social opportunities? Are there good schools nearby? Will they suit the ages of your children? Will the rest of the family be able to find work? Will planning permission be necessary to convert the property for medical use?
* The local medical facilities
Is there a good local hospital or health centre? What other doctor are available for consultations and referral? Are they likely to be co-operative?

Since this may be one of the most important decisions you ever make, give it enough thought and attention, and don’t just accept the first opportunity which comes your way. It might be a good idea to serve as a locum or an assistant to get a “feel” of what practice in the area is like.

Types of Private Practise

When you commence private practise , you will need to decide which form your practice will take. There are three main options:
1. Single-handed practice.
2. A partnership.
3. A group practice.

Which method you choose will depend on your own physical and mental abilities, financial circumstances and personal aspirations. All the methods have their advocates: it is up to you to determine and define your aims in order to find out what you really want. It need not be an irrevocable decision: you may decide to start working single-handed, and then meet a colleague with whom you feel you could work and form a partnership.

SINGLE HANDED PRACTICE
This is by far the most popular type, and allows you to be completely independent. You have to be dedicated and confident, because you are responsible for everything connected with the practice, including obtaining premises, fixtures and fittings, decoration, practice organization, financial planning and management; and you will have to make all the decisions. Think of yourself as being an entrepreneur starting and running a small company. Independence can prove a little daunting, particularly if you have been working in a hospital where much of the support structure is provided and the responsibility is mainly clinical. However, you do have the satisfaction of knowing that the success of the practice is all your own work and, of course, the patients are entirely yours. This type of practice is very flexible: it can be started without legal formality and the accounting requirements are fairly straightforward and simple. It gives great freedom, but it brings great responsibility. Many practitioners enjoy working on their own and have highly successful and profitable practices. You can make decisions yourself without having to waste time on committees and meetings – and you can mold your practice so that it is as efficient as possible.

The disadvantages occur when you are ill or you wish to take a holiday, for unless you close the practice or find a suitable locum, holidays become non-existent. You might also find it harder to compete with larger group practices which have greater financial muscle, so you will have to work harder to attract new patients. If you are ill and cannot practice, there is no income – effectively, you are a “daily wages” earner ! Solo practice is still the commonest form of private practice in India today.

PARTNERSHIP
If you want shared responsibility, a partnership with one or more colleagues may be the answer. A partnership is preferably a formal legal relationship rather than an informal agreement with no legal authority. A partnership consists of two or more people, who join together with a view to making a profit. The partnership is subject to certain legal formalities such as the sharing of profits. Each partner is personally liable for the debts of the partnership or of the individual partners if they are unable to meet their own debts. Therefore, there must be complete confidence and trust.

Partnerships have many advantages. Each partner may contribute capital and will devote time and energy to the success of the practice. Special skills and expertise may be complementary, thereby expanding the range of patients the practice can accept. Decisions, responsibilities and management of the practice will be shared. A partner may well bring in valuable referrals and contacts. In addition, an older and more experienced practitioner can be of considerable benefit to the practice. A partner is invaluable if you are ill, have an accident or if you have to give time to a family crisis. Whether you personally are at work or not, the practice will continue, the patients will be seen and you are relieved of the worry of finding a colleague to cover for you while you are absent. Partners should not only be regarded as useful for the difficult times- it is also very pleasant to share success with somebody else and to plan for the future.

A partnership is, however, a close relationship and entails a great deal of tolerance and understanding if it is to be successful. A shared decision can mean one, which is reached only through compromise and possibly argument. Disagreements are rarely over patients, but usually center on management or financial matters. Patients identify with a particular partner and there is occasionally a cross over during holidays, professional courses or sickness, so the attitudes and behavior of the partners should convey an atmosphere of stability. Take your time over entering into a partnership. It may be a good idea to work together informally for a while to see how compatible you are before signing any agreements. A partnership, whether informal or formal, is a social contract, and as in marriage, divorce can be expensive and upsetting.

