Wednesday, April 30, 2008
An illness is just an episode in the patient's life; and that while the doctor usually sees only a disease which needs to be treated and is fixated on fixing the medical problem, the patient has a life which is much more than just his illness.
One way of putting the patient at the center is by changing the way we look at doctors. Doctor should be treated as just one of the tools which are available to patients to help them manage their illness. There is no doubt that the doctor can be an extremely valuable tool, but this is no reason to treat them as gods.
The doctor is so important because he plays so many roles. He needs to make the right diagnosis; confirm it ; formulate the treatment plan ; and provide counseling . The doctor acts as a gatekeeper to the entire healthcare system and the good doctor guides the patient down the right path. However , doctors are not indispensable , and thinking of the doctor as a tool helps the patient to realise how important the role he himself plays .
Smart patients know which tools to use- and when. Clever patients have multiple tools in their toolbox - and these include: spirituality; friends and family for support; humour ; and information therapy. The more the tools you have in your armamentarium, the better equipped you are in your ability to manage your illness.
As with all tools , doctors can be used and misused. The trick is to identify the right tool and use it for the right purpose. While doctors may be very good at making a diagnosis , mastering the tools to live with the illness are skills the patient needs to learn for himself. Insulin is a tool a diabetic uses to to manage his illness. However, he cannot depend upon insulin alone. He also needs to learn how to control his diet ; how to exercise; and how to improve his lifestyle.
Similarly, a doctor is also a tool - and patients need to learn how to use this powerful tool intelligently and sparingly !
Tuesday, April 29, 2008
The four components necessary to treat diabetes, or any other disease, are
4.Attendants. [ = Family = nurses]
Just as successful cooking requires utensils, fuel /fire, food items and a cook, successful medicine requires all the above four. Similarly, the potter has to coordinate earth/clay, water and his wheel to create good pottery.
And just as a strong table needs four equally stable legs to stand, all four components of the quadruple of Atreya have to be equally effective .A chain is just as strong as its weakest link, and diabetes practice cannot be stronger than the weakest link of the quadruple.
Thus the concept of team work, patient education and diabetes awareness was propounded over 3000 years ago. The physician represents today’s diabetologist or endocrinologist, while the patient stands for an educated, empowered person with diabetes in equal partnership with his doctor."
There's nothing new under the sun !
On the other hand, while some patients are quite happy to be the center of medical attention because they have a complex problem, most just want a solution so they can move on with their life.
A good doctor will spend as much time and energy on crafting a treatment plan for the patient, as he will on creating a plan for a diagnostic workup. This can actually be harder to do, because it requires the doctor to see things from the patient's point of view - and offer advise which the patient is willing to carry out !
Let me clarify.
1. Most doctors are not good educators. They use complex medical jargon and are not able to simplify matters, so that that patients often cannot understand what they are saying.
2. Doctors have not been taught how to teach patients , and this is not always an easy skill to acquire.
3. Because doctors can be intimidating , patients are very reluctant to ask questions. This means that even though the doctor feels that he has provided an adequate explanation, the patient often understands very little, and is still full of doubts and queries. After all, good communication is always a two-way process.
4. Often , the doctor may not provide the right information , because of a vested interest or a hidden agenda.
5. Doctors find educating patients very boring and get fed up very quickly of answering the same questions
6. The doctor's time is precious , and could be better utilised in providing clinical care ( making the right diagnosis; and executing the treatment plan. )
So what is the solution ? Just like we have independent trained counselors who can guide patients, we need to have patient educators to educate patients. This does not mean we need to create new jobs or positions. It just means that the clinic should identify one person who likes talking to patients and is good at this . This is often an innate skill( these are "people persons " !) which can be polished with training . This person could be a nurse or a secretary who then takes on the additional responsibility of educating patients. They are likely to do a much better job than the doctor can , for many reasons.
1. They often have more time
2. Patients are much more comfortable talking to them , rather than the doctor; and are much more likely to ask questions
3. They are much more likely to use the local language , when providing explanations. This helps patients to understand complex concepts much more easily
4. Because they spend a lot of time educating patients , constant repetition will ensure they get very good at it. They can use a number of teaching tools and models to help them get their point across
This is a much more cost effective way of educating patients , rather than using the doctor's expensive time !
This model means that doctors will continue to prescribe information therapy. It is just that the information therapy would be dispensed by someone else in the clinic other than the doctor.
In the past , doctors would do all the lab tests themselves. Today , these lab tests are outsourced to a specialised pathology laboratory. Using exactly the same analogy , patient education can be better provided by an individual who has a special interest in this field. This creates a win-win situation, where everyone benefits. More importantly , it also serves to emphasize how highly the doctor regards patient education ! If we have specialists for taking x-rays ( called X-ray technicians), why can't we have specialists for educating patients ?
