Monday, March 31, 2008
STOMP offers a new way to help smokers quit, with the advantage of being relatively inexpensive, personalized, and age appropriate. It enables health authorities and government agencies world-wide to focus on preventable disease reduction such as smoking cessation by offering various intervention techniques to participants’ mobile phones."
Second, who should receive care?
And third, how can health-care costs be controlled?
A-Concise answers to complex questions can easily be misconstrued, but I'll try if you allow me to amplify my position as we proceed.
First, health-care is the responsibility of individuals, not the government nor their employers.
Second, everyone who can afford to pay for it, or can attract a charitable group or individual to voluntarily provide it, should receive care.
Third, care will become affordable only under a free market system where consumers, rather than third parties, such as government and employers, pay directly for the care they receive."
I'd go one step further ! Why depend upon your doctor to keep your records ? Why not keep them yourself by starting your own PHR ? You can do this free at http://healthphr.yoscare.in/ ! What do you have to lose ?
1) Bring more value to the consumer/customer to get them to actually use their PHR. This is arguably the top reason as they have invested quite a bit in the PHR and my guess is that they are still struggling to gain traction among those 16.8M lives covered.
2) Aetna wants to be perceived in the market, particularly among investors, that they are out in front of their competitors in pushing/encouraging consumer engagement in their health with the perceived (and hoped for) benefit being lower medical loss ratios (MLRs) leading to better margins.
3) Changing perception also extends to their big customers, employers. Aetna can point to announcements such as this to make a compelling argument to employer benefit managers that Aetna is taking proactive steps to help them control their healthcare coverage costs as well."
Today, the public perceives health insurance companies are villains , because they often refuse to pay for medical treatment procedures , often using flimsy excuses to do so , in the attempt to save themselves money.
If Aetna can get its customers to remain healthier, they will be doing their customers a very valuable service - and will also get a healthier bottomline in the bargain. A great win-win scenario !
The Utah Health Story Bank is a collection of health-related stories from Utahns who wish to share their experiences with others. We want to use these stories to help put a face on today's health issues. By sharing your story, you can increase awareness of these issues, and encourage others to be healthier."
Why hasn’t this happened in health care? Something is missing.
Recently, major global information and communication companies have announced their intention to bring their technologies and business models to health care. While the creation of Google Health (GH), Microsoft HealthVault (HV), and Dossia (sponsors include Intel, Wal-Mart, AT&T) are important news items by themselves, what’s more important is what they represent collectively — a new Personal Health Information Network (PHIN). The PHIN and applications developed around the PHIN will fill in many missing pieces and bring health care into the Information Age."
The PHIN will put patients back in control of their healthcare. We seem to have forgotten that it's only been over the last 150 years or so that we have handed over control of our health to the medical profession. Even 200 years ago, most people were born at home; died at home; and were cared for at home when they were ill. Hospitals were only for the very poor - who did not have a home; or for the ones who were critically ill. While the medical profession has helped to improve care of the sick, they have exacted a price - the biggest one being that we have abdicated our responsibility for our own health and handed this over to the doctor. Hopefully, the PHIN will help to redress this imbalance by reminding patients that they are in charge of their own health !
Reality: While patient engagement is desirable long-term, there are many applications of PHI that are not dependent upon short-term patient engagement with HV. The key is patient “permission”, not engagement."
* Health care cost trends pushing care away from the hospital and doctors offices and toward people’s homes, communities and workplaces, and
* Technology trends enabling and pulling care toward environments preferred by patients — their homes, communities and workplaces.
I’ve worked with a wide range of companies, both big and small. BHT health care clients have included health plans, pharma, medical device, DM service organizations, IT, e-Health, remote monitoring, and others. Most recently clients have included several multinational consumer technology companies — companies not traditionally involved in health care, but that have a vision of creating a hybrid of consumer and health care technologies to deliver health and care anywhere.
I’ve held on to my vision of local care providers taking on a greater role in the deliver of chronic care management services. Now, more than a decade after reading “The Promise of Disease Management”, that vision is becoming much closer to being a reality."
The best place to manage these diseases is the home - not the hospital; and the best person to manage them is the patient - not the doctor !
Doctors' education: the invisible influence of drug company sponsorship -- Moynihan 336 (7641): 416 -- BMJ
We’ve all been there—the educational seminars, the medical symposiums, and the scientific conferences generously sponsored by big drug companies. The visible signs of sponsorship at these events are obvious: the smiling drug company representatives, the colourful company logos, and the high tech stalls in the exhibit halls. But what about inside lecture theatres, where high quality education is delivered to doctors by respected speakers? Surely the sponsors have no input into those sacred places of independent education?
It seems that invisible influence may be flowing through these sponsored seminars—even those accredited by august associations—far more often than many of us realise."
Sunday, March 30, 2008
Best ways to communicate with specialists - This doctor learned that reading others' chart notes is not enough. - Medical Economics
In the second type of communication—interactive medicine—doctors discuss patient care with each other, either on the phone or in person. The interaction facilitates the exchange of information. And communication is enhanced through body language in face-to-face conversations, and by word emphasis and the give and take of dialogue. By working together this way, doctors can sometimes diagnose a condition or solve a medical problem that had remained elusive, despite the best efforts of each individual."
They tell stories, she went on, even when no one is around to listen — to clarify their own thoughts, to teach and to stimulate research. “It’s not surprising they write,” she said."
Take the example of DXplain, one of the more popular diagnostic software tools around for physicians. DXplain is available for free on the Internet to every licensed health care professional in the United States. Yet fewer than one in 10 physicians has used the program during its more than 20 years on the market, estimated Dr. Edward Hoffer, a key DXplain developer and professor of medicine at the Beth Israel Deaconess Medical Center in Boston."
