Sunday, April 30, 2006

Excess in the pharmaceutical industry

Excess in the pharmaceutical industry: "The excesses of the pharmaceutical industry are perhaps the clearest example of the folly of allowing health care expenditures and policies to be driven by largely unregulated market forces and the profit-making imperatives of investor-owned businesses."
An excellent expose of what's wrong with the pharmaceutical industry today.

Pharmaceutical Marketing and the Invention of the Medical Consumer

Pharmaceutical Marketing and the Invention of the Medical Consumer: "But pharmaceutical marketing is more closely aligned with consumer marketing in other industries than with medicine, for which the consequences are not trivial. Once we view pharmaceutical industry activities in this light, we can disentangle industry's influence on contemporary medicine. Because we believe that we owe corporations our wealth and well-being, we tend not to question corporations' fundamental practices, and they become invisible to us. What follows is an attempt to demystify some of the assumptions at work in the “culture of marketing,” toward the goal of explaining contemporary disease mongering."
The next time you see an ad on TV pushing the lastest "miracle cure", remember to take it with a pinch of salt !

Should I Be Tested for Cancer? : Maybe Not and Here's Why

Amazon.com: Should I Be Tested for Cancer? : Maybe Not and Here's Why: "The cost of medical malpractice soars as patient lawsuits proliferate, and healthcare providers react with rounds of 'defensive testing' that boost insurance costs. Add to those trends 'early detection' as the watch(buzz)word associated with the most dreaded of diseases, cancer, and you have Americans possessing health coverage routinely undergoing test after test. What of the downside of testing healthy people? Welch, a specialist in cancer detection, challenges common knowledge about everyday screenings, such as mammograms and PSA (prostate specific antigen) tests, citing patient anecdotes and research data on the most commonly diagnosed cancers in this readable, thought-provoking book. He argues that of the two basic cancer-prevention strategies--health promotion (diet, exercise, etc.) and early detection--the latter is the easier sell, and he notes that most tested people never develop cancer; screenings tend to miss the fastest-growing, most deadly cancers; and cancer-free patients with abnormal screenings often endure seemingly endless, sometimes risky testing that leads to unnecessary treatment. Accessibly written, Welch's perspective provides needed balance to current emphasis on testing. "
Very wise book by Dr Gilbert Welch. It's likely to put a wrench into the cancer industry's mass screening programs, which have been " designed to save lives". This is the other side of disease-mongering - test-mongering. More grist to the medical industry's wheels !

Corruption and Health

Corruption and Health: "Health is a major global industry, a key responsibility and budget expense for governments and businesses; but more than that, it is a global human right. Corruption deprives people of access to health care and is one reason why so often increased spending does not correlate with improved health outcomes. Corruption in the healthcare sector can erode public trust in the medical profession."
When one thinks of corruption, it's usually politicians, policemen or businessmen who come to mind. This eye-opening report documents how pervasive this problem is in healthcare too !

Parenthood - Right or Privilege ?

Parenthood - Right or Privilege ? I always though it was a right - until I read this article ! May open your eyes !

The Fight against Disease Mongering: Generating Knowledge for Action

The Fight against Disease Mongering: Generating Knowledge for Action: "Disease mongering turns healthy people into patients, wastes precious resources, and causes iatrogenic harm. Like the marketing strategies that drive it, disease mongering poses a global challenge to those interested in public health, demanding in turn a global response. This theme issue of PLoS Medicine is explicitly designed to help provoke and inform that response.The problem of disease mongering is attracting increasing attention [1–3], though an adequate working definition remains elusive. In our view, disease mongering is the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments. It is exemplified most explicitly by many pharmaceutical industry–funded disease-awareness campaigns—more often designed to sell drugs than to illuminate or to inform or educate about the prevention of illness or the maintenance of health. In this theme issue and elsewhere, observers have described different forms of disease mongering: aspects of ordinary life, such as menopause, being medicalised; mild problems portrayed as serious illnesses, as has occurred in the drug-company-sponsored promotion of irritable bowel syndrome and risk factors, such as high cholesterol and osteoporosis, being framed as diseases."
Another excellent book to read which describes this phenomenon well is "The Last Well Person".

How many embryos should I transfer ?

Deciding how many embryos to transfer remains the most difficult decision patients and doctors need to make in an IVF cycle. In a perfect world, if IVF technology ensured a 100% pregnancy rate, everyone would transfer only one embryo, so that all patients would have one baby ( actually, many would transfer two so that they could have twins) - and then there would be no need for websites like this one !
Achieving this goal remains the holy grail for IVF doctors , but the technology is still not perfect, and because we cannot regulate the implantation process, we still cannot ensure that each embryo we transfer will become a baby. One easy way of improving the chances of achieving a pregnancy in an IVF cycle is by transferring more embryos. However, as with everything else in life, the price we pay for this is that the risk of having a multiple pregnancy also increases. Obviously, there is a point of diminishing returns, and by transferring more than 4 embryos at a time, one only increases the chances of a high order multiple birth, without increasing the chances of getting pregnant.
Ideally, patients should be free to choose for themselves how many embryos to transfer - after all, they are the ones who have the most at stake. However, because the burden of caring for high order multiple pregnancies ( and the triplets and quadruplets who are born as a result of these) falls on the government, many countries have strictly regulated the numbers of embryos which can be transferred back, and in UK and Australia, doctors are allowed to transfer only 2 embryos. While this is quite sensible and appropriate for the majority of infertile couples ( young women doing their first IVF cycle), this is not sensible for older women, or women who have failed multiple IVF cycles in the past. However, the rules in these countries ( as it typical of most bureaucracies) does not allow for any individualisation or flexibility, which means that poor-prognosis patients are poorly served by these rigid rules.
In such difficult patients , our pregnancy rates are very high, because we can transfer more embryos in them ( unlike clinics in UK and Australia, where the number of embryos which can be transferred is limited by law). While transferring more embryos does increase the risk of high-order multiple pregnancies, this risk is negligible in difficult patients ( for example, the older women or women with previous failed IVF cycles). In our clinic, we customise the number of embryos we transfer for each patient we treat, rather than just blindly follow a guideline ( which has been laid down for the general population, without considering each individual's specific problem).
Are we being irresponsible by transferring too many embryos ? I don't think so . I understand it is a calculated risk, but I feel our approach is more enlightened, because we are allowing our patients to make this decision for themselves. After all, it is the patients who need to suffer the consequences of this decision, so why not let them decide for themselves ?
As I explain to patients, there are 3 possible outcomes in an IVF cycle: one good, and two bad.
The good outcome is when they get pregnant with one baby ( or two, for most infertile couples). This is a happy ending, and most couples will forget the trauma of decision making once they get to this point.
There are two possible bad outcomes:
a. not getting pregnant at all
b. getting pregnant with a high order multiple ( triplets or more).
From a government's point of view, they would prefer that patients not get pregnant at all ( outcome a) rather than have a multiple ( outcome b). This is because if the patient fails to conceive, this is her personal private loss. However, if she has a multiple, then the government needs to pay for the medical care of her newborn babies - and this can be very expensive !
However, from the patient's point of view ( especially if this is the third or fourth attempt), then not getting pregnant is a major disaster. If she gets pregnant with high order multiples, this is still the lesser of two evils, from her perspective. She can choose to carry the pregnancy ( taking the risks of prematurity into account, after being counselled about these); or she can opt for a selective fetal reduction. While it is true that this can be a heart-wrenching decision to make, the fact remains that it is being done to save the lives of some of her babies , and this therefore acts like a safety net ( much like abortion does when contraception fails). I advise my patients to "take the path of least regret", so that they have peace of mind they did their best !

Reservations and quotas - a new solution

The decision to "reserve" seats in colleges and universities for backwards classes is making the Indian summer even hotter for students, their parents - and the government. The problem is that everyone is still too focussed on the problem - how does one carve up the limited number of seats in a fair and equitable manner ? At present, the problem is that there are too many students chasing too few seats; and no matter what solution we come up with, it's bound to be unfair to the group left out, who are going to be resentful. Also, no one seems to think of the human cost of depriving a student of an educational opportunity he wants to pursue. Also, the students who do not get an education can no longer contribute as effectively to the economic growth of the country - which means everyone suffers when seats are "reserved". I feel that instead of thinking about problems, we should concentrate on solutions. I have an alternative perspective, which is worth considering.
Why not increase the seats in all the courses, so that everyone who wants to enroll can do so ? Instead of offering "brick and mortar" colleges and universities, make them all online and deliver the educational content through TV and the internet. Everyone who wants to enroll can do so , because it's as easy to teach 100000 students online as it is to teach 100 students. Students can then form their own study groups; and are free to explore additional educational opportunities on their own, if they so desire ( tuition classes, real-world teachers, and so on). The key is that there will be a really difficult examination which will be given at the end of the course - and only the ones who pass this will be entitled to graduate.
I feel this is a win-win situation.
It does not deprive anyone of the opportunity to pursue further learning, if they so desire. This is only fair and just.
Many students will drop out on their own, when they find they cannot cope, or they don't like the subject. This will not hurt them or cost them - they can then puruse alternative options.
Many more students will be able to learn using this model - and the pool of bright, educated citizens in this country will grow progressively, so that we all can do better in the future !
Can you think of any downsides ?