Flock said applying those same concepts to the health care industry would provide tools that would allow for better and more relevant information sharing, collaboration, and ultimately better care as consumers gained more control over their information and, ultimately, their health.
Web 2.0 features like product and service ratings, information search, social communities, and tools are a natural evolution of health care technology, Flock said, and represent a new business paradigm that companies and institutions will have to adopt in order to remain competitive and relevant."
The application enables diabetic patients to enter their blood sugar readings into their mobile phone and receive real-time feedback on what they should eat and other ways they can help stabilize it. The software also can alert patients when they need to test their levels.
Further, the application sends the data to the vendor's servers, where it is analyzed and can be accessed by the patient's physicians and disease management case workers. It also can support glucose meters that can send data via Bluetooth wireless technology."
It's a good idea for doctors, too, said Dienst, who is among the first physicians in Central Florida to conduct online, reimbursed consultations with patients. With three major health-insurance plans now reimbursing physicians for online consultations, Dienst expects he'll soon have plenty of company."
Monday, April 28, 2008
Now you can get an elite doctor to weigh in as well: Top medical centers such as the Cleveland Clinic and Partners' Center for Connected Health (which is affiliated with Harvard Medical School) offer second-opinion services via the Internet. This practice of consulting from afar using patients' medical records and test results is having a profound effect on how problems are treated. According to Partners, although its experts changed only 5% of diagnoses during its first year of providing e-consults, 90% of the treatment recommendations differed from the referring physician's plan."
I have now been offering a free second opinion for infertile couples for over 5 years . I enjoy doing this - and have helped many couples , which means good karma for me !
· To set up a Multimedia Patient Education Resource Center in the hospital to attract more patients; improve patient care, and enhance patient satisfaction.
· HELP is a one of the world’s largest patient education and information centres. It has been recognized by the Limca Book of Records. Established in 1997, HELP has over 10000 books and 500 videos. It set up India’s first health website www.healthlibrary.com. It is a self-sufficient, registered charitable trust and a non-profit organization.
Current Market Status:
- Being made to wait
- Not being told about how the patient is progressing
- Poor doctor-patient communication
· Slowly, but surely, hospitals are realizing the fact that educated and informed patients are happier patients. Further, partnering with a patient’s family to provide information is a vital ‘differentiating’ factor for a hospital.
HELP value proposition:
- HELP sets up a branded information centre in the hospital. This centre is instrumental in increased patient satisfaction as it provides vital information to the patient and his family. For example, a son can learn about his hospitalized father’s hepatic failure in the information centre.
- The centre also draws in people from the neighborhood. People living in the close vicinity of the hospital enhance their knowledge about the chronic conditions being faced by themselves or their family members. For example, A type II diabetes patient can frequent the centre and subsequently can become a patient in case he needs hospitalization.
- The information centre also solicits questions from the users. These questions are then e-mailed to the main HELP hub in Mumbai. The answers to these questions are sent within 48 hours of receiving them. Moreover, the website the hospital also carries a link where people can post queries and the answers are given on the behalf of the hospital within 48 hours.
- Patient education has been shown to improve doctor-patient communication; save the doctor’s time; improve patient satisfaction; and improve patient compliance and treatment outcomes. Information Therapy can be a powerful medicine.
- Each inpatient gets at least about 5-15 visitors daily. In one 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. Visitors can spend time at the patient education library , which is likely to induce them to select your hospital whenever they need medical care.
Thisfree service will also help to create a lot of goodwill for the hospital; improve brand visibility; and provide a unique selling proposition.
- A Patient Information Centre site is recognized at your hospital.
- This site is ‘branded’ and done up by you based on the recommendation of HELP. The required amenities like book shelves, computer, etc. are installed.
- Patient educational material is provided by HELP
- Your staff members are trained by HELP to run and manage the Patient Information Centre. All aspects of running the centre are taught to one or two of your staff people.
- An additional backup to answer patient’s queries free by email is also set up. Your web site ‘Ask Us’ icon is linked to our main information hub.
- Printed information prescription pads to encourage doctors to refer patients to the information centre are provided.
- The collection is upgraded every year.
- HELP provides the books (100 titles ) and DVDs (50 titles) to start the core collection.
- You provide space ( about 500 – 1000 square feet in a high traffic area) and infrastructure ( racks for the books; signage; DVD player with TV; Xerox machine; internet computers) ; and staff. Branding material is provided by HELP, which is installed by you to do up the information centre.
- HELP trains your staff members (free 3-day training at HELP) so they can manage the show effectively.
- HELP provides strategic guidance as to how you can maximize the utilization of the library – for example, by developing your own patient educational materials; having talks and seminars by your doctors.