If we want to increase the utilisation of these programs, we should start allowing patients to use them. Patients have much more at stake; and will be much more willing to get an electronic second opinion, even if their doctors aren't ! Check out wwww.freemd.com which provides a patient-friendly version of Dxplain !
How To Gut Your Office Of Inefficiency In ONE Move | The EMR/EHR Show: Making Your Electronic Medical Records Really Work
The trouble is that doctors take so much pride in doing everything themselves ( they make excellent micromanagers because they are good at nitpicking and pay close attention to detail !), that they waste a lot of their time ( and that of their staff) doing stuff which is best done by their employees !
Maybe patients can take the lead and upload their videos to google video. Maybe their doctors will be too busy to view them - but medical students might - and this will help them to become more empathetic ! This would also be a great way of networking with other patients - and helping each other out ! Patients need a chance to tell their stories - and using a video is a great way of doing this !
How can we do this? We bypass the insurance middleman. Instead of spending that 40% of what you pay for primary care on back office staff and accounting or giving it to the insurance company, we use it for state of-the-art technology, more providers, longer operating hours and lower prices. The bottom line is that you—not the insurance company—become our customer and benefit from true patient-centered primary care."
Here's a great example of using technology to help doctors provide better care directly to patients. Why don't more doctors do this ?
Depending upon the nature of your symptoms, you will be able to make an appointment for a house/office call, a video chat, an IM, or simply send us an email. A hello health doctor will then show up at your apartment/office or meet you virtually on the web. We’ll also have an exam room in our office for problems that require a doctor’s office visit. The appointment process will nearly exactly mimic making an appointment at the Apple Store Genius Bar.
Depending upon the nature of your symptoms, you will be able to make an appointment for a house/office call, a video chat, an IM, or simply send us an email. A hello health doctor will then show up at your apartment/office or meet you virtually on the web. We’ll also have an exam room in our office for problems that require a doctor’s office visit. The appointment process will nearly exactly mimic making an appointment at the Apple Store Genius Bar.
Our market is the 47 million people in America without health insurance; the other millions of Americans who are underinsured; and the 40 million Americans over the next four years who will have high deductible health insurance plans. In essence, there will be nearly 100 million people in America in 4 years who have to pay cash for their healthcare. Our other market — considering half of my current patients have insurance and simply pay for accessibility and convenience — are people who value relationships and communication with their own personal doctor.
hello health is concierge service for all.
We will add significant value to the cost of the subscription fee by taking advantage of the weaknesses and insufficiencies of the traditional healthcare system that has left behind the healthcare consumer."
What a great idea ! It's a very good example of how technology can be used cleverly to cut out all the "middle-men" between the doctor and patient, so doctors can focus on doing what they do best - providing high quality medical care - one-on-one !
Friday, March 28, 2008
You see, we believe sharing your healthcare experiences and outcomes is good. Why? Because when patients share real-world data, collaboration on a global scale becomes possible. New treatments become possible. Most importantly, change becomes possible. At PatientsLikeMe, we are passionate about bringing people together for a greater purpose: speeding up the pace of research and fixing a broken healthcare system.
Currently, most healthcare data is inaccessible due to privacy regulations or proprietary tactics. As a result, research is slowed, and the development of breakthrough treatments takes decades. Patients also can’t get the information they need to make important treatment decisions. But it doesn’t have to be that way. When you and thousands like you share your data, you open up the healthcare system. You learn what’s working for others. You improve your dialogue with your doctors. Best of all, you help bring better treatments to market in record time.
PatientsLikeMe enables you to effect a sea change in the healthcare system. We believe that the Internet can democratize patient data and accelerate research like never before. Furthermore, we believe data belongs to you the patient to share."
What a refreshing change !
Thursday, March 27, 2008
Just like we have a Right to Information Act to help citizens get better governance, I also think we need a Right to Health Information Act, to help patients to get access to their own medical records. Sometimes these are locked up and hidden away from patients - so that doctors and hospitals block patient access to something as basic as to what their diagnosis is and what treatment is being given for this.
Patients - and their family members need to know that they have a legal right to access their own records - and no one can refuse to share this with them. Unfortunately, the big hospitals often act as bullies, and refuse to provide this basic documentation to patients.
This is a completely new way of doing medical research, using the power of Web 2.0 ! Not only will the research be much less expensive; it will also be tailored towards finding solutions to the problems patients want answers to - not to questions the pharmaceutical companies pay for !
Historically, clinical research in Parkinson’s and other diseases has required patients to travel, often several hours or more, for in-person interviews, examinations and tests. This is a burden for anyone living with a disease, and takes an incredible toll on people with PD, where unpredictable motor and non-motor effects, as well as the efficacy and side effects of medication, vary from day to day.
“A Web-based clinical assessment can never entirely take the place of face-to-face interactions between patients and researchers,” said Katie Hood, CEO of MJFF. “But as a supplemental measure it could heighten efficiency and help speed progress toward new treatments."
This is a great idea . I am sure it can be applied to lots of other diseases as well ! Patient support groups can use the power of numbers to do their own research with such clever applications.
Saturday, March 22, 2008
The government is now passing new rules and laws which curtail medical autonomy and this bodes ill for the future of our profession. We have no choice but to become politically active, if we want to regain control over our professional independence.
An excellent example of the increasingly intrusive government policies in healthcare is the recent amendment to the PNDT ( Prenatal Diagnosis and Treatment) Act . This amendment is a major slap in the face of all medical professionals, because it treats all doctors as potential criminals, who need to be constantly policed. Thus, the Act mandates that all clinics which perform ultrasound scans should prominently display a sign saying, “ Fetal sex determination not performed here”. This is highly demeaning and is an insult to all doctors ! Why should doctors have to put up a sign which says they do not perform an illegal act ? Using the same analogy, all police stations should also have a sign saying , “Bribes not taken here “ ! To compound the insult, the Act has created an avalanche of non-productive paperwork, because all ultrasound scans performed during pregnancy need to be reported. Even worse, this Act demands that we compromise our patient’s confidentiality, because the name and address of every pregnant woman undergoing an ultrasound scan ( which today has become a routine procedure) should be reported to the government !