GROUP PRACTICE
Group practise is becoming increasingly popular in India now. Here, two or more practitioners' join together to share expenses such as rent, rates, electricity and water charges. In this type of practice, therefore, you would have to access to all the facilities, such as the receptionist but remain independent, responsible for your patients and with complete control of your own finances. This option has many attractions, particularly the shared responsibility for the premises and facilities and the contact and friendship of your fellow practitioners. This can be very useful for referrals, on call duties and holiday arrangements. In the US , after the advent of managed care, most doctors have turned to group practise, because they found it difficult to meet the bureaucratic hassles and paperwork demands of HMOs. Many US doctors want the protection of an established practice, with someone else running the business, so they don’t have to cope with administrative hassles, and can focus on providing good medical care to their patients.
The ideal size practice is represented by the fingers of one hand for specialists and the fingers of both hands for primary care physicians. Specialists shouldn't try to grow much beyond four or five because they start acting like employees and refusing to compromise for the good of the group. And, there's nothing to be gained by getting bigger. All the subspecialty skills can normally be covered by four or five colleagues and there are few economies of scale to be gained by further growth. The statistics are clear: the larger the practice, the higher the overhead.

HOSPITAL PRACTISE

There are additional options too. Many doctors now prefer to work full-time for large corporate hospitals. While this provides the prestige of being a consultant in a reputed hospital, a steady stream of patients, an established infrastructure, access to the latest medical equipment, and no administrative responsibilities, you need to pay a price for this. While the job satisfaction can be tremendous, since you are working in a “state of the art “ medical facility which attracts challenging patients from all over the country, and serves as a referral center for difficult cases, since the hospital retains the majority of the patient’s fees, your financial benefits are capped as compared to doctors in private practice. Also, most hospitals are hotbeds of petty medical politics, and the amount of backbiting and bitching which goes on amongst the medial staff can be frustrating. You also need to know how to butter up the hospital’s administration and trustees to keep them happy. Many doctors find that not only does the hospital administration retain the lion’s share of the profits, leaving them with chickenfeed, they also force them to admit a minimum number of patients and to generate a certain amount of income every year , as a result of which they lose their medical autonomy. Since competition for these hospital attachments is intense, the fear of being thrown out of the job is always present.

GOVERNMENT PRACTISE

Many doctors find practicing in a government hospital satisfying. They do not need to worry about attracting patients or raising money to start practice. They usually have the pleasure of being able to teach the next generation of doctors, and this interaction with medical students and residents keeps them young. Job satisfaction can be considerable, since the sickest and most complex patients often end up in government hospitals. One is also on many government regulatory bodies and committees and can wield considerable power in public health, government projects, and professional medical societies. As a Professor, many doctors are leaders in their profession . However, dealing with the bureaucracy and government machinery can be a uphill task. One needs to keep the VIPs in power happy, and buying new equipment can be a frustrating exercise. Also, promotions and professional opportunities are restricted; you are forced to live with limited budgets and miles of red-tape; and many doctors find the chores associated with administering a department very unwelcome.

Key advisors you will need to help you start

When practicing medicine, you will need advisors to help you with your various business, legal and accounting needs . Rather than solicit informal advice from friends, family or others, you will be better served if you select professional advisors in the very beginning. You may want to seek recommendations from other physicians concerning these advisors. Interview each of them. Once you are convinced that they have the experience you need, determine whether you can establish a rapport with them individually, and if they can work with each other. Choose these advisors with great care and forethought – they will play a vital role in the future growth of your practice. Perhaps one of the most important characteristics to look for should be how well you can relate to him, because this relationship requires a high level of trust and understanding. Once you have found an advisor you are happy with, you can ask him to recommend another advisor in the other fields you need help. Thus, an accountant you are happy with may recommend an attorney, or vice verse.

The accountant
The accountant will be responsible for the following:
1. Setting up and monitoring financial record keeping
2. Establishing sound financial guidelines on expenditure, salaries and pensions.
3. Advising on, analysing and projecting the growth and development of the practice.
4. Preparing the annual balance sheet and income statement.
5. Dealing with all tax matters.

The lawyer
A lawyer is another necessary advisor. You must ask his advice in connection with all legal matters. Lease agreements, conveyance documents, partnership, limited company and insurance agreements must all be seen by him. A small legal practice with two or three partners is usually the best option for most doctors, to ensure that your lawyer has enough time for you.