Clever new uses of the internet by infertile couples

The internet has proven to be a major boon for infertile couples. It has allowed them to think out of the box; and to explore new options which are not available to them in their own country ( because of governmental rules and bureaucratic regulations). This freedom has allowed many couples to achieve their personal reproductive goals, which they would never have been able to do a few years ago, because they were not aware of options outside their own country. Of course, not all couples have the courage to make the decision to travel outside their own country to take treatment, and they are often discouraged from taking this step by friends and family members. However, simply because IVF treatment is so ridiculously expensive in the US, many well-informed couples from the US ( many of whom are doctor and nurses themselves, and who know a good medical deal when they see one !) are making the decision to seek treatment overseas. This trend has been well-documented, and is often called reproductive tourism ( a pejorative term which has been coined to preserve the status quo, because US doctors feel threatened, in my opinion).
While an IVF cycle in the US costs about 2-4 times that in India, this discrepancy is much more pronounced when couples need to make use of additional options such as using donor eggs . A donor egg IVF cycle in the US can easily cost about US $ 25000 plus - and most of this is because of the legal burden ( lawyer's fees) and the agency ( who sources the egg donor) fees. Clever infertile couples are now overcoming the stranglehold of these "middlemen" , thus helping to cut down their financial expenses ( after all, the medical treatment remains similar, so it's hard to justify paying a premium of over $ 15000 to the mediating agencies). Many are now advertising for and recruiting their own egg donors; asking their local doctors to screen them for their health and fertility; and then flying down with their own egg donor to India for treatment. This means that one donor egg IVF cycle becomes half the cost of what a clinic in the US would charge ( even after you include the cost of the hotel and the air tickets) - and the donor also gets an exotic overseas holiday in the bargain !

Friday, April 28, 2006

HealthCast 2020

HealthCast 2020" It is time to look outward. The attitude that all healthcare should be local is dangerously provincial and, in extreme cases, xenophobic. The days when healthcare sectors operate in silos must end. New solutions are emerging from beyond traditional boundaries and innovative business models are being formed as healthcare becomes globalized. These solutions are changing the way the Chinese think about financing hospitals, Americans recruit physicians, Australians reimburse providers for care, Europeans embrace competition, and Middle Eastern governments build for future generations.
In a world in which economies are globally interdependent and the productivity of nations relies on the health of its citizens, the sustainability of the world’s health systems is a national competitive issue and a global economic imperative. Moreover, there is a moral obligation to create a global sustainable health system. The stakes could not be higher.
The idea of sustainability is subject to many interpretations. It is often used in the context of environmental protection and renewal of natural resources. One comprehensive definition can be found in Paul Hawkin’s book, The Ecology of Commerce: “Sustainability is an economic state where the demands placed upon the environment by people and commerce can be met without reducing the capacity to provide for future generations.” This definition applies in profound ways to healthcare."

Here's the full-text of the HealthCast 2020 report. Very thought-provoking !

Consumer-Directed Health Plans

Consumer-Directed Health Plans" To gain early insights into what is, arguably, the most important development in health insurance since the widespread introduction of HMOs in the 1980s, McKinsey & Company recently completed extensive primary research on Consumer-Directed Health Plans (CDHPs). To our knowledge, this is the first research of its type to eliminate the possibility of major adverse selection bias because it studied the behavior of consumers whose employers had made the bold move of offering only a CDHP to their employees (i.e., they offered fullreplacement accounts). Overall, this research demonstrates the potential for CDHPs to alter consumer behavior in ways that could fundamentally change how consumers think about their health – and how they utilize health care resources."
The US has always been the test-bed for new ways of delivering healthcare - and this is an exciting development. Only time will tell how well it works in practise !

The Swiss healthcare system - an alternative model

" The Swiss healthcare system - an alternative model: "Imagine an economist taking the place of a surgeon at an operating table. Such an inhumane experiment would undoubtedly result in a serious bodily harm for the patient. Now let us picture another experiment: a Ministry of Health managed by a physician. What would be the difference? The extent of the death toll. An economist at an operating-table would never be able to cause as many premature deaths as a doctor trying to handle the funding of health care without a basic knowledge of how markets work.

In many countries, common sense is not so common in the health-care finance. We should therefore look at the system used in a country where pragmatism means everything, and ideology means little: Switzerland. No health care system is perfect, but the Swiss one makes very few people complain. It is able to provide services to heads of state as well as the poorest, including immigrants from different countries, who make up about a fifth of the population.

What lesson should we take? Swiss common sense tells us that the market is the best solution for almost all areas of human activity, including the provision of health-care services. Public funding comes only when the private sector fails. What a difference when compared to the statist approach prevailing in Scandinavia, United Kingdom, Canada, Czech Republic and many other countries. Also, 'public' does not inevitably mean 'state'. Swiss health care is extremely decentralized. Switzerland does not have any Ministry of Health. Every canton and every self-governing administration unit is in charge of its own regulation, hospital accreditation, and funding. Thus, there are 26 slightly different systems in a country with a population of 7 million. A statist bureaucrat will immediately think of the chaos that must reign there. But an economist sees a different phenomenon: competition."

Different strokes for different folks - is this a replicable model ?

Creating a sustainable future - Healthcast 2020

Creating a sustainable future - Healthcast 2020" There is growing evidence that the current health systems of nations around the world will be unsustainable if unchanged over the next 15 years. Globally, healthcare is threatened by a confluence of powerful trends – increasing demand, rising costs, uneven quality, misaligned incentives. If ignored, they will overwhelm health systems, creating massive financial burdens for individual countries and devastating health problems for the individuals who live in them." This is a PriceWaterhouseCooper report on possible solutions.

UNDERSTANDING THE MIND

" Chapter 2, from Dr Kamath's book, Kamath Sutra.

2.1: The mind has two distinct compartments performing two distinct functions: the conscious mind and the unconscious or hidden mind.

[Understanding the distinct functions of two distinct components of mind is essential to understanding stress. The conscious mind is the one we use at any given moment. It is like the screen of your computer in front of you. We can see only one page at a time on the screen. Likewise, the conscious mind is aware of only one topic at any given moment.
The unconscious mind, hidden away from our immediate awareness, is like the hard drive of your computer with all its files and software. It holds millions of bits of information in it that we gathered over a life span. We are not aware of that information until a specific bit of information is brought up on the screen of our mind. After we have used it, it goes back to the hard drive. For example, you were not thinking of your grandma till I mentioned her just now. You will remember her and some good or bad feeling associated with her. Memories and emotions related to your grandma will go back into your hidden mind the moment you think of something else.]

2.2: Three functions of the conscious mind are thinking, feeling and acting in response to various life-situations.

[Any information mind receives via its five senses must be made sense of immediately. The first task is to think and assess if that information is good or bad for us. If the information is good, we feel good. If the information is bad, we feel bad and we experience one of thirty five painful emotions noted above. Even one of these emotions could bring on stress symptoms. Then we act. If we like what we perceive we want more of it. If we don’t like it we want to get away from it.
Let us say, you see a snake in your bedroom. Your mind thinks, “Wow! I have a snake in the bedroom! This is not good!” You would probably feel terrified and you would experience many severe stress symptoms: fast heart beat, heavy breathing,, etc. Now, if you are bold and experienced in snake-handling, you would try to get the snake out of the room. If you are timid, you would get the hell out of there as soon as possible. Almost all our interactions with sense objects have these three elements in them.]

2.3: The function of the unconscious or hidden mind is that of a reference library that tells the conscious mind how to judge a situation, what to feel about it and how to respond to it.

[What makes the conscious mind think that what it saw was a snake and that it could be harmful to us? Well, the conscious mind asks the hidden mind, “I see something
here. What is it? Is it good for me or bad?” The hidden mind tells the conscious mind, “It is a snake. It could be poisonous. Be afraid of it for it could bite and kill you!” If the hidden mind does not have that information in it the conscious mind would be baffled or puzzled by the snake, but not upset or stressed. Our mind is now said to be na├»ve, ignorant or clueless. Hence the statements: Ignorance is bliss. It also explains why “Our eyes can not see what our mind does not know.”
If our hidden mind has experience as to how to handle the snake safely, we would act prudently. Such prudent action guided by wisdom yields good results. Instead, if our actions are guided by ignorance, conceit, arrogance and know-it-all attitude, it could result in the snake biting us. Such imprudent action based on ignorance and human weaknesses is called stupidity. Opposite of knowledge is ignorance; opposite of wisdom is stupidity.]

2.4: The reference library in the hidden mind guiding all our actions consists of 1) Seven positive elements collectively known as wisdom: memory, knowledge, reasoning, judgment, insight, moral values and noble virtues; and 2) seven negative elements collectively known as personality weaknesses: greed, arrogance, lust, hatred, possessiveness, jealousy and insecurity.

[Any event could activate any of these factors and influence our behavior. For example, if we see a hungry child in the street, our compassion could become activated and we might give some food to it. If we see an expensive Lexus car in our friend’s driveway, our jealousy could become activated and we might buy a BMW to be one up on him. If we see a wad of dollars bills on a table, our greed could become activated and we might want to put it in our pocket. If we hear of a worthy cause, it might activate generosity in our mind leading to making a donation.
The behavior of a person at any given moment clearly reflects which of the “software” in the hidden mind is running the conscious mind. In general, weaknesses have far greater influence on our actions than wisdom.]

2.5: The conscious mind could be compared to a balloon and the hidden mind could be compared to a soda bottle with gaseous soda in it. Bad events and problems could be compared to a pump attached to the balloon.

[A balloon attached to the open mouth of a soda bottle with gaseous soda lends itself as a model of mind very well. A pump attached to the side of the balloon represents life’s bad events and problems. When one is upset by a bad event or problem the conscious mind is filled with painful emotions no different than air filling into a balloon. The mind experiences emotional tension just as the balloon experiences air tension. Stress symptoms appear immediately.