The fact that such a poor piece of legislation was passed in the first place makes for an interesting story, and underlines how powerless doctors have become in the face of vested interests. After the Census 2001 figures were released, an NGO moved a public interest litigation in the Supreme Court, claiming that the decline in the sex ratio was a result of fetal gender determination, because the government was not implementing the PNDT Act properly. In response to the Supreme Court directive, the Health Dept secretaries were hauled up, and they promptly bent over backwards to comply. Unfortunately, bureaucrats only understand paperwork, and the Act was passed uncritically, because it appears to be designed to protect the girl child. In reality, this amendment encroaches on our patient’s reproductive rights, because it prevents them from using technology to plan their family. Unfortunately, no one has spoken out against it, and sadly, future generations will pay the price ! What is to stop the government from further restricting reproductive freedom by implementing an even more coercive population policy which enforces a one-child or two-child norm, as suggested by former Union Health and Family Welfare secretary, A.R. Nanda ?
Doctors are obliged to protect their patients’ best interests and we need to stand up for our patients. We do not function in a vacuum, and we need to take a leadership role in shaping medical policies which affect public health and private medical care for the sake of our patients – and for our sakes as well ! This is an opportunity we need to seize, and while individually there is little we can do, together we can command respect and clout. An excellent example of our collective power is the fact that a surgeon kidnapped recently in Bihar by goons was released only after the members of the Indian Medical Association of Bihar jointly threatened to strike.
We need to learn from doctors in the U.S. . Predatory insurance contracts, HMO cost pressures, burdensome government regulations, and the threat of unjust malpractice suits have galvanized them into organized political action. They can no longer afford apathy since their survival is now at stake, which is why they are playing an increasingly active role politically. They have realized that if they wish to continue to practice quality medicine , they have to get legislators to pass doctor-friendly and patient-considerate reforms. Doctors have started to lobby for their rights, and many medical societies are active and alert in this area. There are none so blind as those who will not see, and if Indian doctors continue to turn a blind eye, we will soon find ourselves in the dire predicament the medical profession in the
Healthcare has become an important issue in
Doctors are well-educated, and because they are in constant touch with their patients, they are aware of ground reality. They are highly respected members of society, and are likely to become much better leaders than the present tribe of politicians, many of whom are corrupt and semi-literate. But can doctors become good politicians ? Isn’t this role better left to others ? Interestingly, there is a strong tradition of doctors entering politics. Our past history provides many role models of doctors who have become excellent leaders, and a shining example is Dr Jivraj Mehta, the Dean of Seth G S Medical College, who later became the Health Minister of
It’s also worth recollecting that the very first article in the very first issue of the largest selling medical journal in the
Organizing doctors, the saying goes, is like herding cats, and because of their fiercely independent spirit, Indian doctors have failed to play an active role in healthcare policies, because they are not organized or united. The tragedy is that we often waste our time and energy fighting each other. While many doctors are politically active , they are usually active only in medical politics , where they squabble over promotions, medical society chairmanships, and grants. What a waste !
Many doctors are now sitting for the IAS examination to become IAS officers, because they want to take a more active role in running the country. Doctors often top these examinations, and they do become good bureaucrats, because they are trained to think scientifically, search for the truth; and to fight for their patients and to serve them. As an aside, it’s interesting to note that politicians want to stop doctors and other professionals from applying for IAS jobs, because they are worried that it will be difficult for them to coerce educated public servants into doing their bidding !
The best way is to start small – apply for a corporator’s seat, for example. Unfortunately, many doctors have huge egos , and expect to get elected just because they are doctors. Ground reality can be unflattering and you’ll have to learn humility - don’t expect to become health minister just because you are a doctor. Fortunately, you may not have to indulge in corrupt practices to get elected, because good doctors have lots of good will in the community . If nothing else, trying to get elected will teach you the art of negotiation and compromise ! Don’t expect other doctors to be supportive – and even your family members may feel you are crazy to leave the security and comfort of your medical work. While it is true that becoming politically active may cut down your medical practice , you may find that your patients may be your most loyal supporters.
We all need to evolve with the passage of time , as Shakespeare so eloquently described when talking about the seven stages of man, and joining politics allows a doctor to do so. Your sphere of influence grows, so that your “stage “ is then no longer your clinic or your hospital, but the city or the state – and your patients are then no longer just the ones who come to your clinic, but rather the entire population. You start to think on a much larger scale , so that your potential for doing good also becomes much larger. In
( and a member of the German parliament ) wisely said many years ago, “ Medicine is a social science and politics is nothing else but medicine on a large scale. If medicine is to fulfill her great task, then she must enter the political and social life. Since disease so often results from poverty, the physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”
Doctors will make far better leaders than the politicians we have today. Because they are educated, financially well off and able to think scientifically, they will be able to make decisions which are in the best interests of society, rather than only looking out after their personal selfish interests. Unfortunately, most able doctors are so devoted to their profession , that they hesitate to take on the larger work of helping to heal the ills of our nation. However, we owe this to our colleagues, to future doctors and to our patients !
Friday, March 21, 2008
The iPhone is cool - and cool ( young ?) doctors will want to use such cool tools !
This is one of the best resources on community health insurance in India I have seen anywhere. Great starting point if you want to explore what works - and what does not !
Chicago-based Health Care Service Corp., parent of Blue Cross and Blue Shield of Illinois, added the word 'wellness' to the mission statements of its four health plans.