- HELP answers questions free by email, through your website , if your patients have further queries
Implementation Time line:
1. Identifying and Purchasing books – 1 month
2. Supplying books – 1 month
3. Training your staff members – 3 days
4. Inauguration of fully furnished library – 3 months
1. Visit HELP so you can see the valuable services a Patient Education Resource Center can provide
2. Sign MOU
3. Identify space and set up infrastructure
4. Depute staff member for training at HELP
5. Include the Ask HELP service in your website
6. Set up a Department of Patient Education in the hospital.
The research, the focus of this week's editorial in the Lancet, finds that when doctors speak to their patients using the terminology they learned in medical school, patients can fail to identify what it is that's being said, be confused about their diagnosis or incorrectly interpret their condition.
According to health experts, the confusion can happen very easily.
'There are words that sound the same, like hypo and hyper,' Dr. Peter Lin, a Toronto-based general practitioner, told CBC News Thursday. It would be very easy for a patient to hear the opposite of what was said by a physician, leading to an incorrectly interpreted diagnosis, he said."
Sunday, April 27, 2008
What are commonest complaints patients have about hospitals ? It’s a long list, but the primary concerns are:
1. Waiting interminably to see the doctor
2. Being kept in the dark about the treatment
3. Not knowing how much it’s all going to cost
What can you do to take care of yourself ? The simple answer is – find a good doctor in a good hospital. While this is the best possible solution, it’s also a fact that you may not be able to do this. So, is there anything hospitals can do to resolve the problem ?
Hospitals need to reinvent themselves to keep up with the changing times, and there is a simple solution which can help them to keep their patients happy . The answer is Information Therapy for patient education. This is a win-win situation, which will help hospitals, doctors and their patients.
Hospitals need to understand that patient education is not an expense – it’s a basic service which can actually help them to improve the quality of their medical care – and their profitability as well ! A Patient Education Resource Center is a great way of marketing medical services and getting more patients. For example, if a patient is admitted with asthma and they sell books on asthma, the chances of the patient ( or his relatives) buying this book are huge ! Ideally, the hospital should have a circulating collection of books, which patients can borrow and read, so they understand more about their illness. This is an effective way of empowering patients.
Another great opportunity which hospitals routinely ignore is educating the patient’s visitors and relatives. Every patient in hospital routinely gets about 10-15 visitors every day. However, most hospitals barely tolerate the presence of visitors, who are usually treated as pests who just get in the way of the staff and the medical treatment. However, these are all potential future customers for the hospital, and should be treated with respect ! Because they have come to visit someone who is ill in hospital , they are very motivated to do something to prevent themselves from falling ill. ( For example, if you go to visit a friend who has had a heart attack, your wife would be very happy to buy books on how to prevent a heart attack !). Not only is this a great “teachable moment”, it’s also a good way of promoting the hospital’s heart health care services to potential new customers !
Similarly, the TV screens in hospital OPDs can be used to show health educational films, so that patients can learn about their health and ways of improving it, instead of watching soap operas or the news.
It’s a fact that patients are increasingly unhappy in India today – and while they are still not as likely to sue as in the US, angry patients do burn down hospitals and beat up doctors. Errors do happen even in the best run hospitals – and well-informed patients ( who ask questions and know what to expect) are extremely good at preventing problems because they can speak up and prevent errors. Patient education has also become an integral part of risk-management. While a bad outcome does not always mean to a lawsuit, if this mistake is compounded by poor doctor-patient communication, this is likely to lead directly to the court. By educating patients and communicating with them on an ongoing basis, the chances of the aggrieved patient going to a lawyer are dramatically reduced.
Some doctors used to feel threatened by a well-informed patient. However, this is no longer true; and the younger generation of doctor respects a well-informed patient, because both doctor and patient are on the same side. It’s true that patient education can take time – but it’s much better to answer the patient’s questions now , rather than his lawyer’s questions in a court of law !
In a hospital setting, doctors are a scarce resource and they are usually the bottlenecks. By setting up a separate Dept of Patient Education, the doctor’s time can be saved; and your time can be utilized constructively, instead of wasting it. Patients often get impatient when made to wait without rhyme or reason ! Thus, if you go to see your doctor and if he is running 45 min late because he is held up in surgery, his secretary can request you to go to the library where you can read a book or watch a DVD about your problem. You will be called on your mobile when the doctor comes to the clinic. Not only will this prevent you from getting upset because of the delay; it will also help to save your doctor’s time, because you will be much better informed about your problem. Similarly, your doctor can hand out patient educational brochures ( published by the hospital, with their logo and address) to you patient after the consultation. Not only will this reinforce the information given to you; it will also help to improve the level of health information in your family - and thus the community .
Patient education can be a great way of improving patient satisfaction, because a patient who has had all his questions answered , is likely to be much happier with the doctor; and have realistic expectations of the treatment. Patient education also helps to cultivate empathy in the medical staff, who learn to see things from the patient’s perspective; and can help to teach the staff to respect the patient.
