Friday, February 27, 2009
Over all, they found that dual-doctor marriages were relatively happy and stable. Compared with other physicians, doctors in dual-doctor marriages reported greater satisfaction in discussing and sharing work interests with their spouses, more involvement in child rearing by both partners and a higher family income."
Dealing with difficulty signifies mastery rather than weakness. Olympic dives are rated in terms of difficulty, as are mountain climbs, hiking trails, musical works, crossword puzzles and highly technical procedures. Partnering with patients in the challenging aspects of their health, lives or medical care is a stepping stone to surmounting together the difficult encounter."
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”"
So why blame the doctors ? hey are responding to economic incentives as rational, intelligent human beings !
Wednesday, February 25, 2009
Tuesday, February 24, 2009
Monday, February 23, 2009
He looked progressively blank, and did not have a clue as to what the answers were. I was even more dumb-founded than he was, Imagine going through an expensive and time consuming treatment like IVF - twice ! - and not knowing the answers to such basic questions. He became defensive and challenged me , saying - I am sure my doctor knows all this stuff - why should I know any of it ?
I think he did finally realise that his earlier doctor had not been frank and forthcoming, so I did not pursue the matter any further, but it still amazes me that patients will insist on an invoice and a receipt when buying a TV set - but will not ask for a copy of their medical records !
I think it boils down to the fact that doctors can be intimidating and that patients think twice before asking them questions. They are scared of their doctor and do not want to offend him. Their concern is that if they ask too many questions, the doctor will get angry or irritated; and may take offense, because asking questions may suggest that the patient does not trust the doctor.
I think it's important that patients should trust their doctors - but this trust needs to be earned - it cannot just be given away ! In the attempt to not rock the boat, not asking questions can actually end up creating lots of problems, when medical problems occur - as they invariably will, a certain proportion of the time. A patient who has asked questions and received satisfactory answers will be in a much better position to cope with these complications, if they do occur. Good doctors understand this, and encourage questions. Clever doctors have developed a wide range of techniques to raise questions and answer them, without spending a lot of their own time in doing so. These techniques include: providing patient educational materials with FAQs on the web or in the form of brochures; and hiring nurses and assistants, whose primary job is to clarify the patient's doubts.
However, sometimes this focus on saving money can become an obsession; and this means that sometimes doctors cut corners, which ends up becoming much more expensive for their patients, because the right diagnosis is delayed; or the correct treatment is not started on a timely basis.
Some shorts cuts end up wasting time - and actually represent a penny wise and pound foolish approach. The key is to develop clinical protocols which can be documented and justified, so we can practise cost effective medicine without hurting our patients, just because they are poor.
Sunday, February 22, 2009
" All of us are ignorant - only about different things" !
We expect our doctors to be experts and specialists and to tell us everything we need to know so we can get better. However, the truth is that there are lots of areas about which doctors know very little - and a good doctor will be one who is willing to share his ignorance with you, so you know when you are treading in uncharted territory.
Unfortunately, many patients don't want to hear the truth because the illusion of an omnipotent and omniscient doctor is very comforting when you are ill. However, this delusion can prove to be expensive in case the outcome is bad - but complaining at this time will not really help.
The biggest danger is when a doctor is unsure and uncertain, but will not share this fact with his patient. This is a dangerous situation to be in - for both doctor, and patient !
A mature doctor is happy to let his patient know what the limits of medical science are, so that they can explore the unknown together. However, it does require a mature patient to understand that when the doctor says - " I do not know" does not mean that the doctor is an ignoramus !
Tuesday, February 17, 2009
Couples who have tasted infertility during their marriage turn to IVF when they discover that their other options are limited. And when they do, they are hardly aware of what they are getting themselves into. Yes, the doctors in the team are kind and courteous, they understand and empathize with you, and they explain the whole procedure so that you know what’s happening at every stage of the procedure. But what they don’t, or rather can’t, tell you is how you’re bound to feel, how your emotions are going to go for a roller coaster ride, and how you’re supposed to deal with the hodgepodge of feelings you’re bound to go through. If you’re thinking of going in for an IVF cycle, here’s what you need to do:
- Surround yourself with people who love you: IVF is a very stressful procedure, so make sure you have the support and love of people who are close to you – friends and family members who understand your feelings and are willing to put up with your occasional tantrums and moodiness.