The bank manager
A sympathetic and helpful bank manager is essential in financing the initial capital expenditure and providing you with a reserve to pay continuing expenses until the practice begins to generate some income. It is a good idea to have a talk with him before you begin looking for premises or take the first steps towards starting a private practice. He then knows what you have in mind and can advise you on a number of matters. He may even put you in touch with the other professional people who may be of help to you. Banks, on the whole, are kindly disposed towards applications for professional practice facilities, because doctors usually have a good track record in repaying their loans, and are considered to be excellent credit risks. Unless there is a serious problem, you will have no difficulty in obtaining the money you need for the practice.

There are other advisers you will need as well, and one of the most important is an insurance agent. Don’t even dream of starting practice without ensuring that you have a valid professional indemnity insurance policy to protect you from malpractise claims. You will also need to insure your clinic ; and the expensive medical equipment you buy. Other advisors may include: financial consultants, to help you manage your money as your practice grows; and marketing consultants, to help you grow your practice. In the US, medical practice management firms will often provide these services under one roof.

Getting referrals

The first few months after you start practice are usually the most difficult for most doctors. You are full of enthusiasm and your technical skills are finely honed, but you may find that attracting patients is very difficult. If you are fortunate and come from a family of doctors, this will help you immensely in getting off to a flying start – but what happens if you have no doctors in your family ? Most doctors will go through three stages in their professional life.

1. No work, no money, lots of time
2. Some work, some money, some time
3. Plenty of work , plenty of money, no time

Unfortunately, many doctors who start practice end up falling prey to the temptation of giving cuts and kickbacks to referring doctors. They are so desperate for patients, that they are willing to stoop to any depth to allow them to make ends meet. They justify their approach by saying “ Everyone does it anyway”; and are worried that if they don’t, they will starve. However, this is a very short-sighted tactic, which will end up hurting you in the long run. Not only will it reduce your self-esteem because you are behaving unethically; it will also force you to do things you are ashamed of doing ( for example, unnecessary surgery, because the referring GP insists you do it). Also, you could devote the same energy more constructively to building direct referral channels to your patients, which is far more satisfying and rewarding in the long run !

So what can you do to get more patients ? Actually, quite a lot ! Sitting and waiting for patients to come to you will not help – you are going to need to get out and let people know about your skills, so they will want to send patients to you. In order to get referrals , you need to rely on an ever-widening circle of friends, colleagues, and contacts. In order to do so, you need to learn to "network" , that intangible collection of skills that successful businesspeople seem to use effortlessly. Networking, when handled skillfully, is, more art than science , just like medicine is. Whether its simple rules are followed by either a new doctor or veteran physician, networking can produce decided benefits. You first need to start by networking with colleagues. Unfortunately, most doctors still treat colleagues as competitors. They are seen as rivals, and petty medical politics often result in rivalry and pulling each other down – energies which could have been constructively used instead to build each other up ! United we stand , divided we fall is as true today as it was centuries ago. Networking allows you to pool your skills with others, so that the sum of the parts is greater than the whole. Just like some doctors naturally acquire a polished bedside manner, others have excellent networking skills. Most of these doctors are politically very active, and their “people skills” are excellent -learn from them how to network efficiently ! Treat your colleagues well and trust them . Do not bad-mouth other doctors – word gets around ! Make it easy for them to get in touch with you and update them about their patients. If you are computer-savvy, offer to help them update their skills, so they are grateful to you. Attend medical conferences and use these as opportunities to meet as many of your colleagues as you can. At social occasions, instead of hanging out with old friends, fraternise as much as you can so you can develop new contacts.

Successful networking is about meeting people and forming relationships – you help them so that they will help you. Try to do as much good to others as you can ! If you want to increase the number of referrals to your primary-care practice, interact with potential sources of new patients. Determine who the relevant people are - you need to perpetually scan your environment and mentally tuck away the names of people and organizations that will eventually be of use to you. You also need to be able to give them good reasons as to why they would be better off sending their patients to you, rather than anyone else. They key to networking is to follow up and stay in touch. For example, sending a personal note of thanks is one task that many of us fail to do. The benefits of such a simple act are incalculable.