When upset about something one could say, “My balloon is inflated.” When one feels better after coping with it he could say, “My balloon is now deflated.” When a life problem has been solved, one could say, “I have turned the pump off.”
The fizz that is dissolved in the soda represents all the elements noted in 2.4 above. If one suddenly remembers an old bad event and becomes upset over it, he could say, “My soda bottle is shaking and the fizz is spewing into my balloon!”
Remember: For one to understand anything, appreciate anything, enjoy anything, feel anything and do anything, he must have the necessary validating information in his hidden mind/soda bottle. You can refer to a clueless or ignorant person as someone who “does not have it in his soda bottle.”]

2.6: The “inflating” and “deflating” of conscious mind/balloon with painful emotions happens day in and day out resulting in appearance and disappearance of stress symptoms.

[We experience upsetting events and situations several times a day, some small, some big. After we have coped with these, the balloon shrinks, stress symptoms go away and we calm down. Even when asleep, our balloon could inflate in response to a bad dream, say, a tiger chasing us. We would then experience many stress symptoms: Sweating, fast heart beat, shortness of breath, etc. When we wake up and realize it was only a dream, fear disappears from the mind, the balloon deflates brain chemicals go back to their normal state and we feel calm once again.]

2.7: Coping consists of promptly emptying the conscious mind of toxic emotions and restoring peace and tranquility in it.

[To cope with stress, one must promptly get rid of toxic, painful emotions from conscious mind. The balloon must be shrunk. This results in brain chemicals going back to their normal state. Stress symptoms disappear. Any mechanism that does not get rid of painful emotions from the conscious mind (jogging, relaxing, etc.) is useless in coping with stress. Also, activities that enhance pleasure in the mind are uniformly useless as they do not cancel-out painful emotions. Common potentially harmful pleasurable

6
activities are: smoking, drinking alcohol, overeating, gambling and illicit sex. Some useless pleasurable activities are: Hiking, skiing, cruising, bungee jumping and vacationing.
People who are not good at shrinking their balloon would need a shrink to do it for them sooner or later! Now you know why psychiatrists are called shrinks.]

2.8: Managing stress consists of adopting a simplified, wisdom-based lifestyle which prevents stressors and maintains peace and tranquility.

[By adopting a lifestyle based on wisdom, and not weaknesses, one could prevent occurrence of various life-events and problems. In the above model, this consists of controlling the function of the pump. All serious life-problems are caused by the influence of personality weaknesses on our actions.
This simple example would suffice: A wise man avoids drinking too much. If per chance he does, he is wise enough to avoid driving. A stupid man might think that he could drive safely even when drunk. Such a man would soon get into an accident or get arrested. Now he has created serious financial, health or legal problem for himself.
Likewise, people who apply wisdom in handling money would avoid financial problems by adopting a few wise rules: I will live within my means; I will not buy anything to impress others or to compete with them; I will balance my income and expenses; I will minimize waste; I will simplify life, etc. All wise people have hundreds of such simple prudent rules guiding various aspects of their lives. On the contrary, an insecure or jealous person afflicted with “Comparing and Competing Disorder” could get into a big financial hole by living ostentatiously on borrowed money. Wisdom-based lifestyle means living a simple life.]

2.9: The mind which reduces emotional attachments to people, money, power, etc. and connects with inner wisdom achieves steady state of mind that is immune to stress.

[This is spiritual approach to stress. The goal of all great spiritual texts such as Bhagavad Gita and Bible is the same: to achieve lasting peace and tranquility of mind. They all recommend four paths: 1) Rid your conscious mind of painful, toxic emotions (“conquer your fear with faith; destroy your anger with forgiveness;” etc.); 2) Rid your hidden mind of human weaknesses which create stress (“give up your greed, hate and lust” etc.); 3) Simplify your life and let all your actions be guided by wisdom in the hidden mind; and 4) Reduce or eliminate your entanglements with sense objects (people, money, power, etc.) while fully engaging yourself with them, i.e. living a full life. The last part is like the ant that enjoys drinking honey to its heart’s content from a bowl without drowning in it!]

2.10: Ability to change deep-rooted perceptions, ideas, opinions, views and beliefs is essential to successfully deal with stress.

[The importance of knowing this lies in the fact that an open-minded person steadily grows as an individual by giving up outdated ideas, perceptions, etc. and replacing them with newer ones based on current reality. This is called learning. The more we are in tune with the realities of the world the more we could avoid stress and the more successful we would be. This does not mean we give up our basic principles, philosophy or codes of conduct. We simply adjust our views and opinions to fit the new realities of the fast changing world. A closed-minded person who is not open to new ideas and information becomes stressed-out very soon due to conflicts between his beliefs and realities of life.]

Tuesday, April 25, 2006

No sex please, but we want babies

" Busy Men Bank Sperm For Wives
Charles Assisi | Times of India, 29 April 2006

Mumbai: There’s a hypothesis, apocryphal perhaps, that students of economics like to relate with great relish. Because entertainment options are limited in poorer countries like India, men and women end up making love. The happy by-product includes babies. The answer, therefore, to tackling population explosion in countries like India includes building more entertainment options.
At a south Mumbai infertility clinic though, it is fairly obvious the hypothesis dates back to an India in the socialist past. “I keep telling my patients making babies in the bedroom is more fun,” says Dr Anirudha Malpani. “But they don’t have the time,” he rues. Having said that, a pregnant pause envelopes his fifth floor office in a swank high rise. His usually articulate wife and co-practitioner Dr Anjali Malpani, lost in thought, looks away at a toy stork that resides smugly on the table.
Roughly, of every 10 people that visit their infertility clinic hoping the metaphorical stork will eventually visit them, four don’t really need to. The stork would, if only they could come around to making love. But making love takes time. And time, not surprisingly, is the first casualty when an economy starts to boom. People work harder and don’t need to be entertained anymore.
“I’d think the problem is most acute with senior software and management professionals,” Anjali points out. Then there are folks in the media like journalists and ad film makers documenting the boom. They keep unkind hours and come home to an exasperated wife who’s already called it a day.
Dr Kevin Quadros, a gynaecologist who practices at a leading hospitals in Mumbai like Holy Spirit and Hiranandani, agrees, but not quite. “In my experience, people seeking help aren’t restricted to any single social class. You’d be surprised at the numbers that come to me for assistance.”
Adds an andrologist who practices at Hinduja Hospital, “I’ve come across cases where people are so busy they’ve stopped enjoying sex, but want babies. What else do they do but go to a sperm bank?”
These are the kind of fertile folks, the good doctors say, who are now seeking assisted reproduction. Their problem is a fairly straightforward one. In the rare event that these folks manage to spend time together, the chances of the wife passing through a fertile period is rarer still. Which is why, they seek out science to help make babies for them. It isn’t fun. But what the hell!
So the busy men troop in with their wives into sperm banks. Out here, they pour their seeds into test tubes. No rocket science there. The unlettered call it masturbation. Doctors politely call it manipulation. Lab technologists quietly take over and freeze the motile vials of genetic material into cryogenic chambers. The sperm waits there, patiently, until the lady in the relationship starts to ovulate and comes back to be inseminated artificially.
These dramatic changes are not a function of changes in the male lifestyle alone. Single women in their early 20s are now walking into clinics like theirs to bank the eggs they produce. The argument is a simple one. These women don’t intend to have babies for a long time—perhaps until their late 30s or early 40s when hopefully, their careers will be on solid ground. For better or worse, the best eggs a woman produces are when she is younger. As she grows older, the quality of the eggs she produces are increasingly suspect.
To all of this, add the emergence of alternative lifestyles. Single women who refuse to get involved with a man, but want to raise a child they can call their own. Or for that matter, lesbian couples dealing with intense maternity pangs. For them the options are limited—head to a sperm bank and buy pre-tested vials of sperm uncontaminated by sexually transmitted diseases or obvious genetic defects. They can choose the profile of men whose sperm they want. Height, weight, body type, and some such assorted variables.
Elsewhere in the world, like the US, things are different—a little more evolved if you will. On sites operated by sperm banks like the FairFax Cryo Bank, women can shop online for sperm. They are allowed to filter out undesired donors on the back of variables like ethnicity, whether the sperm owner has straight hair or wavy, blue eyes or brown, and so on. Incidentally, sperm originating from a doctorate’s testicles command a premium. At the very least, $60 for a potent vial.
“Do gay men visit you to have a baby?”
“Yes, they do. But the logistics of finding a surrogate mother is difficult. So I send them back,” says Anirudha. “Aren’t there any moral issues that trouble you?” “My Catholic sensibilities don’t allow me to practice assisted reproduction. So I send them to other practitioners,” says Kevin. “What else do you caution patients about Anirudha?” “Once you’ve had a baby, there is a no-returns policy.”
This is an interesting article on how people use modern technology to change their lifestyles.

WHAT IS STRESS?

From the book, Kamath Sutra - The Owner's Manual for the Stressed Mind, by Dr K P S Kamath.

1.1: Stress means getting upset about something; peace and tranquility of mind are gone.

[Let us take a simple example: Imagine you have just lost your wallet along with its contents: money, credit cards, driver’s license, etc. You would be upset, won’t you? You are now stressed. In the course of life we become upset over thousands of small and big events and problems: death of loved one; breakup of relationship, betrayal of confidence, family problem, and the like. If it is not one thing it is another. These bad events and problems upset us and destroy our peace and tranquility of mind.]