If it’s so simple and obvious, why doesn’t every hospital do this ? Actually, the world’s best hospitals do this routinely. For example, Mayo Clinic has a separate building devoted to Patient Education. Also, the JCAHO guidelines ( the US body which provides accreditation to hospitals) also makes patient education compulsory. Unfortunately, it’s not a very glamorous service to provide, which is why most Indian hospitals don’t bother to do so. Also, they are so busy competing with other hospitals on how many slices their newest CT scanner offers, that they end up ignoring such a basic need. This is a shame – and a great opportunity as well , because a simple inexpensive change in attitude can remarkably improve the patient’s hospital experience – thus improving the hospital’s bottom line !
I write this article for my Empowered Patient column for Times Wellness.
Thursday, April 24, 2008
Although it is far from complete, there is a great deal of patient health information today within the health systems, and there is value to be derived from mining this data to provide better outcomes (Aetna, Humana). Perhaps most interestingly, the government is highly motivated to find effective ways to control chronic disease costs and improve patient satisfaction before the baby boomer retirees swamp the Medicare system."
For the past 19 years, our mission in life has been to create an environment of care that provides a loving, nurturing feeling for families and their loved ones. It has been to provide a center of excellence that addresses not only the need to be competent, but also the need to be human.
It has been my goal to create a truly healing environment where patients have an opportunity to take part in their care and to make decisions about the type of care they receive. It has been about creating a place where Care Partners provide support for their loved ones and where they can actually participate in their loved one’s care. "
MedPlus solution’s Care360™, a patient-centric physician electronic network, will serve as a platform to securely transfer patient diagnostic and laboratory data onto the Google Health portal, Google’s new offering, created to enable patients manage and control their personal health information through a 24/7 secure access to an efficient online medical record system. More than 100,000 physicians employ the Care360 suite of products to access online diagnostic test results, share clinical information, and perform electronic medication prescribing and ordering of lab tests. Through this collaboration Quest diagnostics would develop solutions that allow these physicians to securely transfer current and historical laboratory information into the patient’s Google Health account and provide an overview of test results to explain their health status."
These innvoations will change the entire healthcare ecosystem !
This is a “major turning point” according to Gardiner, “that could present greater challenges for healthcare professionals, organizations and the patient or client.” How will providers adapt? What impact will Google et al. have in their attempts to “own” the health care consumer? And how will even newer information technologies — such as digital video change the healthcare landscape, she asks.
The distinction Gardiner makes is an important one. "
Reader's Digest is a lot more readable and far more interesting ! I am sure JACC can learn from the RD editors as to how to present their matter more entertainingly !
This means that I or one of my colleagues will:
1. Involve you in decisions about your care, and respect your preferences. This means I will listen to you and do what I have promised.
2. Ensure that you are treated with dignity and respect.
3. Be honest with you about your management options and the evidence supporting them and make sure you understand them.
4. Keep you fully informed about what is happening with your care.
5. Provide you with written information about your diagnosis, treatment and what will happen at each stage and, if applicable, support you in your self-management strategies.
6. Ensure you have access to information about the quality of care and waiting times to help you make informed choices.
7. Copy you in on all correspondence with other people involved in your care.
8. Put you in touch with other patients or groups who can provide support.
9. Respond to your messages/queries within an agreed timeframe.
10. Respect your wishes on how we will involve your family.
11. Seek out and respect your preferences on end of life care if necessary.
This agreement requires that you as a patient/patient representative/carer be honest and open with the treatment team."
He felt that most doctors were happy to remain just skilled labourers. They were so focussed on providing high quality medical care to their patients, one-on-one, that they failed to think about the bigger picture, leave alone trying to improve it.
This is extremely true, and I think there are many reasons for this.
Firstly, it's the way most doctors are trained. The heart of medicine is the doctor-patient consultation, and most doctors are taught to do this extremely well. This is why most patients are quite happy with their personal doctor, even if they feel the healthcare system itself is sick.
Secondly, doctors are not taught to look at the big picture - and even if they are, they don't know what to do about it. While they are very good at talking to individual patients and treating them effectively, their skill-set stops here. Thus, even though they are taught about community medicine, they don't know how to deal with the community or society at large.
Finally, doctors are not very good at taking collective action. Doctors are happy to become members of medical associations and societies, but these are often quite impotent, because they are not formed with the intention of helping to fix societal problems.
This tunnel vision is hurting both doctors - and their patients. Most doctors feel that if they take good care of their patients in their personal practise, they are doing a good job. I don't think this is true. As Rudolf Virchow pointed out many years ago, " Medicine is a social science and politics is nothing but medicine writ large !" As advocates for our patients, we need to take a more active role in helping to improve the care everyone in society receives.