Networking involves honing your interpersonal skills and the following acronym will help you network more efficiently.
N: Remember their names.
E: Eye contact is key.
T: Talk less and listen more.
W: Write follow-up notes on a consistent basis.
O: Be open and ask open-ended questions.
R: Become a resource to others.
K: Knowledge is power; know people and know their work.

Your patients can be very helpful in your networking efforts. You can capitalize on their goodwill to make new contacts and explore new opportunities. Most patients are grateful towards their doctors, and are more than happy to help them ! Many doctors have made good use of their patients to build up their practice and so can you ! Learn to speak in the local language – this simple act will help to set your patients at ease, and increase your practice
manifold !

Here are simple techniques successful networkers use

1. Speak
Take every opportunity to speak about your specialty – both on a one-on-one basis, to making presentations to large groups. Be enthusiastic and willing to talk – and have ready-made presentations for those “last-minute” invitations ! Eloquent doctors are always in demand !

2. Participate
Join medical organizations. It is better to belong to fewer organizations and take an active role in them than to belong to many with superficial connections to the membership. Truly participating allows you to really get to know people and thereby supports your desire to build professional relationships with them. If there isn't an organization that fits with your objectives, create one. It can be a physical organization or a virtual one. Being the founder of the organization gives you instant credibility with your entire membership and gives you an opportunity to define and mold it.

3. Publish
Write articles ! While this can be difficult, it will get easier as time goes by – and the more you write, the more you will be asked to write ! Doctors who can express themselves clearly are always in short supply !

4. Volunteer
Volunteering is a great way to build professional relationships while giving back to the community. Take a volunteer position that allows you to use your skills and express your passion. Your network will grow along with your sense of accomplishment.

5. Socialize
Socialising is great way to build and nurture your network . It’s very useful to host an event. This can be a party at your house or a recurring event at a chosen meeting place. This will provide an informal way to get together and connect the members of your network with each other. If each member brings a member of their network, it will also help to significantly expand yours. Remember, the secret for success if often not knowhow , but know who !

As with any job, well begun is half-done, and while your first few years in private practice can involve a lot of hard work, this investment of time and energy can pay off in spades for the rest of your life. Don’t get disheartened when things don’t seem to be going well in the beginning – remember that everyone has to struggle to establish themselves !

Saturday, March 04, 2006

Planning your career – a guide for doctors

This is Chapter 1, from our book, Successful Medical Practise - Winning Strategies for Doctors.

Many doctors naively believe that once they start earning lots of money and have a long line of patients waiting for them, they will have it made. Once they reach this point, many are quite happy to cruise on their reputation and skills for the rest of their lives. However, to judge the health of your career, it’s not enough to just look at your income statement – you need to assess your personal balance sheet as well. You are a professional and your major assets are your medical knowledge and skills. You need to keep on building these if you want to remain successful. The Japanese call this kaizen, which means constant improvement. If you do not actively work at it, your career prospects will decline, even when (or perhaps especially when) you are making lots of money. In fact, the more “successful” you are in later years, the greater the temptation to exploit existing skills - and the harder you need to work to make sure that you don’t just rest on your laurels. You have to find ways to continue to develop the knowledge that your patients value. Doctors get paid for their time, but that's not what we sell. We sell our medical knowledge and skill, and left untended, these depreciate in value surprisingly quickly ! This is especially true in medicine, where the knowledge base expands exponentially every year, and new discoveries are being made all the time. We all need a personal strategic plan for our careers, and the sooner you formulate this, the easier it will be for you to progress.

Most doctor’s careers have the following five stages:

* Entry, when you are starting out;
* Establishment, when you have created a name for yourself;
* Exploration, when you look for new fields to conquer;
* Specialization , when you settle down in your niche; and
* Mastery, when you establish yourself as the Expert in your area of interest.

Whether you are 25 or 55, you always need to think about where your career is headed. The one constant in life is change – and as medical technology , governmental regulations, insurance reimbursement policies and patient expectations change, you will need to change with them. As you think about your career, here are some questions to ponder:

* In what way are you personally more valuable to your patients than last year ?
* What specific new skills do you plan to acquire or enhance in the next year?
* What is it that you want to be famous for ?