1.2 Actual loss or fear of loss of sense objects is at the root of all stress.

[Sense objects are those things we perceive by means of our five senses. They are two kinds: tangible things such as people (relatives and friends); money and various materials we buy with it (house, car, gold, food and drinks); and intangible things we cherish in life such as love, power, position, status, honor, security, liberty, etc.
Our emotional attachment to these sense objects predisposes us to the pain of loss. More attached we are to these more we suffer when we lose them or fear losing them. When we lose these objects, we suffer grief. When we are afraid of losing these, we suffer anticipatory grief. That is why people with less attachment to sense objects experience less stress whereas people excessively attached to and possessive of sense objects suffer more stress.]

1.3: The only two causes of stress are bad life-events and bad life-problems.

[Bad life-events are one-shot painful events in which we have actually lost one or more sense objects. Death of a loved one; break up of a relationship; accident; betrayal of trust; being assaulted verbally or physically, etc. are some examples of bad events. Most, but not all, bad life-events are beyond our control. However, sometimes bad events are our own creation. An intoxicated man getting into a serious car accident is an example.
Bad life-problems are those which upset us a little bit at a time, day after day, week after week and month after month. In bad life-problems we are afraid of losing one or more sense objects and we experiences a threat related to one or more spheres of life: family, marriage, relationship, job, health, finances, etc. These problems are considered bad because they are extremely difficult to solve and one feels trapped in them. Bad life-problems are mostly our own creations. Problems at work due to tardiness; marital problems due to selfishness; relationship problem due to controlling behavior and chronic

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health problems due to bad habits are some examples. We often find one or more of personality weaknesses such as insecurity, greed and jealousy underlying all bad life-problems.]

1.4: When upset we experience one or more of thirty five painful and potentially toxic emotions: Fear, hurt, anger, sadness, guilt, shame, disappointment, frustration, helplessness, hopelessness, humiliation, hate, bitterness, resentment, envy, jealousy, terror, horror, disgust, embarrassment, rage, exasperation, insecurity, despair, dejection, remorse, regret, worthlessness, hostility, vengefulness, dread, sinfulness, sorrow, despondency and uselessness.

[Most of us experience these emotions sometime in our life. Some experience many of them all at once in response to tragic death of a loved one or discovery of spousal affair. These emotions are all connected to one another like links in a chain. They have a tendency to cascade. For example, hurt could cascade into anger, rage, hate and vengefulness. Pain in the brain is the foundation of all stress.
In small to moderate doses painful emotions stimulate emotional growth and maturity just as a small dose of fertilizer helps an indoor plant to thrive. In large doses, however, these painful emotions are toxic to brain no different than a cup of fertilizer is toxic to a plant. People, like over-fertilized plants, wilt when overdosed with toxic emotions. When we refer to certain people as toxic, we mean they upset us a lot.]

1.5: It is the presence of these toxic, painful emotions in the brain that alters brain chemicals resulting in various physical, emotional, mental and behavioral stress symptoms.

[The mind is the function of the brain. Brain is intimately connected to all body organs via circulating hormones and a vast network of nerves. When stressed, painful emotions bring about chemical changes in the brain. These chemical changes send messages to various body organs resulting in stress symptoms. In other words, we experience stress in the form of symptoms. Some common stress symptoms we experience on daily basis are: irritability, sleeplessness, sleepiness, anxiety, tension, depression, headache, tiredness, poor concentration, worrying, loss of appetite, thumping of heart, tightness of chest, sweating, and many more. If painful emotions are somehow gotten rid of from mind, brain chemicals go back to their normal state and stress symptoms also go away.]

1.6: Severity of stress symptoms depends upon the number and intensity of painful emotions in the mind.

[A woman would be very much more upset if she discovered her husband’s extramarital affair than if he forgot her birthday. In the former case, she might experience many of the above listed painful emotions with great intensity. In the latter case, she might experience only a few painful emotions with low intensity: crying, irritability, etc.]

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1.7: Stress leads to wisdom in some and stress-related disorder in others.

[Stress is the main sources of knowledge and wisdom. Knowledge is the correct understanding of the nature of people and other sense objects we deal with on daily basis. Wisdom is appropriate response to life’s events and problems based on knowledge and life experiences. It is said that good judgment comes from experience; experience comes from bad judgment. Life without stress is meaningless. Another name for paradise is boredom.
Excessive stress combined with inappropriate coping leads to stress-related physical (high blood pressure, obesity, etc.) and emotional (depressive and anxiety) disorders.]

1.8: Everyone responds differently to the same stressor due to differences in genetics, temperament, perceptions, depth of attachment to sense objects and prior experience.

[No two people respond alike to the same loss or threat of loss due to factors listed above. In fact the same person might respond differently to the same stressor at a later date. He might not get upset at all if he became wiser by the experience; or he might get more upset by it if he was traumatized and sensitized by it. All depends on how one dealt with the stressor when it occurred.]

1.9: Seven personality weaknesses of mankind create serious stress: greed, lust, jealousy, arrogance, possessiveness, hate and insecurity.

[It goes without saying that various common human weaknesses listed above negatively affect one’s behavior resulting in serious consequences to himself and to people around him. For example, greed often impairs one’s judgment leading to stress-producing stupid behavior. Arrogance earns one unnecessary enemies. Possessiveness of relatives and friends results in controlling behavior and conflicts.
Moral values and noble virtues counter the influence of these human weaknesses. The Ten Commandments are moral values all Christians are supposed to follow. Cultivating codes of conduct to cancel-out these personality weaknesses greatly reduces chances of bad life-problems.]

1.10: Three ways to deal with stress are: coping, managing and developing immunity to it.

[Coping with stress simply means getting rid of painful emotions from mind. Managing stress means cultivating a wisdom-based lifestyle that minimizes or prevents occurrence of bad life-events and life-problems which bring on stress. Immunity to stress is achieved by cultivating a steady state of mind which does not get upset in the face of stressors. To achieve these three goals, one must understand how the mind works.]

One of the reasons I love the internet is that it gives everyone a voice ! This blog allows me to become a micro-publisher, and I am very pleased to be able to publish the chapters from the book, Kamath Sutra - The Owner's Manual for the Stressed Mind, by my good friend, Dr K P S Kamath. Not only is he a wise psychiatrist, he also has a knack of playing with words to get some complex ideas across very clearly. Stay tuned, as the book unfolds on this blog.

Expanding from super-speciality to multi-speciality may not be a great idea

There comes a point in a single speciality hospital’s life when it finds itself on crossroads. This is more likely to happen if the hospital is doing well. The promoters of the hospital are in a dilemma, whether or not they should be adding new specialities. They want the label of multi-speciality set up. Marketers know of this phenomenon as ‘line extension’.
There is a school of thought among the marketing strategy gurus that line extension is a trap which tempts many organisations successfully. What is behind the thought of extending the line? The answer to this question requires a bit of common sense.
Firstly, the hospital owners think that one speciality has done well and therefore if they extend the services, the existing goodwill will act as a lever and the new service will take off instantly.
Secondly, the extra funds created by the success of the one speciality, give the extra courage to the promoters to experiment and thirdly, in wake of existing or future competition, the hospital decides not to put all its eggs in one basket.
A classic example is one orthopaedic hospital called Dr Chandan’s Ortho Centre (not the real name). Dr Chandan did his MS in orthopedics from a leading medical college and then went to UK to do his (M Ch). On his return, he got a break with a big multi speciality hospital in his city.
Fortunately, he made a good name for himself and soon he was the most sought after doctor in orthopedics. In due course of time, he was tempted to open up his own nursing home, which he did. Fortune favoured the brave doctor as his practice went roaring within a year. There was no other orthopedic centre in the city which could boast of gadgets like image-intensifiers and top of the line X-ray machines.
After a few years, he decided to be brave again. He thought that it would be great if his wife, who was a gynaecologist, left her present job and joined him. He even invited his childhood friend, Dr Harish (not his real name), who was a good laparoscopic surgeon in the neighbouring town to join him. Dr Harish also had a medico wife who had specialised in pathology and was keen on jumping on to the bandwagon.
The whole idea made perfect sense. The hospital was already well known. So, the word would spread around easily. The doctors had already earned enough and the funding of new equipment was not a problem. Moreover, since they shared a strong bond of being friends, the idea sounded exciting. They were ready to rule the town to the extent that the big hospital that Dr Chandan had initially worked with, could also face competition from them. Alas! It was not to be.
The start was too slow. Dr Chandan’s work did not get affected much, but the other specialities just did not pick up. So, the promoters decided to pump in some money to boost the new specialities. They even changed the name of the hospital to Dr Chandan’s Multi-Speciality Centre.
Dr Chandan also lost focus and his practice started to go down for the first time in his life. A pro-active competitor took opportunity. He hired a strategy consultant and started to improve upon his single speciality orthopaedics hospital.
He bought a top of the line image intensifier, employed a part time neuro surgeon and a part time plastic and reconstructive surgeon. Soon, he came to be known as the number one trauma and orthopaedic centre in the city. Till date, he does at least 30 per cent extra surgeries than his counterpart, who is still struggling to get his new specialities to take off.
I am sure many of you would ask,‘How come?’. Some of you may even go the extent of saying that this story can not be true. So let me explain what went wrong.
Marketing in a competitive environment is like waging a war. As in war, there are objectives (customers) to be achieved before the opponent reaches them. Also, you need to defend your territory aggressively by improving yourself ongoingly.
In this case, the hospital in question already had captured a major chunk of the territory. But when they decided to employ new forces and capture a new region, it made them weak in defence. All of a sudden, they realised that capturing this new market, with the new service, will mean fighting a new set of competitors. These competitors were, in addition to the existing ones.
Moreover, they were already established in their respective fields. Not only those, the existing resources of Dr Chandan’s Ortho Centre were divided along with his focus. This made it easy for the existing competitors to make inroads into his defences.
A very important factor that led to the failure of this ‘exciting’ venture was, the displacement of the place that Dr Chandan’s Ortho Centre held in the minds of the prospects. All of a sudden, the prospects had to create a new place for the hospital, which did not gel with the existing reputation.
It was as if Maruti had suddenly decided to manufacture scooters and in addition to that, it was trying to push this idea down the throat of its prospects, based on its impeccable reputation as a car manufacturer.
Marketing is a game of perceptions. People do not buy your product or service. They buy the perception or image that is associated with it. It will be very useful to add that, in some instances ,the extension of services into a new area can be successful. Especially, if the area in which the extension is being done is devoid of competition and there is a demand for the new service.
Also, it may help to offer the new services under a new name, so that the existing ‘positioning’ is not meddled with. All in all, my phrase of advice to the people in this dilemma is-‘be careful.’
(The writer , Vivek Shukla, is a healthcare and marketing consultant. Email:vivekshukla2002@hotmail.com)