But just adding the words to the company mission statement makes it more than corporate speak from the Health Care Service human resources department, company executives said. Rather, the company has embarked on a variety of wellness initiatives, including incorporating wellness programs in basic health benefit packages it sells just like hospitalization coverage and physician care has been for years."
All insurance companies will do this soon - it makes a lot of business sense do so ! After all, every time a customer falls sick, the health insurance company has to shell out money and pay for his illness care . It's far cheaper for them to make sure their customers remain healthy - prevention is much cheaper than cure !
After all, it is meant to be a health insurance policy - not an illness insurance policy.
Thursday, March 20, 2008
However, as times have changed, I now actually feel sorry for them.
India has now become a world-class destination for certain medical procedures, such as IVF. We use exactly the same equipment and technology anyone else in the world does - and do an extremely good job at it.
However, we have a number of advantages. Doctors in the US today are very unhappy. They are squeezed by :
- demanding and unhappy patients who are happy to sue at the drop of a hat;
- a restrictive reimbursement system, which wants them to work harder for lesser pay
- a maze of rule and regulations which shackle their autonomy.
In India, on the other hand, we can provide high quality world-class personalised care - at a fraction of what US doctors charge . We are in our honeymoon period - and before it gets sullied by Indian bureaucrats, I am happy to be a doctor practising in India for now !
They have a very positive and optimistic approach towards life.
They look for solutions, and don't get hung up on problems.
They deal with failure every day - and know how to cope with this and move forward.
They are smart people - and capable of changing the world.
They have certainly changed my world view !
Today, this autonomy and freedom has been taken away - from both the doctor and the patient. They are told what they are allowed to do - and what they are not - and this has become the norm for many areas in medicine.
An excellent example is my specialty - IVF. Today, in the UK, doctors are allowed to transfer upto a maximum of only 2 embryos for IVF
We all understand that the best outcome of an IVF cycle is a singleton healthy pregnancy ( though twins are a welcome bonus for many infertile couples !) However, IVF technology still has a long way to go and it's extremely inefficient today. Even perfect embryos have only about a 30% chance of becoming a baby. While SET ( single embryo transfer) is the holy grail we should aim for, the fact remains that we are a long way of from reaching this stage.
This means that while this policy is sensible for a 30 year old woman doing her first IVF cycle, it does not make much sense for a 41 year old woman who has already failed 3 IVF cycles.
In her case, her best option would be to transfer more embryos, to maximise the chances of at least one of them implanting successfully.
Common sense says we need to individualise care for each patient and formulate a personalised treatment plan for each patient, depending upon their history , clinical circumstances and personal choice. In fact, this is exactly what doctors are meant to do even today !
However, this right , privilege and responsibility is gradually being taken away - by bureaucrats, who want to tell doctors how to practise medicine.
The modern view is that doctors cannot be trusted to make the right decisions; and that they need to be monitored and policed. This is why they need to be regulated by bureaucrats, who can decide what is best for everyone !
Unfortunately, the problem is that one size does not fit all. Bureaucrats treat everyone as a number - and because they are nameless and faceless, while they excel at dealing with groups, they are not very proficient at handling individuals.
Like all good officials, they do take advise from medical experts when drafting their guidelines - but as anyone who has been part of the process will tell you, this is just a sham. Since they decide which experts to invite, they selectively stack their committees with doctors who toe the party line - and tell them what they want to hear. They are masters at manipulation; and since they are the ones who do the final drafting, they conveniently leave out everything which is inconvenient for them.
The treat doctors as puppets - and since most doctors are too busy taking care of their patients , they get easily manipulated !
Bureaucrats think in terms of numbers only - they think " big" ! However, this means that while they are good are creating rules, they are terrible at dealing with the exceptions to their rules. They ignore the exceptions - or are happy to sacrifice personal desires, at the altar of a greater " social good. " They treat everyone as part of a homogeneous whole; and for them, the inconvenient square pegs need to be forced into the round holes they create.
Doctors deal daily with individual patients who are hurting on the inside. They are extremely good at solving an individual's problems one-on-one - but because they do not have the skills to tackle bureaucrats, their ability to do so has been gradually eroded.
Bureaucrats specialise in creating hurdles - in telling people what they cannot do. Doctors , on the other hand, are experts at solving problems - in helping patients to achieve their personal goals.
This sad state of affairs means that doctors have lost their autonomy . They can no longer practise medicine the way it should be - to maximise their patient's personal best interests.
This will hurt all patients - and all doctors.
The sad reality is that by abdicating their responsibility, doctors have failed themselves; future doctors ; and their patients.
Listening - and telling - stories is good for both doctors and patients !
'When patients are in the hospital, they often feel like they've lost a certain degree of control,' said Tracy Charles. 'The most important aspect of a [patient-centered] system is helping patients feel empowered.'"
Wednesday, March 19, 2008
3. difficult to access
Not surprisingly, the patient is often confused by the complex care she has been getting from multiple clinicians--and by all the medications that she is supposed to be taking. She is discovering that health care for people with chronic conditions “... is a nightmare to navigate.”"
Let the patient look on
Eye contact with the patient
Value the computer as a tool
Explain what you are doing
Log off and say you are doing so
The accompanying chart, Do Your LEVEL Best With the Computer in the Exam Room , applies these five communication behaviors and details some recommended actions to use and scripts to say to effectively integrate the computer into your exam-room interaction with your patient."
Tuesday, March 18, 2008
By brokering interaction with available providers, American Well allows consumers to have immediate, live conversations with doctors and specialists - giving them convenient access to care when they need it most. Consumers can get care on their own terms, from home, the office or even their mobile phone."
The important thing is to find a doctor whose style matches your own !