We need to step outside the comfortable environs of the four walls of our clinics and hospitals ! Doctors have the training and intelligence to become agents for improvement on a much bigger scale - why are we wasting this opportunity ?
Using examples, this report describes how the Web is becoming a platform for convening people with shared concerns and creating health information that is more relevant to consumers. Social networks, ranging from MySpace to specific disease-oriented sites, are proliferating so rapidly that new services are already under development to help health consumers navigate through the networks.
The report details how innovative collaborations online are changing the way patients, providers, and researchers learn about therapeutic regimens and disease management. It examines the benefits and concerns regarding Health 2.0 and it also includes an extensive listing of health media resources."
Wednesday, April 23, 2008
HOW INFORMATION THERAPY
HELPED ME GET BETTER MEDICAL CARE
“ An excellent place to be if you really want to empower yourself and not let the doctor take you for a ride. This is the place to be. Keep it going. – wrote a reporter from a leading Mumbai newspaper.
These are only a couple of compliments being regularly received by us from our readers and speakers at Health Education Library for People – HELP.
At HELP we have made it our goal to provide the best health information for every patron every day. The words of our readers say it best. Their stories are really the story of our Library. All the formal awards and accolades just can't tell the HELP story better than the words of our readers.
When one is very ill and things look their worst, nothing seems more inspiring than reading about how other patients survived against the odds and coped with their situations. There are as many different ways to survive as there are patients, and so we can learn something different from each one. At the same time certain similarities, certain patterns emerge.
Now, you can actually tell us how Information Therapy has helped you look after yourself or your family members, your acquaintances etc to help each other.
Perhaps you have a story to contribute. You need not be a "miracle cure" to contribute here - all you need is the desire to use your experiences to help someone else.
Some of the people have voluntarily come forward to share their experiences with HELP. Their ‘stories’ have helped us to provide better information to other, newer readers. Each of these stories illustrates the way someone was helped to overcome and defy the odds and shows how people have redesigned their lives to be meaningful and fulfilling following what could have been a life-shattering event. Their stories are tributes to the ability of people to triumph over adversity and to succeed when life is at its hardest. You will be amazed at their courage, energized by their achievements, and awed at the miracles they managed to accomplish. Some of these stories will bring a tear, some a smile, but all will inspire you with the knowledge and confidence that ‘ordinary day-to-day miracles’ do happen. Some were born with disabling conditions, others suffered illness, some were injured, and some experienced the ordinary conditions of old age. All of them required help to learn or relearn the skills they needed for the job of living, and with the aid of a good book, a CD, or a HELP Talk, they all found the strength and courage to do so.
Nowadays there are so many tragic and angry stories about healthcare--not just in Mumbai and rest of India, but everywhere. What we are looking for are stories that show the humanity within the medical system… stories of hope that were made possible by services offered by Doctors, Nurses, Emergency Medical personnel or HELP Library.
These stories could also be about those times that a medical professional has allowed compassion to be their guide and have "bent the rules" “gone out of their way” in order for you or your loved one to experience a joyful moment, something meaningful. These events are the sorts of things that never seem to make it into the local newspapers---but we tell our readers and the world and we will never forget them.
We now INVITE you to share your story with us. The best of your stories will be posted on our website – with your permission of course! The best story of course deserves to receive a prize – we will send you a copy of our publication – The Healthwise Handbook – so remember to send us your address.
- You could avoid the diagnostic test details and mention only the main problem.
- Names of Doctors/Hospitals may be avoided to protect privacy.
- Nature of research conducted by you to help yourself – this could also include any second opinions, research from books, visits to quacks etc and their effect on the problem.
- The story could be in the form of a skit, poem, or plain essay.
- You may protect your identity/privacy by writing in the third person.
- Stories should REACH US BY 5th May’08 either by email: firstname.lastname@example.org or email@example.com or by post/courier at the following address:
Aniruddha Malpani, MD, an IVF specialist in Bombay, says India's booming healthcare industry might become too much like the United States."
Please listen to my interview with Rick Johnson, Senior Editor, Healthleadersmedia.com, and let me know if you agree !
“The problem in dealing with health care issues in the world today is not ignorance, but pre-conceived ideas.” Hans Rosling, MD, PhD, Professor of International Healtht, Karolinska Institute, Sweden
“In today’s world, more efficient and effective caregivers simply deprive themselves of income.” George Halvorson
“Interestingly, physicians practicing in regions with the greatest supply of hospital beds, or regions with the greatest supply of specialists, perceive the greatest shortage of those beds or specialists.” Elliott Fisher
" When you pay for incremental reforms in funding, you only get incremental reforms in care.” Mark McCellan
“Health care costs are a very solvable problem. 70% of costs are driven by behavior. 74% of costs are confined to just four chronic conditions.” Steven A. Burd, Chairman, President and Chief Executive Officer, Safeway, Inc.