Monday, April 24, 2006

I wish someone had told me about how I lose eggs as I grow older

I just completed doing an IVF cycle for a very nice 32 year old woman. She is happily married, confident, articulate; and has a very successful career. She now wants to start a family, and has found to her dismay that she can't conceive on her own. During her workup, she found to her shock that her egg quality was poor. She could not understand why her egg quality was an issue when she was only 32 years old.
I explained the biology of fertility to her. All women are born with a certain number of eggs - and they don't produce any new eggs during their lifetime ( unlike men, who produce millions of sperm daily). As women grow older, their eggs start getting depleted, until they run out of eggs and their periods stop for ever. This stage is called the menopause. However, for a period of about 10 years before they reach the menopause, their egg quality declines silently, so that it's enough for them to get regular periods, but not enough for them to conceive. This phase is called the oopause, and is "silent" - there are no signs or symptoms, as the biologial clock ticks on with a vengeance.
This is why when a young woman with regular cycles finds out she is infertile because of poor quality eggs, the news comes as a rude shock.
This is the first time these young people are having to confront their own biological limitations - their own mortality. Most other things in life have fallen into place for them. They work hard, do well in their exams and jobs, earn more money, get a promotion, buy a new car, a new house - and this is the first time they are being forced to deal with a situation which is out of their control - no matter how hard they work at it, or how much money they spend on it. This can be a very uncomfortable feeling, and they find their life spins out of control.
The commonest complaint I hear is - I wish my doctor had told me that my fertility would drop so dramatically. I wouldn't have wasted so many years taking birth control pills ! Why didn't my doctor warn me ?
This is why most women find themselves between a rock and a hard place when they try to balance childbearing and their career.
In all women, fertility declines after the age of 20 , but from 20- 30 the decline is so gradual , that it really does not matter much. After 30, it does become an issue, and after 35, the decline is precipitate.
However, the rate of decline varies from woman to woman, and while some 40 year old women can happily make babies in their own bedroom, many 35 year olds have a hard time conceiving, and need IVF treatment.
The easiest way to monitor your ovarian reserve ( your fertility) is by doing a simple inexpensive blood test which measures your FSH ( follicle stimulating hormone) level. This is best done on Day 3 of your cycle. As a woman grows older, the FSH level rises, and high FSH levels correlate well with poor egg quantity and poor egg quality.
Unfortunately, most family physicians and gynecologists are clueless about the importance of this test. When a 28 year old asks them whether it's safe for her to postpone childbearing, most of them give her a reassuring pat on the head, and tell her not to worry !
While this advise may be fine for some women, it's a major disservice for others. I feel women need to take matters in their own hands, and ask their doctor to measure their FSH levels, so there is a sound scientific basis for their reassurance. If the FSH level is borderling high, which suggests poor ovarian reserve, further testing to check ovarian reserve is called for, including an ultrasound scan for antral follicle counts.
I feel women already bear a disproportionate burden of responsibilities in our world.
Educating them about how they can check their fertility reserves can help them deal better with the career versus baby conflict so many of them have to deal with in their lives.

Sunday, April 23, 2006

Marketing lessons for hospitals and doctors

"There were times when marketing was looked down upon as something not worthy of being associated with the noble profession of medicine. However, things have changed for the better now.
Marketing strategies, market development, etc. are being taken seriously by hospitals. Of course, hospitals cannot market themselves as other service providers like hotels and airlines, but still they can market so as to gain maximum advantage.
The three commonest mistakes made while marketing services are:
1. Providing a service and then looking for clients.
Dr Amit completed his MD in internal medicine and he opened a small clinic with 5 beds and a lab in small locality in Delhi. Having done some research in the field of cardiology, he was confident that he could do a good job with heart patients. Even the board in front of his clinic read- “For heart and other ailments.” He even gave some initial free check-ups to heart patients and charged nominally for ECGs and lipid profile investigations.
Logically, everything should have gone right for the doctor. But even after six months his practice did not pick up. The problem was that the incidence of heart disease in that locality was not high. Instead the adjoining factories and mills made it difficult for people to breathe in good air.
An asthma clinic would have done better under the circumstances. As many as 35 per cent people had respiratory problems in the area. So, after that doctor changed the clinic’s positioning to asthma treatment from heart ailments, his practice grew by over 40 per cent in three months.
He had to change his boards and buy a spirometery machine. Moreover, he never offered free check-ups and discounts on lab tests. If you look around closely, this is not a unique example. This kind of mistake is being made almost everywhere.
People offer what they can do best, but they do not care to see if the customers really want it. Ideally, it should be the other way round. We must first identify what the market needs. Then we must see if we can provide that.
2. Reducing prices as a strategy.
A leading gynaecologist Dr Sumita was running a nursing home in a big city and was feeling threatened by another young gynaecologist Dr Mona, who decided to open shop in the same locality. To make things worse, this young new doctor was advised by her friends and relatives (who had no expertise in the field of business strategies) that she offer her services for a lower price in order to attract more patients.
Like 90 per cent of amateur businessmen, Dr Mona saw it as a master plan to topple the market leader. So there she went offering the same services at a cheaper fee.
As a result, Dr Sumita, who was already threatened (though there was no reason to be), reacted by lowering her fee too. Dr Mona, in retaliation, decided to not only reduce her fee once again, she even ran messages on cable TV and local newspapers about her low fee.
The patients knew what the two women were upto. So a trend of bargaining started in both the nursing homes and their profits dipped simultaneously.
In the end, none of the competitors won. The moral of the story is: “never try to outrun the competitor by reducing prices because it gets you into a vicious circle.”
Seasoned marketing professionals hardly get into a price war. Ever wondered why Pepsi and Coke cost the same to the customer when both have the capacity to easily reduce the price by at least one rupee?
3. Copying the leader.
Dr Sinha, a pathologist, opened a massive diagnostic centre with a MRI, CT scan, ultrasound and many modern laboratory machines. He also employed a couple of radiologists and a junior pathologist. More than that, he employed PROs to collect samples from various places in the entire district. Everything he did to promote his centre was strikingly similar to the ever-popular Das Diagnostic Centre, which was running very successfully for the past 5 years.
Sinha Diagnostic Centre had replicated the success formula to perfection including the name. Even the colour scheme and interiors of his building were similar. Unfortunately, Dr Sinha learnt it the hard way. The market already had one provider doing a decent job so there was hardly any room for a duplicate. Your business has to be unique and original. Not only that, the uniqueness and originality has to be relevant to the consumer so as to invoke sufficient interest in her so that she buys from you.
The trick to successful marketing is to identify a ‘vacuum’ in the market and fill it up before anyone else does it. Never try to fill up a vacuum that has already been filled by someone else. As entrepreneurship takes over the society in our country, marketing will become more and more relevant. As long as we indulge in ethical and professional marketing activities, it will be a win-win situation for everybody, including the service providers and patients; not to mention the consultants, like yours truly!
(Names of people mentioned have been changed to protect their identity).
(The author , Vivek Shukla, is a healthcare and marketing consultant with The Marketing Plans. E-mail:vivekshukla2002@hotmail.com)"

Saturday, April 22, 2006

Everyone seems to be an infertility specialist !

Infertile couples are bombarded with advise - what to eat; what not to eat; when to have sex; when not to have sex; how to have sex; in which position to have sex; which doctor to go to; and which pill to take. The old wives' tales about fertilty are mind-boggling - I still come across new ones even today, which continue to amaze me. Unfortunately, because infertile couples are so desperate and vulnerable, it's hard for them to separate the wheat from the chaff - and they often end up making a bad situation worse by trying to follow all this advise - some of which is contradictory, and most of which is rubbish. Unfortunately, most of this advise is well-meaning - and comes from well-wishers who are trying to help them to start a family.

Many people believe that just because they have made a baby in their own bedroom without any help from anyone, this makes then an infertility specialist , qualified to dispense advise !

Please don't so this. Infertile couples have a rough time as it is. Don't add to their stress levels by providing them with advise they can do without !

Seven Deadly Marketing Sins for Doctors

Seven Deadly Marketing Sins for Doctors

This is a guest blog by a clever friend of mine, Mr Vivek Shukla. He provides wise advise to doctors, which they would do well to heed ! Doctors are also businessmen, but they often behave as if they were immune to the laws which apply to other small businesses. This ignorance ( and foolhardiness can prove to be expensive for them !)

" Marketing is a simple phenomenon. You find out what is required by people and you give it to them [of course at a price]. Technical language for this is - ‘find the felt needs of the target market and find ways to satisfy those needs at an appropriate price.’