I agree it's much easier to do this. When you are ill, the last thing you want to do is "homework" about your problem. You'd rather conserve your energies in getting better than in researching your problem - and isn't that what you are paying your doctor for ? Why duplicate his efforts ? There are also the unexperessed fears that :
- you may not be smart enough to make sense of what you find ( "biology was my worst subject in school") ;
- the information may confuse you ( " I cannot even pronounce these Greek and Latin medical terms, forget making sense of them" ) ;
- the conclusion you come to may be at odds with what your doctor recommends, which will then put you in the uncomfortable position of having to challenge your doctor and make a final decision;
- the worry that your doctor may get upset if you ask too many questions.
Unfortunately, ignorance isn't always bliss ! While your doctor maybe a medical expert and may know a lot about your disease, you are the expert on yourself - and your doctor does not know too much about you ! He cannot read your mind or figure out what your preference are, unless you tell him. Yes, this does involve doing some work - but it's a worthwhile investment of your time and energy. This decision is too important too outsource to someone else - no matter who the other person is, and how much you trust him.
In fact, a well-informed patient and a well-informed doctor play a complementary role. It's not antagonistic - after all, you are both on the same side - yours !
What strengths does the doctor bring to this partnership ? Most of these are obvious.
- clinical experience;
- clinical judgment;
- understands the jargon;
- knows all the specialists and experts in this field;
- is detached and can provide a professional opinion.
However, every doctor does have certain weaknesses, which you need to be aware of.
- have a hidden agenda ( for example, his focus maybe on maximising his income, rather than your personal well-being).
- be too busy to spend enough time thinking about your problem. This is a major issue if you have a disease which is complex or rare.
- have a bias . For example, surgeons are much more likely to advise surgery rather than conservative treatment . A famous cardiac surgeon once threw a patient out of his consulting room when he asked him if angioplasty was better than bypass surgery ! He said - Why waste my time coming to me unless you want surgery ?
- not be uptodate. Many surgeons are so busy operating, that they do not have time to keep up with recent advances.
- not be aware of other options available in alternative systems of medicine.
- be unwilling to refer you to a specialist, as he does not want to lose income.
- not know much about you as a person or what your personal preferences are.
- When you are ill, you are likely to be emotionally distraught, which means you may not be able to think rationally .
- Since the jargon is unfamiliar, you may need to read the same material repeatedly, before it starts making sense to you
- You may be so worried about making the wrong decision, that you may be paralysed into inactivity
- Since you may have never done this before, you may be unsure how to proceed, since this is unfamiliar territory
- Your doctor may intimidate or bully you into agreeing with him, rather than respct your opinion or judgment
- You may get very little social or family support because you are "thinking out of the box"and it's not considered to be accepat
However, you do have a lot of valuable inputs to provide. What are your strengths and what can you do optimise your role ?
- You have the time to explore multiple options. You can do a lot of research - and since you do not have any preconceived notions or limitations of time, you may be able to craft a unique solution which is optimal for you
- You know yourself and your feelings . How much are you willing to spend ? How far are you willing to travel ? Are you happy with what is available locally ? Are you willing to take a gamble on an expensive but unproven treatment; or are you contented with what the standard treatment options are ?
Decision making is the most important skill in medicine - and while your doctor can lay out all your options, only you can decide which option is the best for you, based on your personality; philosophy; and background. There are always going to be multiple choices and because it's such a complex process , how can the doctor possibly know what your preferences are ? The answers to all these questions are very personal and individual , which is why your input is so important.
In any medical encounter, there are 4 possibilities.
1. Poorly informed doctor and poorly informed patient. I think this is true of the vast majority of
medical encounters, but because most medical problems are self-limited and get better on their own, it does not adversely affect the outcome most of the time
2. Well informed doctor and poorly informed patient. This is a very common scenario, when the patient leaves everything upto the doctor and allows him to decide. Fortunately, since most doctors are competent and professional, the outcome in this situation is usually quite good for most patients
3. Poorly informed doctor and well-informed patient. This is becoming increasingly common. Many patients are now very well-read; and know a lot about their options. They will often make the decisions for themselves - and get their doctors to endorse these. While some doctors are happy to oblige, others may take offense at this role-reversal.
4. Well-informed doctor and well-informed patient. This is the best combination. While it does not happen too often, when it does, the doctor-patient relationship becomes a work of art - and is gratifying for both doctor and patient !
For most common medial problems, the outcome is likely to be good, no matter which of the above you fall into. However, you can never be sure that your doctor is truly well-informed. This is why you need to make sure you are well-informed, so you craft a winning partnership !
Monday, March 17, 2008
For some patients, a better alternative maybe what I call POM - Peace of Mind medicine . This refers to treatment options which may not be the generally accepted norm , but maybe the best alternative for the patient, given her individual circumstances !
Medical care needs to be personalised and individualised - and while EBM is great when dealing with groups of patients; or in areas where the evidence is unambiguous, EBM is often not the best option in all circumstances.
POM allows us to take the patient's feelings into account, so that she can provide her own inputs into the treatment plan. For example, consider a women who has an elevated FSH level of 15 mIU/ml. She has poor ovarian reserve, and her chances of getting pregnant with her own eggs are very poor. EBM recommends that we do donor egg IVF for her, but this is not an option she is willing to consider. The simplest course of action is to refuse to treat her - but is this the right thing to do ? As long as she has realistic expectations and understands her chances are poor and still wants to go ahead, are we justified in refusing to treat her ?
Doing IVF with her own eggs may not be EBM, but it will give her peace of mind she did her best. It is POM medicine - and while outcomes with EBM are always uncertain, the peace of mind which POM provides is priceless !
POM allows to to offer personalised medicine and lets patients make their own decisions ! Why should we take away their choice ?
Here's a typical quote.