Traditionally, doctors have adapted themselves to their jobs – and most have uncomplainingly and blindly done what the rest of their colleagues are doing. However, many are increasingly finding that this is a difficult burden to bear. This is why, rather than change yourself, it is better to create a job which is especially designed for you. A niche is “ any position specially adapted to its occupant” , and if can find your niche where you can practice effectively , this will help to make your career in medicine enormously rewarding. After all, we all have different interests and talents. Why not use these to stand out and shine - you need to play from your strengths ! Find your special interest as soon as possible. What turns you on ? What do you enjoy most ? What part of your work would you be happy to do daily without pay ? The secret for success is to find something you love doing and very good at – and then to attract patients who will pay you to do this for them ! A niche does not need to be some new thing imposed on you (unless you want it to be) nor does it need to be a whole new aspect of your life (again, unless you want it to be).

If you want to make yourself a truly valuable asset, then you have to focus your attention on building a highly specific set of knowledge and skills – you have to carve out a niche for yourself. With ever increasing sophistication in medicine, patients value specialization, and you have to consider what your patients define as value. For your patients, your asset is valuable only if you have technical skill as well as the ability to apply it in a customized way to their situation. It is important to make a distinction between knowledge and skill. Knowledge is relatively easy to accumulate, but it depreciates. Skills are harder to win, but keep their value a little longer. For most doctors, technical skill alone is rarely enough. To be a valuable doctor in the eyes of patients, you need to learn a wide variety of interpersonal skills as well, which allow you to communicate effectively with your patients.

Each patient encounter can teach you – if you are willing to learn. Many good surgeons will take time at the end of an operation, for example, to ask themselves, “What went well, and why? What didn’t go so well, and why not ? ” . This self-imposed discipline allows them to critically analyse their performance, so they can come up with ideas that will help them get better the next time. Keeping notes will also help you remember and apply the lessons next time. Take every opportunity to discuss your work with colleagues, so you derive value when they ask “Why did you do it this way? What would have happened if you did that?”

Although creating a niche for yourself can be a lot of hard work, there are ways to make the job easier. For instance, if you want to be known as an expert in a specific area of medicine, it helps if you give professional talks on the subject. Start locally and expand your horizons as word of your expertise travels. If you are inclined to write, publishing articles in peer-reviewed journals or the lay press will help to further establish your credibility as an expert. Join professional organizations that can provide valuable information in many forms, including publications, seminars and formal coursework. For example, if you are interested in writing on medical topics, you can check out the American Medical Writers’ Association (AMWA). If you are interested in becoming a hospital administrator, you can contact the American College of Physician Executives (ACPE). Having a niche allows you to differentiate yourself from other doctors, so that you can attract more work . Being different can be very helpful in becoming the leader, so don’t waste time trying to be everything to everyone and ending up becoming nothing to no one !

The secret for planning your career is to pick a clear focused personal professional goal. As physicians, we aren't used to choosing our own professional goals because they were usually chosen for us. Throughout our training, we were told what we were going to do, and when and how we were going to do it. But by not setting our own career goals, we have no direction—which is why, after 10 or 15 years of practice, some physicians end up saying, "Is this really what I wanted to do? Did I train 16 years to do this?" When you set a goal, and every day do some work toward reaching that goal, you begin to take control of your professional life. That's why choosing a professional goal is the most important single thing you can do—it starts to put you back in control of your career. Each year, perhaps on a specific date such as your birthday, you might want to reflect on the path your career is taking. Think about what things you can do in the coming year to further define your niche. As time goes on, you will develop new interests. At some point, you may even want to move in a completely different direction. Taking the time to reassess what you are doing on a regular basis allows you to incorporate these new interests into your life , and to get rid of things that you really don’t want to continue pursuing. Discovering your true mission in life, and then allowing that to frame a career that is specially designed for you, can help to make you a true healer. Both you and the people whose lives you touch will reap the rewards of the careful thought and planning that go into creating your own personal place in the world—your niche.