Sometimes people don’t know that they want some service/product. In this case the marketer first makes them realize that they need the product/service. After the people find out that they need it, they start asking for it. The jargon for this is – ‘find the latent needs of the target market and provide ways to satisfy those needs once they become felt needs, at an appropriate price.’

Simple laws of marketing like the ones describes above are ignored by entrepreneurs. They commit, what I call marketing sins and then they pay for sins by losing business and money. I have attempted to highlight the 7 deadly sins of marketing below with an intention that people are enlightened about what not to do while marketing their hospitals/services.

1- Arrogance. This seems to be the most common of all marketing sins. People are arrogant enough to enter a market with a service and not even care whether the service is required in that market or not. They seem to tell the world- ‘this is what I have, take it or leave it.’ Well, the world doesn’t care. They give a damn about what you have. Everybody is obsessed with what they want. If you’ve got what they want, you’ve got a chance of surviving. A smart way of doing business is finding out what they want and how they want it. Thereafter, telling them in their language that you have all that they want and may be even more. If they want it, they can have it at price. Gone are the days when Henry Ford said, ‘Give them any colour of the car as long as it is black.’

2- Injustice. I am so surprised at the amount of effort and money people put into marketing their services and in training their employees. Building a hospital, clinic takes a lot of money. In addition to that, installing machines, studying to get a degree, etc also costs a lot. How come, when so much is spent on building a product, there is hardly anything spent on promoting it? This is an era of competition and marketing. Millions are being spent in many industries to market the products and services. Products are being packaged, priced and promoted in many attractive ways. There are teams of people who are dedicated to marketing only. In my opinion, building a world class product is useless if it remains the best kept secret in town.

3- Ignorance. Lets face it, if you are ignoring the image building exercises of your product, you loosing out on an opportunity to rule the thoughts of people. Every business has an image in the minds of the people. This image can be either created consciously or it gets created by default. Pro-active marketers create the image for their product by putting in well designed efforts and by using various vehicles to reach the people. They know that if they don’t do it, people will themselves create an image for their product. If Deccan Airways doesn’t create an image of a ‘no frills cost effective’ airline, people may say ‘it is a cheap, poor quality carrier.’ It is therefore smart to create a positioning in the minds of people rather than leave the job of creation to the them.

4- Counterfeiting. Becoming a copy cat is an expensive proposition. As I always say, ‘Who will go for a cheap imitation, when the original is already available?’ lack of confidence prompts people to copy a successful business model. It kills the opportunity to be unique and creative. They want to be similar. Not a good idea though. A genuine person is favoured for his originality and a fake is always shunned.

5- Impatience. How much time have we thought that a free camp did not yield results and therefore free medical camps are a waste of time? We want instant results. This is a period in the world where fast food and instant coffee rule. So why wait for results in work scenario? Well, the old and have always said, “Good things happen to those with patience.’ Perseverance is a virtue every entrepreneur should learn. It takes years to build a brand before enjoying its fruits. Preparation and execution of marketing plans, day after day, month after month and year after year is the only way out. In any case doesn’t the Bhagvad Gita say ‘To action alone thy has a right and not to its fruits?’

6- Fighting the wrong battle. To attack a competitor where he is already strong is never a good idea. If the competitor hospital is known for its emergency services with the target market, you must know that the ‘emergency services’ place is already taken. No matter how hard you try to prove yourself better, it will be next to impossible to dislodge the position from the minds of the prospects. A bright strategy will be to find out is the competitor is perceived as weak in some area that the prospects want. For example if the same competitor is known for long hospital stay for patients, that is where you can create a place for yourself. They may be good for emergency services but they make the customers wait a long time before sending them back home. Our emergency service are also good, moreover the average stay of a patient in our hospital is 20% less than others. Attack the weakness and not the strength.

7- Getting distracted. Losing focus of ones core competencies is very easy. An orthopaedic set up can easily fall into the trap of adding other specialties just because orthopaedics had seen success in the recent past. It is a far better idea to improve upon the existing specialty rather than create a new department altogether. The biggest harm done by line-extension is the dilution of the brand image. People already have a certain perception of your brand. Now, trying to mess with that perception causes dissonance in the minds of the target market. They start getting confused about your identity. If you had started off as a multi specialty set up in the first place, then there would have been no problems. So, stay focused and keep improving upon what you are already known for.

The lord forgives the sins of humans. After all, to err is human. Regrettably, the sins of marketing prove very costly. The jungle [market] is unforgiving. Only the fittest survive here. It makes sure you pay for your sins in this lifetime itself.

-Vivek Shukla"

Friday, April 21, 2006

Controversial Twist on Outsourcing 'Labor'

Controversial Twist on Outsourcing 'Labor': "Dr. Marshall questions whether it's fair for physicians in India to help recruit eligible surrogate mothers in their country when such a significant financial incentive is part of the equation. 'It's not necessarily unethical, but it's not necessarily right.'"

Looks like US physicians have major double standards ! It's OK for US lawyers and agencies to recruit surrogates in the US for 10 times the cost - but it's not allright for Indians to do this ! I guess they are now jumping to illogical conclusions beause they feel threatened !

Thursday, April 20, 2006

The problem with reservations in India

India is now in a turmoil because the government wants to extend the proportion of reserved seats in educational institutions. While the rationale for reserving seats for "backward classes" in order to help them develop themselves makes sense, I feel this is the wrong approach. Let's take a brief look at the issues, since they are quite complex.

India has a long history of ill-treating its backward classes. They were ostracised and treated as outcasts. After independence, in order to help them join the mainstream, it was decided to reserve seats in educational institutes, so that they could educate themselves, and better their prospects. Not only were places in colleges and universities reserved for them; jobs in the public sector were also earmarked for these classes.

While this was a reasonable way to trying to atone for the sins of past generations, this reservation soon got out of hand. In fact, today in some colleges, over 70% of the seats fall into the "reserved" category - which means that 90% of the students need to compete for just 30% of the total seats.

The reason this farce carries on is political compulsion. The backward classes represent important votebanks for politicians ( the poor will turn out in large numbers to vote, while the rich in the world's largest democracy usually are too busy to vote !), so no leader wants to anatagonise them.

However, the consequences of this reservation policy have been horrendous. While it's reasonable to use reservations as a crutch, to help underprivileged youngsters to catch up, they should have been phased out. Unfortunately, they are being misused, and no one wants to give up the free ride these reservations offer !
They breed corruption. Many influential people get false certificates to "prove" that they are from a "backward class" - so that their children can take advantage of the reserved quota.

The reservation is on the basis of social origin - not on economic grounds ! This means that even very rich students who happen to have been born in a "backward class" take advantage of this reservation - though they are not disadvantaged at all. This means the system is rampantly misused.

The system also breeds segregation and resentment. Rather than helping the backward classes to achieve mainstream integration, it has just created unhappiness and frustration amongst the general public, who now feel "underprivileged" because their children no longer have access to educational opportunities, because most of the seats have been reserved !

This has also ended up diluting standards. While it might be allright to reserve seats in undergraduate courses, to do so in postgraduate courses is unfair - if these students have still not caught up, they are never going to be able to . Even worse, since many of them cannot read and write English, teachers are forced to dilute their courses, resulting in a poor overall quality of students who graduate from Indian universities.

Our graduates represent our best opportunity at allowing Indians to remain competetive in the world. If we turn out poor quality graduates in order to accomodate the backward classes, we are headed for disaster !
The other students now feel illtreated and deprived - they have become the new backward classes ! This is a shame, and has created a lose-lose situation !

Unfortunately, we cannot solve a problem at the level at which it was created.

The problem is that we still persist in approaching this mess from a position of scarcity. Our mind set is that we have limited resources , which means we need to reserve these seats for the backward classes, in order to ensure equity for them. However, in our quest to give them a fair opportunity, we seem to be giving everyone an unfair break !

What we need to do it to increase the size of the cake, rather than think of ways of slicing it ( no matter what method you choose, it will always be unfair to some group !)

Let's approach the problem from a position of abundance. Education is not a non-renewable resource ! The more you teach - the more learning there is. It's like love - it multiples , it does not get divided ! There is plenty to go around - let's think of clever ways of ensuring that we can teach everyone to the same high standards, so no one who wants to learn is left out.

We need to create new opportunities to spread learning, and modern technology allows us to do this. Why do we still think in terms of "brick and mortar" colleges and universities ? Why can't we clone the IITs to create a much huger virtual IIT ? Anyone who wants to participate in the courses should be able to do so online !

We can capture the learnings of exemplary teachers from all over the country; and deliver these online to anyone who wants to learn from them ! While there will be a certain amount of expense and effort involved in the beginning, this will have a multiplicative effect, and has the potential to touch millions !

India has enough clever teachers and money to be able to do this on its own . The technology is now mature enough; and a small investment in this can result in huge dividends.

This is a great opportunity - and anyone who does it well can make lots of money as well !

My godson is now one !

Emergic: April 17, 2006 Archives. Father to Son . : "This week on Wednesday, Abhishek turns one. Continuing what I began last year, here is my next letter to him. Dear Abhishek, Happy Birthday! It is hard to imagine you are one. (There are also times when it is hard to imagine that you are only one!) You'll be much older by the time you can read these letters, but I thought I'd still continue the series so you have a little written record of your life and the world around."
Rajesh is a very close friend, and Abhishek is our godson. He'd come over for his first birthday yesterday. This is one of the reasons why I love being an infertility specialist. The work we do can change people's lifes so dramatically - and the results keep on growing !