Amit Kumar, 43, is accused of running a private hospital just outside Delhi which allegedly lured or forced hundreds of poor people into giving up their kidneys, and made millions by selling their organs.While his actions are inexcusable, I am surprised not one single reporter has focussed on the patient's side of the story. Doesn't this need to be covered ?
They claim he has done hundreds of transplants . Each kidney transplant is a life-saving operation, which means he must have saved the lives of hundreds of patients. I am sure many of his patients must be rich and influential VIPs . However, not one single patient ( or their family member) has stood up for the doctor !
When they were desperate, they must have promised him the earth. " Doctor, my father is dying. Only you can save him ! We cannot get a donor kidney ! Can you please help us ? We can pay you what you want ! "
Today, no one is willing to help him !
If it was your own mother who was dying of kidney failure, what would you do ? Why has not even one reporter tried to track down the patients who received the transplanted kidneys - and a new lease of life - and get their version of the story ?
The fact remains that patients were forced to seek extra-legal remedies because the regular healthcare system has failed them miserably.
While I am not condoning his actions, making this doctor a scapegoat does not address the underlying problem ! All it seems to do is to give people a pulpit to beat up on the medical profession.
We need to look for constructive win-win solutions and different points of view.
Each patient who is admitted in a hospital gets at least about 5-15 visitors daily. In once sense, this is a captive audience who is very likely to be responsive to healthcare marketing, because they have come to visit someone who is ill, and therefore have a heightened sense of their own biological frailty. Unfortunately, hospitals do very little to market to these visitors. Most of them are treated as second class citizens, whose presence is just about tolerated during "visiting hours". Why not treat them as potentially valuable future customers - which they all are. If they are treated well, they are much more likely to choose your hospital when they fall ill , rather than the one down the road ! There are many opportunities to create great word of mouth marketing for these visitors - and this can be done quite inexpensively, rather than wasting money on conventional advertising.
Simple examples include : setting up a patient education library for these visitors, so they can learn more about their own health; having lectures by doctors to teach them about their health; and to show videos and films about health and common medical problems in the visitor's waiting areas.
Just like most hotels rooms have a Gita or a Bible, each hospital room should have patient educational books ( for example the Healthwise Handbook; or How to Get the Best Medical Care , so that visitors can browse through them and use their hospital visit to improve their own health ! This is a valuable USP - why don't more hospitals do this ? Not only will this help them to improve their market share, it will also help to improve the level of health in the community !
Thursday, March 13, 2008
I answer a lot of queries from patients all over the world by email. Here's one I received recently.
I replied saying,
I am writing to apply for a Gestational Surrogacy Treatment of your clinic. I heard Malpani Infertility Clinic is the Best hospital in India.
My name is SK. I am a 40 years old Japanese female.
We (I and husband) have been married for 10 years, trying to conceive and having intercourse around the days of ovulation but failed again and again.
Causes of our infertility is never identified after extensive investigations, but a doctor said there may be an immune problem because we have HLA Agreements (Parental HLA Sharing) and Lymph Mixture Reaction Negative.
I have regularly ovulating, viable eggs, open fallopian tubes with no adhesions or endometriosis, no structural abnormalities of the uterine cavity fallopian tubes; my husband has normal sperm production (but sometimes low sperm count); and the postcoital test is positive.
・In-Vitro Fertilization (IVF),
As below, we have failed repeated IVF attempts as fertiled eggs cannot implant and continue to grow in uterus; implantation dysfunction with unexplained reasons;
・Frozen Embryo Transfer (FET),
・2-step (Consecutive) EmbryoTransfer
(Assisted Hatching, at the natural cycle, still keeping a frozen embryo)
Now we are considering to hire an experienced surrogate mother for Gestational Surrogacy in India.
Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.
I think you have occult PCOD ( www.drmalpani.com/pcod.htm)
Repeating the ICSI cycle in our clinic with better superovulation and careful monitoring and transferring more embryos would be your best treatment option as it would maximise your chances of conceiving. You can read more about our approach at www.drmalpani.com/failedivf.htmTime is now at a premium for you - please don't waste it ! When you are 50 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. While the outcome of any treatment is always uncertain, taking treatment at a world-class clinic can give you peace of mind you tried your best, which can be priceless !
She then emailed me back, saying
If I have PCOD, I expect from my Japanese doctors way of talking, it's not so serious. A doctor said I possibly had slight tendency of Luteal dysfunction, but my menstrual periods and ovulating are regularly every month, I've never taken hormonal tablets (progestins) to induce a period, BBT (Basal Body Temperature) is normal between 35.98C (low) - 36.76 (high), now I gain weight but ususally at 60kg-64kg, I am a rather muscular than fat, no-hirsutism, I have vaginal ultrasound examinations but my ovaries are not so enlarged except when strongly stimulated with HMG...
It's said that I have not PCOD under the Japanese diagnosis criteria; because of no androgen excess, ovulating every month, and no polycystic ovaries by gynecologic ultrasound. But the doctor admitted the immaturity of eggs ovulated or retrieved on Day 12. Usually on D12 I have follicle grown over 20mm which looks like nearly ovulating.
I replied saying,
This is exactly why it's called occult PCOD - it's easy to overlook ! The eye only sees what the mind knows !
She emailed me back,
Thank you very much for your replying soon, and I always deeply appreciate your deliberate and thoughtful advice.
Yesterday I went to see the doctor, confirmed my medical problems and I found some misunderstandings; my blastocysts Day5 had only 20%-30% possibility to be successfully implanted. I completely mistook it "70%-80%"of success rate instead of failure. I found I ovulated with rather poor quality egg for fertility.I learned a great deal with reading this site, and I'm deeply impressed with the noble philosophy of Dr.Malpani. I must study more and think again. Even if I can hire a gestational surrogacy, my poor quality egg leads to only miscarriage and fatal risks of a surrogate woman. I should adopt the idea of donor eggs. However sorry to be insistent on saying such things but indeed I 'd like to have a baby of genetically myself and my husband. I may be too desperate to think reasonably.