The most important factor in your career design is to shape your practice around your abilities. In doing your self-assessment, five areas are key:

* Values: What motivates you? What would make you feel you were devoting your time and talents to something extremely worthwhile?
* Skills: What's your strong suit? Which strengths do you have that complement your medical skills? Are you skilled at something you don't enjoy doing? If so, you'll want to de-emphasize it so you don't gravitate toward something you won't like.
* Behavioral style: How do you approach problems, people, rules, and procedures? What kind of pace do you like to keep?
* Cultural preferences: Do you like the intimacy of small medical groups or the anonymity afforded by a larger organization? Are you a traditionalist, or an innovator who prefers a fast-moving, entrepreneurial culture?
* Lifestyle: Are you a family- and community-oriented person? An outdoor enthusiast who needs the right setting to pursue other passions? A travel bug who needs to take vacations on your own schedule?


Thus, if you are an orthopedic surgeon and find you are technically clumsy in the operation theatre, it’s better to stay out of the OR and not botch up surgical operations. Instead, you could choose to specialize in medical legal work, by providing advise to lawyers in medical compensation cases - a very remunerative field. If you enjoy what you are doing, you will do a much better job at it !

You don’t have to limit yourself to medicine either ! Many doctors have successfully pursued careers in many other fields, such as information technology, writing, law and business management. Some start coaching classes to teach medical students, while others serve as consultants to the pharmaceutical industry. In today’s world, your options are limited only by your imagination. Other doctors have been even more enterprising and have a portfolio of careers – after all, there is no rule which says that you have to slavishly do one job all your life ! Having a career portfolio can add colour to your lives , because it ensures you have multiple interests to pursue, which keeps you on your toes; and also allows you to create a financial buffer, in case one career is not doing well at a given time.

Remember that you are your most important asset . You can think of yourself as a small company – You, Inc, which you need to nurture. It’s no longer enough to just become a doctor and work hard anymore. You must do something you love, have outside interests, participate in your community and continue learning throughout your life. These are investments in your future, which help you lead a life full of purpose and meaning. Unfortunately, too many doctors (especially those with successful careers) have forgotten that there is more to life than just earning money. Finding a second source of income, which comes from something you love to do, will make life much more interesting – after all, medicine can become very monotonous if you don’t explore new options. As you get senior, it’s the quality of your patients which counts, and you are not going to be very excited about doing your 500th appendectomy.

Finding a mentor who can give you the benefit of his experience can also help you achieve your goals. This is why every athlete has a coach – to drive them, to make suggestions, to help encourage them to better their best. Coaches know exactly how to get their "stars" to work a little harder, to stretch their horizons, to try things that they ordinarily wouldn’t have tried left on their own. Many doctors hate the business side of practice, but that is exactly where profits are made or lost! So, what’s a doctor to do? Simple - put a knowledgeable coach on your success team, and maybe you’ll win the Olympics of success in practice ! How do you find such a coach ? If you have a friend or relative who is a successful businessman, ask him for help. Many successful people are very happy to share their secrets of success with others. Another useful source is your patients. Pick your most successful patient, and ask for help. Most patients are more than happy to help their doctors !

In his book, Finding Your Niche, author Laurence Pino suggests trying this exercise. “Visualize your own funeral. There will be four speakers at the service: a family member, a friend, a colleague , and an associate from your community. What would you like these speakers to say about you and your life?” This might seem a morbid thought to some, but it’s worth considering Pino’s point. What exactly is it that you hope to accomplish in your lifetime? You then need to plan your life so that you can achieve these goals. Planning backwards works much better than stepping forward into the unknown. If you plan well, you can lead a life which you can look back upon with pride and joy.

Friday, March 03, 2006

Making Electronic Health Records Consumer-Friendly

Making Electronic Health Records Consumer-Friendly: "'Americans use digital information technology to manage their finances, pay bills, book flights, and customize the music they listen to,' noted Baird, president of the Markle Foundation. 'And our research shows they now want to use health information technology to get the best care possible for themselves and be better able to manage their own health.'" The time for the EMR has come - doctor will need to push for it, and patients will need to pull for it !

Patients Willing to Pay for Electronic Medical Records, Surveys Show

Patients Willing to Pay for Electronic Medical Records, Surveys Show: "Consumers are willing to pay as much as $60 a year for EMRs, according to a Web survey released this week by the consultancy group Accenture. The Accenture study surveyed about 520 people. It found wide enthusiasm for EMRs.