“Just like Blackberrys and Smart Phones filled a need for everyone in the audience, there is a deep need for the family health manager to have a mechanism to share store and manage their family health information.” Peter Neupert, Corporate Vice President, Health Solutions Group, Microsoft, Inc.
“Health care has traditionally been horrible about understanding people- consumers.” Reed V. Tuckson, MD FACP, EVP and Chief of Medical Affairs, UnitedHealth Group
“There are two major barriers with health information for consumers. How do you transport information from one setting of care to other settings of care, and how do you educate consumers to be literate about health information?” Reed Tuckson
The Innovation xChange is looking for practical ideas and suggestions for improving the health care system. All participants in the system, from providers and health plans to consumers and government, are encouraged to join in the discussion.
To participate, simply click to register and then submit your idea(s) in one of the following four categories:
1. Helping Consumers Make Smarter Health Care Decisions
2. Simplifying the Business of Health Care
3. Preventing Sickness and Maintaining Health
4. General Innovations in Health Care"
e-Visits, introduced at the start of this decade, continue to gain momentum as technologies improve, consumer demand increases, experience from prior pilot studies becomes more widespread and major health plans advance and adopt e-visit initiatives. For common, non urgent ailments, an e-visit can simplify life for a consumer, and for a provider and plan too (because the entire transaction has already been converted to a documented electronic transaction.)"
Tuesday, April 22, 2008
We use an alternative model, which we feel is much better. Rather than send a note to the referring doctor, I explain to the patient what my findings are and what my advise is. I then request him to go back to the referring doctor, and to tell him what I said. I feel this is a better model for many reasons.
Firstly, the patient is center of all the action, so he does not get lost or confused.
Secondly, it's a great check on my communication skills as well ! If the patient can explain what my treatment plan is to the family physician, this gives a lot of comfort to the doctor that he has sent his patient to the right specialist.
Finally, this is an effective way of improving the level of medical knowledge about infertility in the entire community , so that the many myths and misconceptions which surround this get gradually dispelled.
Monday, April 21, 2008
The tragedy is that a lot of the promises are just hot air. Ideally, the government should promote medical tourism by providing subsidies and infrastructure services to hospitals and doctors so that they can improve the care they provide. This is done routinely for the IT industry, which gets large tracts of real estate from the government at highly subsidized rates, so there's no reason why this cannot be done for hospitals ( which provide employment to thousands and a socially useful service to local citizens as well !) I guess this is asking for the moon, so let's see if they can do something much simpler which would not cost them anything.
In order to promote exports , the government offers a lot of sops and carrots to industries which earn foreign exchange. For example, companies which earn foreign exchange are eligible for tax exemptions , which means they pay much less tax than others. Why can't the same rules be applied for doctors and hospitals who earn foreign exchange from overseas patients ? Why shouldn't the export of all services which earn foreign exchange ( whether in the IT industry, jewellery industry, the hotel industry or the healthcare industry) be treated on par ?
I can think of two simple solutions to improve utilisation.
The " expert patient" is one who has had the illness for some time; knows a lot about it because he has done his homework; and is willing to share his knowledge with others, as a labour of love. This person is likely to be a much better teacher than any other source, for many reasons.
He is much more likely to "think out of the box" and use all the clever new technological options to make the learning much more fun, stimulating and interactive. Most doctors know a lot about medicine - but they don't know much about teaching or learning. E-learning has gone through dramatic improvements, and it's possible to create clever games , simulation and videos to make learning much more sticky and fun !
Because he is not a doctor, he is likely to use simple English to explain complex concepts. Not only is this much easier for others to understand, it is also much easier to read and comprehend. While doctors are good at writing for other doctors, they are often not good at communicating in simple terms.
What about the risk that this information my be incorrect ? It's true that there are a lot of dogs on the internet ; and that a lot of information can be rubbish, but this is true of information published by doctors as well ! Community monitoring to ensure correctness of answers can help to ensure the content is reliable and uptodate. The wikipedia is an excellent example of what an empowered community of lay-people, experts and non-experts can do !
I feel it's not possible to teach anyone - everyone has to do their own learning ! Cleverly produced materials from another patient are much more likely to encourage patients to do so.
Sunday, April 20, 2008
Medical students are going to be the doctors of tomorrow. They enter medicine because they want to help other people ( and yes, they also make money in the process, and I think it's perfectly justified for them to do so !) . Sadly, the conditions under which they work are so miserable, that their resentments and grievances keep on festering; and when they find no one is willing to listen, the only option they have left is to go on strike. Now this is not something which future doctors do lightly. Doctors have a conscience, and the fact that patients may get hurt when they go on strike is a major deterrent for residents. The major focus for residents and students is their education and they want to complete this as expeditiously as possible so they can get on with becoming doctors. Also, it's possible for the government to take punitive action ( such as cancelling their registrations), so going on strike can have serious repercussions . It takes a lot of guts to go on strike !