I'm very interested in IVF treatment of your hospital, but still now I can't get out of the idea of a surrogacy; Obsession! Could you give me some more time for reconsideration? I'll study again.
I'm really appreciating your graciousness and always highly intelligence.
Even though this is a patient I have never seen and may never meet, I still feel we've established a doctor-patient relationship. I hope she has has become more knowledgeable about her treatment options by listening to a point of view which is different from her doctors in Japan; I have certainly become wiser by being allowed to see things from a patient's point of view !
Respected sir,you don't know me but I have always been a reader of your website.It has helped me to conceive in age of 34yrs. I have a daughter of 6and half yrs.As now I am pregnant with 18 weeks and living in China I GOT MY TRIPLE TEST DONE. In that report DOWNS is 1:380 and normal is1:253.AS DOWNS IS HIGH ,the doctor told me to get AMINOCENTESIS done.I got that done yesterday.THE report will take 3-4 weeks for result. Till then I am very much tensed.Can u suggest ME something.It will be great help for me.NB Downs refers to Down's syndrome ( Trisomy 21, the commonest chromosomal error in humans). The triple test is a simple blood test used to screen pregnant women for possible fetal anomalies.
This was my reply.
I don’t think you should worry at all if the ultrasound scan is normal. The triple test is just a screening test. There was NO need for the amniocentesis at all ! A risk of 1:380 is very low – and is better than normal ! It means there is a better than 99.7 % chance ( 379:380) your baby will be normal !
The tragedy is that this patient was pushed into doing an unnecessary , risky invasive medical procedure by her doctor. The normal result of the triple test should have been used to reassure her - and instead is was misused to make her agree to an amniocentesis - a procedure which has a 1:200 risk of causing a miscarriage of a normal fetus !
The bigger tragedy is that this patient was not well-informed enough to be able to protect herself from this doctor and make the right decision for herself !
Tuesday, March 11, 2008
When your doctor suggests or orders a medicine, surgery, a test, or any other kind of care, ask why you need it and what would happen if you waited. If you don't need it now, you might want to wait.
But also remember that there can be costs to doing nothing. The 'wait and see' option is not always the best. If you don't get care when you need it and a health problem gets worse, you may face higher costs than you would have if you had taken care of the problem sooner.
Asking why can help you and your doctor make the decision that's right for you."
'We view the health of employees as directly connected to the health of companies,' Cordani said. 'Through our consumer engagement and outreach initiatives, we positively impact the health and well-being of individuals and further control costs and improve productivity for plan sponsors. This new relationship will enable CIGNA HealthCare to significantly enhance our capabilities in these areas and to lead the industry in understanding and implementing effective strategies to engage consumers in managing their health.'"
Monday, March 10, 2008
CIGNA Well Informed uses evidence-based care guidelines to identify gaps for prevalent conditions in care patterns, disease management, medication adherence, national standards of care, and patient safety. Using these guidelines, it is possible to evaluate physician treatment patterns at the patient level, and patient adherence with their physician's recommended care.
The Well Informed program is intended to support care management efforts by helping to:
- Increase patient compliance with your treatment plans
- Increase preventive health activities
- Support you in managing chronic disease
- Prevent potential adverse drug reactions and avoidable medical errors
- Inform you of prescriptions and services your patients receive from other physicians that could impact your treatment plans
- Alert you to potential divergence from common standards of care
- Bring together disparate pieces of clinical information
- Encourage patients to be involved and informed about their health status
- Flag potential urgent patient health issues and/or concerns"
Sunday, March 09, 2008
Marketing 101 teaches us that the best way to market to a doctor is to establish a relationship with the doctor , which is why companies spend millions on an army of medical representatives ( MRs), whose primary job is to keep doctors happy. However, this is an expensive and inefficient way of doing this - and in an over-crowded field, how can one MR stand out from the hundreds of other MRs who woo the doctor daily ?
Also, it's a fact that times are changing. Many doctors refuse to see MRs because they just waste their time. Also, laws are being passed which prohibit doctors from accepting gifts from pharmaceutical companies . Unfortunately, most companies continue doing what they have been doing for the last decade - and they continue getting the same dismal results.
Here's a much better way. The secret to establishing a successful relationship with a doctor is to give him what he wants. So what do doctors want ? Many things, such as prestige, money and power - but most new doctors want to have lots of patients so see, because once they are busy , most of the rest of what they want will follow in due course.
So pharmaceutical companies should start thinking along the lines of - What can I offer to doctors which will help them to attract more patients ?
Here's a simple, inexpensive suggestion which will and create a win-win partnership. Pharmaceutical companies can offer to print customised patient educational materials such as brochures, booklets and videos for doctors. Most doctors understand the need for educating their patients, but are too busy to actually print their own materials. Many of them don't even know how to go about designing these materials, as a result of which they keep on losing patients to corporate hospitals.
It's easy for a pharmaceutical company to do this in bulk. Each brochure would have input from the doctor; and the text and graphics would be customised to the doctor's practise. These materials would have the doctor's logo on them . They would focus on the top ten problems the doctor sees; and would be printed in local languages also.
Any company which does this for doctors will have lots of grateful doctors - for a very small investment of time , money and energy !
It's important that the brand of the company should not appear on these materials. The aim should not be to market to the patient , but to help the doctor build his practise !
This will help doctors; help patients - and by helping them, help the pharmaceutical company build its brand and market share as well !
Thursday, March 06, 2008
Companies like Healthways are now moving on from Disease Management to Health Management !