- Pamper yourself: You’re bound to feel frustrated with the long drawn out procedure that entails a host of injections, interminable waiting periods at hospitals, innumerable scans, a few surgical procedures, and then the waiting around for the final news. You can prevent feelings of suffocation (from all the inactivity) and frustration from taking a toll on you by doing the things that you like and by pampering yourself.
- Eat sensibly: Moodiness, stress and inactivity tend to make you eat more than you normally do. You tend to sit around the house and stuff yourself with junk food that’s loaded with fat and calories. Besides adding on the pounds, these foods are not conducive to a pregnancy. Eat fresh fruits and vegetables, wholegrain products, low fat dairy products, and lean meats (if you’re a non vegetarian). Also, drink plenty of water and get enough rest.
- Don’t give in to the frustration: You can do this by being ready for anything the treatment throws at you – arm yourself with a book or a video game in preparation for the long waiting periods at hospitals, make friends with the other couples who are there (without being intrusive), and try and stay cheerful through it all.
- Be prepared: I don’t want to sound negative, but it’s best to be prepared to hear bad news at the end of the cycle. IVF cycles have only a 30 percent chance of success, and you’re bound to take the news of failure better if you’re prepared. Remember though, that it’s not the end of the world and that you can try again in a few months when your body has recovered enough.
This post was contributed by Holly McCarthy, who writes on the subject of nursing colleges. She invites your feedback at hollymccarthy12 at gmail dot com
This way, irrespective of whether the treatment results in a baby or not, you have peace of mind you did your best - and this can be invaluable !
How much obstetrics has changed over the last few years ! It's now possible to diagnose fetal genetic diseases based on a blood sample from the mother !
This report provides a comprehensive review of this exciting new technology, including the ethical, legal and social aspects.
Monday, February 16, 2009
Ironically, much of this pain and suffering can be reduced by simple primary level interventions delivered by well-informed health providers.
But for decades, the problem in India has been that very few medical professionals are willing to live and work in the rural areas. We believe the answer lies in equipping local providers to deliver good quality first care. The most widespread and popular health providers of first contact in rural India are rural medical practitioners: private providers with a paramedical or alternative system background, who serve the communities in which they live.
First Care’s core philosophy is directed towards training, mentoring, supporting, and eventually accrediting local providers to deliver simple primary health interventions. To achieve this, we are committed to harnessing the potential of Information and Communication Technology (ICT) in creative ways."
Remote Consultation/ Diagnosis
Remote consultation of diseases, such as skin conditions and cataract, that are amenable to diagnosis using cell-phone camera images and voice-recorded symptoms
Rural Healthcare system efficiency consultation
Consultation on the use of mobile technology, development, deployment and testing of cell-phone based applications to improve the efficiency and reach of existing health delivery organizations
Detection/early warning of diseases, such as HIV, and Cervical Cancer, that are amenable for screening through cell-phone camera images of external manifestations in skin and eyes, and voice-recorded symptoms
Public health data-gathering
Gathering of critical household-level data needed for planning health-related interventions, such as sanitation conditions
ClickDiagnostics provides IT infrastructure, capacity building and implementation support for empowering health-workers to provide services to patients or health-care organizations."
My medical history is as follows. I have been treated for testicular cancer in 2003 and one of my testicles is removed with a surgery. Before and after the surgery I have undergone 4 cycles each of chemotherapy. Every 6 months I get the blood tests done and everything seems to be normal for me. Last year April I have undergone testicular biopsy and it resulted in azoospermia. Last month I got the FSH blood tests done and it came out as 23.51.I have consulted many doctors and as my FSH is high one of the doctor has referred us to sperm donor program. Is this my only option ? Is there any way I can have a baby with my own sperm ?
Unfortunately, this man now has complete testicular failure; and his sperm production has been wiped out as a result of the cancer chemotherapy. Ideally, his sperm should have been banked ( cryopreserved in a sperm bank) prior to his starting chemotherapy. Unfortunately, this was not done, as a result of which his only options now are adoption; donor insemination; or child-free living. His ignorance - and the fact that his oncologist and surgeon did not bother to discuss his future reproductive options wiht him) have proven to be very expensive for him.
There is no doubt that cancer can be a life-threatening illness , but the good news is that many young patients are now surviving their disease and its treatment because of recent medical advances. They have their whole lives ahead of them - and having babies is one of the things most young people look forward to doing. Unfortunately, without enough information, they are not aware of the impact of the chemotherapy and radiation on their testicular function; and when they find out they cannot have a baby, will often resent the fact that their doctor did not discuss their treatment options with them at the time the diagnosis was made.