The tragedy is that these strikes seem to have become regular affairs - and they fail to achieve their purpose. I remember going on strike 20 years ago; and these seem to happen every 3-4 years. The strike is called; the newspapers report this; the politicians and bureaucrats promise to take corrective action so that the strike is called off; but nothing happens, so that the residents are forced to call for another strike after a few years.
The trouble is that it's a very uneven and unfair battle. Residents come and go, because once they complete their training and become doctors, they move on. Unfortunately, government bureaucrats remain forever, so they are formidable opponents, whereas residents are unarmed and inexperienced in these confrontations. Also, the media usually supports the government, because they highlight the adverse effect these strikes have on the poor patients who avail the services provided by government hospitals, which means the public is full of sympathy for the poor suffering patients - and they have little compassion for the suffering medical residents. Unfortunately, there is little unity amongst doctors, so practising doctors do not provide the stroking residents with any support. The biggest tragedy is that the medical professors and teachers , who are supposed to nurture the next generation of doctors, also fail to support them with the result that the strike fizzles out very quickly, and never achieves its purpose.
What was the reason for the present strike ? The medical students and residents were agitating over the fact that the number of recognised postgraduate posts for specialistion in medicine in the government hospitals in Maharashtra has been progressively declining because the government has not bothered to upgrade the teaching facilities; employ the required professors; or get the needed recognition from the Medical Council of India. The authorities have promised to "look into the matter" in order to settle the strike, but it's very unlikely that they will do anything more than paying lip service.
The reason is simple. Along with the declining number of government postgraduate seats, there has been a corresponding increase in the number of private medical colleges in Maharashtra , which are now mushrooming all over the place. These private colleges offer "recognised" medical training for which they charge a fat fee, which means they are extremely profitable to run. And the vast majority of these are owned by politicians in the state. 8 cabinet ministers in Maharashtra own their own medical colleges today ! Not only are these highly profitable ( which is how rich politicians become even richer) - they are also a great way of providing favours for sons of influential and well-connected businessmen and doctors. This is the real reason why there is absolutely no political will to try to improve the sad state in government medical colleges today. After all, if ministers are spending all their energy on getting recognition for their own private medical colleges, why should they care about what happens to the seats in government medical colleges ( which offer serious competition for them ! )
All of us are silent bystanders. Today, it's the medical students and residents who are suffering. Tomorrow, it will be all of us who will pay the price for our inaction and lethargy, because the quality of the doctors which are being turned out is going to drop dramatically as a result of this privatisation of medical education. I guess we will get what we deserve - and we only have ourselves to blame !
The best method would be to ask around, so you can find a good doctor. This is what all of us do informally when choosing a doctor and this is a time-honoured method, because it forms the basis of a professional reputation.
However, this is an inefficient system - and this is especially true when you are new to a city and don't know whom to ask. A very effective solution would be to have a community of patients provide ratings for their doctors . While this can be quite a messy system ( because some patients are likely to be prejudiced for their personal reasons and may provide poor ratings to good doctors) , if you believe in the "wisdom of the crowd" then this is likely to be an effective technique for many reasons.
It will help patients because they will at least have a starting point which they can use as a basis for comparison. Patients will also learn what metrics they can use to better judge the performance of their doctors. Every community will have enlightened and articulate patient-leaders who will provide free and frank feedback, which can be very useful for other patients - and who can be better judge for a doctor than his patients ?
Interestingly, this system can be very useful for thoughtful doctors who are willing to use this feedback to improve. Doctors will get an online reputation , and when doctors know they are being judged by their patients, they are likely to improve their behaviour and better their performance - a very desirable outcome ! Equally importantly, if your colleague is gettig better ratings than you, this is likely to motivate a doctor to upgrade and improve his systems and processes.
I always feel that patients who do not come back to me for treatment after a first consultation can give me a lot of valuable insight as to why they chose to go to someone else, which can help me to improve . Every complaint is a gift - and it's better for me to know why my patients don't come back to me rather than to keep on losing them ! This will only happen when patients are given such a platform, and are empowered to provide frank feedback . After all, how will doctors improve until our patients tell us what we are doing wrong, so that we can fix our errors ?