The most radical change E.B.M. proposes will occur in everyday visits in doctor's offices -- those simple, scary moments when the most important medical decisions are made. The instant the practitioner stops saying, ''I think you should take this therapy,'' and starts saying, ''The evidence is that this therapy will work this percent of the time, with these complications, this frequently; what do you want to do?'' then the power hierarchy of doctor over patient is collapsed, and autonomy is assigned to the patient. This is how the relationship between doctor and patient could be changed by evidence-based medicine. Just as the idea of authority within medicine is rejected, so too, the idea of the profession of medicine itself having authority over the patient is rejected. Giving authority to the data, instead of other people, empowers everyone, the movement holds."
* Dignity and Respect. Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.
* Information Sharing. Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making.
* Participation. Patients and families are encouraged and supported in participating in care and decision-making at the level they choose.
* Collaboration. Patients and families are also included on an institution-wide basis. Health care leaders collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care."
Wednesday, March 05, 2008
However, I don't think trying to train more doctors ( or nurses or physician assistants) is an effective solution. Why don't we focus on teaching patients ( and family members) on how they can take better care of themselves. BY leveraging information technology, we can multiply the efficiency of individual doctors, so that they no longer function as bottlenecks.
Here's an example. Infertile women need to get some basic blood tests done to check the quality of their eggs as part of their workup. However, in order to get these tests done, they often need to wait for 4-8 weeks to get an appointment with a specialist ( an RE). After getting the appointment, the RE orders the tests - and then they need to wait to get a second appointment to discuss the test results ! Why can't we shortcut this by allowing patients to order their own tests, so they save their time - and that of their doctor ?
In collaboration with MyMedLab, we now offer infertile couples in the USA a chance to get their blood tested for the five key reproductive hormones - FSH,LH,PRL and TSH, and estradiol. This test, usually done on Day 3 of the cycle, gives us an excellent idea of their ovarian reserve, and helps them to formulate the right treatment plan.
IHIE continues to expand its network and is working with many other hospitals throughout Indiana to implement the DOCS4DOCS® service.
Because of the wide-spread use of DOCS4DOCS® service throughout Indiana, IHIE has been recognized by the U.S. Surgeon General and the U.S. Health & Human Services as one of the nation's most respected health information exchanges."
Ideally, these test results should become a part of the patient's PHR !
Tuesday, March 04, 2008
I think one way of creating brand awareness of the company amongst the minds of patients is by providing patients with a free PHR ( Personal Health Record), customised to their needs. Thus, if Nicholas Piramal ( which sells insulin) was to offer a free PHR for managing diabetes for all customers who bought their insulin, the customer would use the PHR to manage their diabetes better - and would see the company brand every day. This is a win-win situation, because it would help the patient to manage their illness better - and would also help the company to create brand recognition !
So what can companies do to attract customers ? I think the trick is to offer their customers additional services which will help them to take better care of their own health.
One of the easiest things they can do is to offer their customers a free PHR
( Personal Health Record). Not only will this help their customers to take a more proactive role in managing their own health ( thus reducing unnecessary medical expenses, thus saving the insurance company a lot of money ); it will also ensure that the customer sees the Insurance company's logo every time he uses a PHR - a great way to build a brand !
An additional benefit is that customers who have a PHR will have well-organised medical records, which means that processing their claims will be much
more efficient !
This is a billion dollar market, but it's still stuck in the 1950s. One of the reasons for this is that the marketing budget of pharmaceutical companies is in the hands of product managers, whose primary job is to sell a specified number of cartons of their product. All they care about is meeting this target - and that is something they are very good at doing , by pampering doctors and getting them to prescribe their product. Unfortunately, because these are relatively low level line managers with limited budgets, there is no one focussing on the big picture of building the brand of the company.
This is actually a big opportunity for a clever company. Rather than waste money by gifting a large numbers of doctors with silly trinkets; or a few doctors with expensive foreign junkets , they could make much more efficient use of their marketing budget by helping doctors to build their practise .
This is a win-win situation; and any company which can help a doctor to cultivate a thriving practise would have many grateful doctors .
So, what does a doctor need and want ? He needs to keep upto date , so that he can provide quality medical care to his patients. The trouble is that it's hard to do this in private practise, with the result that doctors are often hard-pressed to keep up with modern trends.
While there is a lot of information available on the web, a lot this is unreliable ! Doctors would rather look up standard medical textbooks or medical journals when they need to find information.
The good news is that the world's largest online medical library, with over 30 full-text medical books and 30 full-text medical journals is available online at www.mdconsult.com !
Smart pharmaceutical companies have started gifting subscriptions to MDConsult to doctors in India ! For information-starved doctors, this is an extremely useful gift, which they use on a daily basis. Interestingly, many doctors are now requesting their medical rep to gift them a subscription. Such a gift helps to create loyal doctors - and also helps to improve patient care !
Sunday, March 02, 2008
When did you last compliment your doctor ? ( And I don't mean just a general non-specific Thank you at the end of the consultation .) I am sure your doctor is doing many ( some things at least ? ) things well , so there are many opportunities for providing positive feedback. Please do so - appreciating what your doctor ( and his staff) does helps him to do a better job . It also considerably improves your chances of getting better care, because it helps you build a better relationship with him ! If you don't want to be treated as just another number, then treat him as a human, by being human yourself.
Why don't patients provide feedback directly to doctors, to help them to improve ? Are they scared that the doctor will take this amiss ? This is possible in the case of some doctors, but most good doctors are mature enough to realise that every complaint is a gift - provided it is presented tactfully ! To make your criticism more useful, please also include practical suggestions as to what the doctor can do to fix the problem. Remember that if you are not part of the solution, you are part of the problem ! Not only your doctor appreciate this - so will his other patients.
Also , remember that not all feedback has to be negative. Compliments are also welcome - and appreciating what your doctor does helps him to do a better
job . Doctors are also human - and respond positively to praise ! When did you last thank your doctor ?
Saturday, March 01, 2008