Oncologists are so focussed on saving lives and managing cancer, that they often fail to discuss reproduction with their patients - and the fact that sperm can be safely and easily banked prior to treatment. This failure causes major heartburn in their patients later on !
This man's story is so different from Lance Armstrong, who banked his sperm prior to taking treatment for his cancer. He used his stored sperm to have his children, after conquering his disease. Lance is doing great work in empowering young cancer patients with information about what they can do to preserve their fertility - I just wish more doctors would do so too !
Consent forms are the antithesis of good risk communication. They are largely a list of possible negative outcomes, and patients simply don’t read the whole form. The wording should be changed to make the information not only clearer but also relevant to patients’ emotions. A simple phrase such as “As you consider the trade-off between the risks and benefits of this procedure” makes the patient feel that the person who wrote the form is on their side; that feeling could prompt the patient to pay more attention and be more likely to supply correct information, which in turn could reduce medical errors. That is key, because such errors pose an enormous risk: They cause more deaths each year than automobile accidents, breast cancer or AIDS."
Moore concedes that the economic challenges are real but insists that the micropractice represents a fundamentally new approach to primary care. “If my goals are the number of patients I see per day and the number of claims I can submit, I’m spending less energy on patient care,” he says. “When you can spend more time improving the human condition, that’s when your work becomes about dignity and respect.”"
Sunday, February 15, 2009
The tragedy is that so many infertile couples are still so poorly informed about surrogacy treatment and who it is useful for. Many couples naively believe that a surrogate is the final answer to all infertility problems; and that surrogacy has a 100 % pregnancy rate ! Sadly, this is just not true !
Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus, or whose uterus is damaged. Older women who are infertile rarely need a surrogate. As they get older, their fertility declines, not because their uterus ages, but because their eggs get old - a condition called the oopause. Since their own uterus is usually completely normal, using a surrogate makes no sense for them at all ! After all, how can replacing a normal uterus (their own) with a surrogate's uterus improve pregnancy rates just because the surrogate is fertile and has had babies in the past ? These couples would be much better off considering the options of donor eggs or donor embryos.
Unfortunately, they are often so desperate to have a baby, hat they do not bother to learn that as their biological clock ticks away, it's the ovaries which get depleted of eggs - not their uterus. Since surrogacy is a lucrative treatment option to offer ( it's the most expensive of all the IVF treatments offered today) , many IVF clinics are happy to offer surrogacy, without bothering to explain to couples why it may not be the right treatment option for them.
It's exactly the same situation with couples who have failed multiple IVF cycles; or who have had repeated miscarriages. They are emotionally very vulnerable and are willing to clutch at straws. They have low self-esteem, since their bodies have failed them, and are very happy to explore surrogacy. However, 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. Even though surrogacy may not be their right treatment option for them, it continues to be overused and misused. This sort of medical abuse it likely to give all IVF clinics a bad reputation.
Friday, February 13, 2009
However, it can be hard to come to terms with this, and many will search for options and alternatives as to what they can do to improve their ovarian response. There is a lot of anecdotal information about what other women with high FSH levels have done to have a baby with their own eggs, including options such as alternative medicine, such as herbs, acupuncture and yoga. In fact, there are many Bulletin Boards, Forums and websites put up by patients, which discuss these options.
I encourage my patients to explore these options, since Western medicine has little to offer them women who are poor ovarian responders ( except for the option of using donor eggs, which has a very high success rate, but may not be acceptable to everyone). However, I also emphasise that while it's fine for them to explore these options on their own, it's hard for me to recommend any particular approach, as there is no evidence to show that they help.
As an IVF specialist, I need to practise EBM or Evidence Based Medicine. However, patients can always practise BBM ( Bulletin Board Medicine) on their own !
Wednesday, February 11, 2009
Venezuela, Georgia, Chile, Bangladesh, Nepal and Pakistan want to emulate RSBY after Indian officials made an impressive presentation of the 'path-breaking' trend at the World Bank's annual development forum meeting in Washington.
European countries too were looking at the scheme. They were more impressed by its cashless aspect.
Under the scheme, beneficiaries are issued a bio-metric Smart Card for cashless transaction of up to Rs30,000 and they don't have to pay anything while seeking medical treatment. The Smart Card carries a unique identification number, which makes the person eligible for life and disability cover, health benefits, old age protection or any other benefit decided by the government. About 5 lakh cards have been issued in 16 states so far and over 1,500 have benefited from the scheme."