Monday, April 17, 2006

Organised pharmacy retailing may threaten traditional medical stores soon

Organised pharmacy retailing may threaten traditional medical stores soon : "High profile pharmacy stores, initiated by Medicine Shoppe a few years ago, are spreading fast across the country threatening to overshadow traditional medical shops with no air conditioning and pharmacists at the counter. This trend has also given a boost to the profession of pharmacists in the process.
International retailers have recognized the opportunity available here and quite a few retail pharmacy chains are coming into the country. Apollo Pharmacy, Medicine Shoppe, Dial for Health, Health & Glow, Guardian Lifecare, Himalaya and Global Healthline are already major names in the Indian drug trade scene today and are planning major expansion of their operations."
A major opportunity for these new pharmacy stores is to offer value addition to their customers by providing them with educational materials about their illness. This will give a big fillip to patient education in India !

Saturday, April 15, 2006

Advise to a young doctor

At a party I attended recently , I met a young consultant obstetrician who had just started practise. She was complaining about how ungrateful patients were, and how they refused to trust her. She had just seen a patient who had a missed abortion - a common pregnancy complication , in which the fetus dies in utero. Once the diagnosis is made, the pregnancy needs to be terminated. She had made the diagnosis, and had advised the patient to get admitted in the hospital, so that she could perform the surgery ( a dilatation and curettage) the next day. The patient agreed, and the doctor was pleased that she had provided good medical advise.
Much to her dismay, she got a phone call from the patient's family physician a few hours later. The family physician wanted to know what the diagnosis was, and whether the surgery was really needed. She did explain the facts to him; but internally she was very upset that the patient did not trust her. She was offended that even though she was a specialist ( and thus "outranked " the family physician in her field of expertise) , the patient still needed to talk to her family physician ( who was a generalist, and not as well qualified as her in dealing with pregnancy complications).
I feel this attitude just reflected how immature she was. Consultants need to understand that even though they are specialists, and technically very qualified, from the patient's point of view, a doctor is a doctor; and the patient needs a doctor whom they can trust - someone they have built a relationship with. This is often their family physician, whom they have known for years. From the patient's viewpoint, counter-checking with the family physician was not a slur on the specialist's abilities; but simple common sense, to confirm that the advise was right. Rather than taking offense at this, she should have taken this opportunity to educate the family physician about the problem, and thus provided additional value.
I also felt that she was not very empathetic. While a miscarriage is a daily "bread and butter" problem which obstetricians deal with daily, it's a major emotional setback for the pregnant woman;who needs a lot of counselling and hand-holding. Unfortunately, few specialists provide this, preferring to take a "cut and dried" matter of fact approach. Thus, while they deal correctly with the medical problem at hand, they provide poor medical care by failing to address their patient's emotional needs.
Unless this consultant learns to see things from the patient's point of view, she is not likely to do well in practise ! Her patients will be unhappy with her - and she will always remain clueless as to why they don't trust her.

Friday, April 14, 2006

Stress Management for Patient and Physician

Stress Management for Patient and Physician: "One of the most important things we can do for patients is teach them about stress management. Even better, we can learn these lessons ourselves and then model them for our patients. Although there are many approaches to stress management, this article lists 10 ways for reducing stress that are practical, beneficial and which even busy physicians can start implementing in their patients' and their own lives."
Good summary of what all doctors need to know - both to teach our patients, and to do, in our own lives !

Dr. Bill Crounse: Healthcare self-service offers patients the conveniences they've come to expect

Dr. Bill Crounse: Healthcare self-service offers patients the conveniences they've come to expect: "Time is ripe to personalize healthcare. The Internet is a valuable tool to personalize healthcare. With access to pertinent information, patients actively participate in their own care, manage their wellness, and make better health decisions. Ultimately, this can lead to increased compliance to treatment regimes, a healthier population, and potentially lower costs for all. These advancements couldn't come at a more opportune time. There are many factors in today's healthcare setting that prompt the need for patient self-service. Exorbitant healthcare costs have dramatically impacted consumers, providers, and health plans, leaving more Americans uninsured and more providers grappling for reimbursements from services provided. Chronic disease is one of the root causes in these rising costs, accounting for approximately � of all healthcare spending. With an aging population and more individuals in need of care, the system will be strained even further, especially in underserved rural communities with inadequate medical resources.

Patient self-service creates positive ripple effect

Patient self-service would have a positive impact on all entities in the healthcare system, much like the effect in the airline, financial, and shipping industries. Within the confines of a hospital or clinic, patients would spend less time waiting and enjoy more time with clinicians. From their homes, patients can register for appointments in advance and/or access medical records and other health-relevant information. Providers benefit through reduced risk of liability, increased productivity of personnel, more streamlined processes, fewer medical errors, and reduced redundancy in data entry. These benefits translate into savings in time and money, high-quality care, and satisfied patients."

So why aren't we doing this ?

Thursday, April 13, 2006

Fertility Tourism: Childless Couples Try India - Newsweek: International Editions - MSNBC.com

Fertility Tourism: Childless Couples Try India - Newsweek: International Editions - MSNBC.com: "And Indian clinics are performing a growing number of IVF treatments for foreigners frustrated with disappointing results and soaring costs at home. By some counts, the industry brings more than $450 million a year into India. British and American couples in particular make up a big part of the recent influx of foreigners. The number of Brits and Americans coming to Malpani Infertility Clinic in Bombay has jumped dramatically in the past three years, says Dr. Aniruddha Malpani, the director. About 15 percent of his patients are now foreigners with no family connection to India."
It's nice to be featured in Newsweek !

Wednesday, April 12, 2006

U.S. Ranks Poorly on Many Measures in Cross-National Patient Surveys

U.S. Ranks Poorly on Many Measures in Cross-National Patient Surveys: "U.S. health care leaders often say that American health care is the best in the world. However, recent studies of medical outcomes and mortality and morbidity statistics suggest that, despite spending more per capita on health care and devoting to it a greater percentage of its national income than any other country, the United States is not getting commensurate value for its money. The Commonwealth Fund's cross-national surveys of patients' views and experiences of their health care systems offer opportunities to assess U.S. performance relative to other countries through the patients' perspective—a dimension often missing from international comparisons."
Patients seem to be getting poor value for their money - in the bastion of capitalism ! Pretty ironic, isn't it ?

Survey: Doctors Favor Patient-Centered Care, Few Practice It

Survey: Doctors Favor Patient-Centered Care, Few Practice It: "A gap exists between knowledge and practice—between physicians' endorsement of patient-centered care and their adoption of practices to promote it, the authors say. Physicians reported several barriers to their adoption of patient-centered care practices, including lack of training and knowledge (63%) and costs (84%). Education, professional and technical assistance, and financial incentives might facilitate broader adoption of patient-centered care practices. 'With the right knowledge, tools, and practice environment, and in partnership with their patients, physicians should be well positioned to provide the services and care that their patients want and have the right to expect,' the authors conclude."

Does information therapy have any adverse effects ?

I am a big believer in prescribing information - and I believe well-informed patients get better medical care. However, sometimes patients tell me that " a little knowledge can be dangerous "; and that they often prefer not reading about their problem, because "ignorance can be bliss" ! All cliches contain a grain of truth, and I am sure these do too - am I too blind to see them ?

A basic principle in medicine is that any treatment which can have good effects can also have bad effects ! Is this true of Information Therapy too ? What could these side effects be ? Excessive worrying ? Needless anxiety ? Hypochondria ? How do we identify them ? And how do we prevent and treat these ?

Is paternalism in medicine a bad thing ?

I am reading a fascinating book by Angela Coulter, titled "The Autonomous Patient - Ending Paternalism in medical care". While I am a big believer in patient autonomy, I sometimes wonder if a little bit of paternalism is really so bad in medicine ? I am sure lots of patients would love to have a doctor who serves as a father-figure and tells them what to do ! I guess the secret for a good doctor is to be able to adapt his style, depending upon what the patient needs - and wants. Flexibility is a useful skill to acquire - and good doctor give patients what they want. The "middle path" proposed by Gautam Buddha would apply well in this situation !

Start Using RSS for Health/Medical Alerts and Data Sharing

Start Using RSS for Health/Medical Alerts and Data Sharing: "RSS is a wonderful solution to the 'how do we tell everyone we have new stuff without sending out a bunch of e-mails?' problem. Although it's quite popular for syndicating content such as news, blog articles, and related information, I think RSS has a chance to make a huge impact on healthcare and medical data sharing as well.
Today medical devices send out alerts using one or more mechanisms in a 'push-based' approach. For example, the device manufacturer has to write software to send alerts via e-mail, pager, phone, etc., whenever some programmed action occurs in the device. In the health-IT world, data sharing occurs through HL7 in a hub-and-spoke or publish/scribe model where all information is published to a broker and that broker is queried for things such as new lab results, updated patient information, etc.Well, what if all medical devices had the ability to respond to RSS requests on various channels? For critical messages, the push method would be fine, but for other kinds of messages, we could have a channel that an IT system could poll every second, minute, or over many hours depending on how often the system wanted an update from a device. Instead of all the devices always sending out all messages, why not put in some simple code to respond to RSS requests and separate the different message types into RSS channels? This way, the pull-based approach allows the device to be more responsive to each client instead of having to use a broker model to send out all messages."
Here's a clever use of a commonly used technology !