More than 90 percent thought electronic medical records could improve medical care and reduce hospital errors.
Ninety-three percent said they wanted emergency care personnel to be able to access their records if it could reduce treatment errors. Most thought health care providers ask the same questions repeatedly and that EMRs could reduce wait-time in a doctor's office. And just over half said they'd be willing to pay at least $5 a month to have their records stored in an electronic format."

Major opportunity here for a bright entrepreneur !

Doctors on strike in Bombay

Bombay has some of India's best medical colleges, and getting into medical college in Bombay is extremely competitive and difficult. However, working conditions can be hell for residents in these hospitals, and they have gone on strike. Doctors are supposed to be dedicated to saving their patients' lives, and the media is giving the striking doctors a hard time. The government is also being extremely unreasonable, and refuses to consider their legitimate demands. In fact, it has threatened to throw them out of their residency, which means their careers are in jeopardy. Who will blink first ?

Here's the resident's point of view.

" WOUNDED HEALERS

26/2/6, 6.30 PM – Resident doctor assaulted by patient’s relatives for informing about a mandatory post-mortem.
27/2/6, 8.00 pm – Resident doctor manhandled by relatives on being asked to keep their chappals out of delivery room/labour room.
27/2/6, 11.30 pm – Resident doctors abused and threatened for life for denying an unindicated politically motivated admission to ward

‘Are doctors justified in going on strike?’ is a common question doing rounds these days. The most obvious response from everyone seems to be ‘Of course not, they must save patient’s lives!’

But the resident is a 25 year old who stays on call/duty 24X7, works 20 hours a day returns to a 10X10 room, shared amongst six other equally tired doctors, all fighting for the coveted two beds, the unlucky ones having to sleep on stretchers or on the table of Hostel Canteen or in the ward for want of space.

The unmarried ones are lucky; they fight for themselves, the married ones become gladiators for their families.

Here is a 30 year old who dares not marry for want of space, privacy, financial stability and time with extended duties reaching upto 36 hours at a stretch. He has no life beyond the confines of the hospital, stuck for months together in intensive care, not having seen daylight.

Nothing seems to be enough. Not that he has buried his face in his books since 10 years of age till date; not that he has passed from the best schools and colleges; not even the fact he has graduated from the top medical colleges to work in the best hospitals in India, away from the cozy comforts of his home.

He is told that he is the cream of the literate society. And here is the cream of your society being slapped on the face for working hard in a place where tempers fly high and emotions cross all limits; with inefficient security in the form of few guards who reach the scene after the harm is done.

We doctors, aren’t on strike to let our patient die; in fact we are on strike so that we can get protection for our life; a right which is the basis of democracy.

So here we are, having put everything in our lives at stake for the society and are now forced to put down our only asset – ‘our dignity’.

We are simply asking the authorities to make manhandling of medical professionals on duty a non-bailable offence

We are not looking for sympathy, we demand empathy for our cause. Can the society justify that these doctors, who save their lives, be taken by their collars by the mob?

We are literally wounding our souls to heal others, meanwhile being stripped of our dignity.

Just give us back our dignity to safeguard this special journey called life………"

Fair is fair - all they are asking for is decent working conditions. How can we continue to subject them to inhuman conditions, and then expect them to perform efficiently as doctors ? Even animals have better living conditions !

Open Source Software: A Primer for Health Care Leaders - CHCF.org

Open Source Software: A Primer for Health Care Leaders - CHCF.org: "As information technology in the health care industry evolves from an administrative tool for billing and bookkeeping to a clinical tool for improving the quality and efficiency of health care, the scope of information sharing is expanding beyond the walls of individual institutions. Achieving this level of integration will require that software models overcome a host of technical obstacles, and that they are accessible, affordable, and widely supported.
This report examines the development and distribution of open source software, a well-established software development model—and a potential solution to the looming challenges of integration—characterized by collaboration among individuals and organizations with common interests, sharing intellectual property, and a commitment to standards."
Using open source software for improving healthcare is such a no-brainer - and such a great opportunity !
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