Saturday, April 19, 2008
I remind my patients that God designed the body with enough sense that walking, running, coughing and sneezing do not cause an embryo to fall out ! Embryos are safe and secure in the womb , and just because they have spent 48 hours in the incubator in the IVF lab does not change anything ! IVF allows us to mimic nature , and once the embryo has reached the uterus, it's exactly like an embryo "made in the bedroom" ( embryos do not have a memory !) After all, when fertile couples have sex and get pregnant naturally, they continue leading a completely normal life after sex , so why should IVF make any difference ? Enough medical studies have been done by many IVF clinic which prove that embryo implantation and pregnancy rates are not affected by rest; and patients can walk out just 10 minutes after the embryo transfer.
In fact, enforced bed rest can have a very unhealthy effect on the patient. Being forced to lie down in bed when you are well can be demoralising, so say the least. Taking a bed pan ( during "strict bed rest") can be extremely humiliating. Also, if you are forced to lie in bed, then you tend to spend all your time thinking about what the outcome is going to be - a very unhelpful process, because the outcome is no longer in your hands. As it is, during the dreaded 2ww ( two week wait between the embryo transfer and the pregnancy test), each minute seems to last for an hour. Lying in bed makes the time crawl even more slowly !
So why do some doctors still insist their patients take "bed rest" after embryo transfer. I think this is a very clever way of "victim blaming" ! If the patient does not get pregnant, they can always "blame" the patient for the failure, because she did not "rest" properly. The biggest tragedy is when the family members start believing this untruth.
I think patients ( and their loved ones) need to understand that activity does not have any impact on the embryo inside the uterus, because it is protected from external influences in its uterine haven. Implantation is a biological process which is not affect by external activity - or by gravity ! We suggest patients take it easy at home for 48 hours after the embryo transfer , after which we encourage them to resume work, so they can keep themselves gainfully occupied. This is actually more for their peace of mind, rather than because it changes the outcome. I always tell patients that if resting helped to increase pregnancy rates by even 1%, we'd happily keep them in hospital for even 15 days after the transfer !
There is a difference between transfer and implantation ! While embryo transfer is a simple mechanical procedure, implantation is a complex biochemical event which involves a dance of exchanged signals between the endometrium and the embryo - something which cannot be influenced by diet or activity !
Being infertile is bad enough - don't make it worse by forcing yourself to rest in bed when you don't need to !
Friday, April 18, 2008
There are many problems; and these include:
1. High costs of medical care, partly because of overtesting, ( imaging companies want to sell their latest scanners , gadgets and gizmos); and overtreatment ( because greedy pharmaceutical companies want to sell their newest ( and most expensive) drugs).
2. Too much paperwork, because of a bloated bureaucracy. There are more medical administrators and paper-pushers than there are doctors in the USA !
3. Poor insurance coverage, because of high costs
4. Rushed doctors, who do not have enough time to spend with the patient, because of the quotas they need to fill, set by the hospital administrators
5. The threat of lawsuits for negligence, which forces doctors to practise defensive medicine and spend more time on documenting care rather than on providing it !
With such a long list of problems, how do we find a solution ? The issue seems too complex , especially when you realise that healthcare costs over a trillion dollars in the USA today.
I feel the real reason for this unhappiness is far more basic. We need to remember that while policy analysts and Presidential candidates love to talk about the "healthcare industry", for most of us healthcare means the one-on-one interaction we have with our personal doctor. This is the heart of all healthcare - the doctor-patient relationship - and this is what we need to improve if we want to correct the present situation.
The rule is simple - unhappy doctors make for unhappy patients - and happy doctors create happy patients. ( Incidentally, the obverse is equally true , in that happy patients make for happy doctors !)
If we want to have happy patients, we need to create happy doctors - doctors who enjoy looking after patients, and have fun taking care of them. If we start from the bottom-up, and then work upwards, we can solve the problem ! It's just a question of improving these "moments of truth" which occur daily in the doctor's life - and which have such a profound impact on the patient's well-being.
If we treat each doctor as just another expensive employee; or a "healthcare worker" ; or a
" skilled professional" with a special skill set, we'll never be able to tackle the problem. However, if the entire industry learns to treat each individual doctor with the same respect and care with which each patient treats their personal doctor, I think we will be able to make progress !
Thursday, April 17, 2008
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Wednesday, April 16, 2008
It’s understandable. The people who write the headlines aren’t usually the people who write the stories and articles, too. The headline writer’s job is to condense information in such a way as to suck people into the rest of the story. They “sell” the article to the reader, so it makes sense for them to be sometimes inflammatory, often intriguing, and revealing of only part of the story."
Until the past few years, the thought that a patient would participate so fully was unheard of. Today, many patients realize that this level of participation is vital to maintaining health in the face of medical problems or challenges."
Tuesday, April 15, 2008
Do you have symptoms? Jot down notes about when they started, what happens when they occur and what makes them better or worse. Are you on a medication? Write down questions about how long you're supposed to take it, the likely side effects, the costs, and if there is any food, drink or activities you should avoid while taking the medication."
Lots of useful tips you might want to review before your next appointment.