Tuesday, April 11, 2006

WSJ.com - Doctors: Post Your Prices

WSJ.com - Doctors: Post Your Prices: "If a goal of health-care reform is to empower the patient, why is there such a mystery about medical prices? Instead of allowing government to set them, which is essentially the case for the great majority of medical procedures, the role of the government should be to make transparent the pricing of these procedures. In our current system, few patients are aware of the costs of their medical care, generally because patients have no reason to ask since it is paid for by third-party insurance programs. This has allowed hospitals and doctors to avoid public view. Patients, however, would greatly benefit if the government required that prices be posted for common medical procedures before the care is administered, in the same way that the government requires clear labeling of medicine and food and open disclosure of prices on gasoline and automobiles. When prices are openly stated and widely known, competition will ensue and prices will come down -- regardless of whether or not patients initially use that knowledge to make their 'purchasing' decisions. This would allow the price mechanism to function again."
This makes a lot of sense. We do this on our website ( www.drmalpani.com) and it helps to keep everyone honest !

Monday, April 10, 2006

Dell Takes Health Care Online

Dell Takes Health Care Online: ""We feel strongly that the whole issue of e-health, that the practices where technology is used to make industries more efficient, needs to be done in health care," Rollins told BusinessWeek Online. "It would make health care more efficient, and spend money on the actual care of people rather than administration."'Virtually every major corporation in America is considering some kind of employee-directed online health-management tool,' says Wayne Gattinella, CEO of WebMD Health, which is supplying the technology for Dell's health-record system. 'Dell is one of the companies in the lead, but we believe [within] the next couple of years most employers will be in a similar position.'"
This is going to provide a big push for PHRs - Personal health Records ! It's just a matter of time when companies in India start doing this too !

Sunday, April 09, 2006

Patient empowerment at Cleveland Clinic

Patient empowerment at Cleveland Clinic : “Patient empowerment is the fundamental issue,” says Holly Miller, M.D., managing director of e-Cleveland Clinic. “We wanted to show patients that we value their time and respect their autonomy by giving them quick and easy access to information and appointment-making at their convenience – not ours.” By using MyChart, one of the first services offered through e-Cleveland Clinic, communication between Clinic patients and their health care team is enhanced, not replaced. Through this service, Clinic patients can access parts of their own medical record via the Internet, any time of day or night.In a fast, easy and totally secure manner, MyChart can display diagnoses, test results and other information released by the patient’s physician."
This is a peculiar notion of patient empowerment ! Why should information have to be "released" by the physician ? Doesn't the patient own this information any way ? What are we trying to hide from them ? and why ?
Why not allow all patients to own their entire medical record ?

Second Opinions Around the World

Second Opinions Around the World: "The medical community’s attitude about seeking second medical opinions has always been straightforward encouragement, and it is all the more so now in the current consumer-driven environment. The Clinic has been performing diagnosis re-appraisals since its inception more than 80 years ago.But the Internet’s reach, coupled with the Clinic’s ever-increasing global reputation, has broadened the possibilities tremendously, leading to creation of the MyConsult remote second opinion service. To handle these mounting requests for second opinions, the Clinic’s medical staff, in conjunction with the e-Cleveland Clinic nursing staff in its Clinical Operations Center, has developed protocols laying out the kinds of information doctors will need in order to perform a quality second opinion.
This material, including X-rays, CT scans, MRIs and other imaging studies, is then assembled into a comprehensive patient file that physicians can more efficiently fit into their regular workflow. And what does the patient receive? “They get a copy of the consult report, and 48 hours later they get a call from the Clinic staff, asking if they have any questions,” Dr. Schaffer explains.
Requests for second opinions now flow through the Internet into the Clinic from almost every state in the United States and nearly three-dozen foreign countries thus far. The list reads like a roster of the United Nations - Bahrain, South Korea, Russia and Argentina among them.
The number of electronically-requested second opinions performed at the Clinic increased by 400 percent from 2002 to 2003, and took another 57 percent leap in 2004.
As Dr. Schaffer reads from a number of warmly appreciative patient letters, some handwritten, sent in the wake of these second opinions, one is struck by how none of the correspondents even make mention of the fact that these consults all happened, not in person, but electronically. That doesn’t surprise the physicians, who have always operated on the notion that the consult is real even if the visit is virtual. “If you do it properly, people don’t distinguish between the delivery methods of care,” says Dr. Miller.
Even insurers appear happy with the result. 'After all,' says Dr. Schaffer, “the right care at the right time is going to be more cost-effective for our patients.” "
Virtual Visit, Real Care. When Mohamed cannot go to the mountain, the mountain comes to Mohamed !

Now, wait for the 'Ix' effect- The Times of India

Now, wait for the 'Ix' effect- The Times of India: "He might not have realised but net-savvy Jain was only following a growing trend across the world of taking a dose of information therapy when hit by any news of sickness. Ix, as information therapy is indexed, is the latest mantra sweeping across health corridors in the United States. From healthcare companies to insurance-providers, everyone is seeking information that comes with a tag of assurance or expertise. This was the essence of a seminar on 'Putting Patients First', held on the occasion of World Health Day on Friday at HELP Health Library on D N Road, where both Kemper and Jain spoke.
"Ix is about building a better public health system. It is about prescribing the right information to the right person at the right time," says Kemper, whose disease database is licensed out to nine of the 10 largest US websites as well as consumer portals. Ix is most relevant to India where patients are either too shocked to hear about diseases or too shy to ask their doctors for a detailed explanation. According to HELP Library's Aniruddha Malpani, many Indian doctors are guilty of not dispensing information — one of the most powerful therapeutic tools at their disposal — to patients."
Ix is now generating interest in India , and this is very gratfiying !

Saturday, April 08, 2006

Sharing Solutions for MS - evil pharmaceutical marketing

Sharing Solutions for MS: “These programs are about uplifting people. It’s about encouraging them, it’s about sharing the faith I have that there’s a drug therapy out there for everyone. I truly believe one day we will find a cure for this disease, but until then, we have to do everything we can to fight it,” said Clay Walker. “If I can convince one person at every program to go out there and take that first step, it’s been worth it.”"Walker will share his journey with multiple sclerosis (MS) and drug therapy with others living with MS and their carepartners."
I feel this is an example of evil pharmaceutical marketing at its best. Using a celebrity to create false hope amongst people with this disease is a terrible thing to do. I wonder under what budget head this expense falls under ? R&D ? At least Clay Walker makes no pretence that his aim to to sell as many patients with MS as possible on the value of Copaxone therapy. Maybe patients wth MS don't need doctors anymore to tell them what to do ! Has everyone sold out to the pharma companies ?

Robot on the medical team

Robot on the medical team : "RONI, the newest staff member in the neurosurgery ICU at UCLA Medical Center, is a popular fellow. Perhaps it's his unusual appearance that makes him a standout among the ICU's caregivers, especially when he's escorting visitors on tours. Standing 5-feet-7 inches tall, RONI weighs in at a hefty 227 pounds. But he has no arms and his rectangular head is just inches thick.

Though he acts like one, RONI is not a human. His name stands for 'robot of the neurosurgical intensive care unit.' Since last September, he's been tending to patients in the eight-bed ICU under the guidance of Neil Martin, M.D., chief of neurosurgery. RONI has become the alter ego of Martin, who can control the robot remotely from either his home or office. With RONI serving as his eyes and ears, Martin can talk to patients and nurses from afar. 'At first, people are amused or self-conscious, but within a few seconds they forget it is a robot and the conversation becomes personal and realistic,' Martin says."

Do more for your patients by seeing some of them less - Medical Economics

Do more for your patients by seeing some of them less - Medical Economics: "The more you can reduce demand for office visits, the more time you'll have to deal with patients who really need personal interaction,' declares pediatrician Donald M. Berwick, president and CEO of the Boston-based Institute for Healthcare Improvement.
Berwick's statement might sound like heresy to physicians who try to accommodate every request for an appointment. But he and other advocates of clinical office re-engineering believe that many patients can be adequately treated outside the traditional one-on-one encounter. Effective use of telephone-advice nurses, patient education, follow-up calls, Web-based home monitoring, e-mail, and group visits, they say, can enhance office efficiency, strengthen physician-patient relationships, heighten patient compliance, and improve the quality of care."
All useful tools for maximising your efficiency !

4 cases that test your malpractice IQ

4 cases that test your malpractice IQ: " No matter how competent a doctor you are, chances are better than even that you'll be sued for malpractice at least once. In this litigious climate, patients often sue for any poor outcome, even if it's a known complication. And if any money is paid to the plaintiff on your behalf, a record of it will go into the National Practitioner Data Bank.
The following case-based quiz is designed to increase your malpractice awareness by focusing on the basic legal principles that underlie some of the clinical decisions doctors commonly face. The answers might also guide you in making changes in your practice that would lessen your risk. A perfect score doesn't mean you'll never be sued; but at least you'll be better able to protect yourself.
Case 1:

After a workup, you diagnose a thyroid condition in a man who has a swelling in his neck. You recommend surgery, and he agrees. You refer him, and the surgery is done. Afterward, although the swelling is gone, he's left with a prominent scar. Later he transfers to another internist who tells him that medication might have alleviated the swelling just as well as surgery—but without the risk of a scar. On that basis, the patient sues both you and the surgeon. Are you liable?

A. No, because surgery is an acceptable treatment given the symptoms.

B. Yes, because you didn't explain any alternatives to surgery.

The correct answer is B. As the patient's primary care physician, it's your legal responsibility to spell out his options, thereby giving him the chance to choose his own treatment. Because you didn't, his consent to your recommendation was therefore not 'informed.'"
No wonder doctors in the US are stressed out ! Imagine having to do all this ( including talking to the patient, making a diagnosis and advising treatment) in less than 10 minutes, 20 times a day !
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