This is partly true in medicine as well. Thus, bypass surgery has become much less expensive after being offered by multiple corporate hospitals, who do compete on price.
However, there are many interesting anomalies, which mean that competition can actually result in increased costs, in some situations, where there is a lot of demand and price is not a constraint. Let's take the example of an expensive elective procedure like a facelift. Now, there are only 2-4 leading cosmetic surgeons in any city. They compete with each other; and since patients often perceive that the cost of a procedure equates with the quality of the surgeon, when one surgeon raises his prices, others will often follow suit, to maintain parity , to show that they are equally good, and can command top dollar !
This is not unique to top doctors, of course, and does apply to other professionals - for example, Supreme Court lawyers, who take pride in charging more than each other !
Monday, February 09, 2009
When I talk to medics about "comics and medicine", they often talk enthusiastically about ideas of using comic books to communicate with poorly educated or semi literate people, to convey basic ideas about health, hygeine or sexual awareness etc. Whilst comics certainly can be used in that laudable way, this conception of the medium probably says as much about the historic cultural stigma attached to it, as about the potential of the form.
This free, web based, flash animated comic book has rather higher ambitions: mixing the accessibility of the graphic medium with in-depth information on reproductive physiology and technological help available to couples. The Doctors run the Malpani infertility Clinic in Bombay / Mumbai, treating patients from around the world. Their stated philosophy, that "patients should become experts on their medical problems" is no mere soundbite, and to that end, rather than printing and selling this detailed guide, they have put the whole volume online, (all 237 pages of it ! ) in a handy flash-based format with realistic page turning features. Dr Aniruddha Malpini is an IVF specialist who believes in information therapy and also runs the world's largest free patient education library, H.E.L.P.
I am rather gobsmacked by the breadth of this volume. It is aimed at couples experiencing infertility problems, but could equally be valuable as an accessible primer for undergraduates or handy reference for the non specialist. The two Drs Malpani, appearing in cartoon form, talk us through 55 chapters. The breakdowns include medical illustrations as well as photographs of tests and procedures. They begin with "when to start worrying" about not conceiving, and general sex advice before delving into questions of declining fertility in modern times and the difficulties of sex education. Male and female reproductive anatomy and physiology is dealt with in detail before discussion of what to expect in consulting an infertility doctor. Extensive explanation of tests available and possible treatments follow, as well as chapters on specific problems such as PCOD and endometriosis. Ethical questions and the psychological dimension are covered too.
The graphic style is "manga-esque" to begin with, becoming more like a graphic textbook later on, with less cartooning and more medical illustration. The participating characters are not obviously of any particular race or cultural group and the book seems to be aimed at a univeral audience. I would wholeheartedly recommend it to anyone wanting to know more about human reproduction and the problems encountered in trying to have a baby.
Sunday, February 08, 2009
Across every industry and every profession, people are hungry for good ideas that will help them solve problems, help their customers, earn more money or simply get home in time for dinner. Family physicians are no exception. Unfortunately, big ideas can be hard to come by, especially in a troubled economy with stagnant Medicare payments and rising costs. When you find yourself sailing in rough waters, it's difficult to think about anything other than just staying afloat. But that's exactly when you need a big idea.
Several months ago, Family Practice Management cast its net for big ideas, asking readers to share the solutions, strategies and principles that have made a difference in their practices. In this issue, we highlight the 10 best, as selected by our editorial board. The ideas are focused on the common goal of improving primary care practice, but they offer diverse perspectives."
First, medical schools and post-graduate training programs do not teach physicians how to cope with the current health care environment.
More importantly, Medical training is inculcating a culture among physicians that may be deepening their woes and contributing to the decline of the profession.
Helplessness can be trained into individuals when, regardless of repeated best efforts that should be rewarded, no reward is forthcoming; as a result, the individual eventually learns to give up and sinks into a lonely feeling of futility and malaise. It would appear that collectively the medical profession has mastered this art and is suffering the symptoms en masse."
This is why so many doctors don't want their children to become doctors !
She called the problem “moral distress.”"
No wonders doctors are getting burnt out !
On reading further you’ll often find the headline has left out something important, like “Injecting five rats with really highly concentrated coffee solution caused some changes in cells that might lead to tumors eventually. (Not to mention that the study was funded by The Association of Tea Marketing)
The most important rule to remember: “Don’t automatically believe the headline.” It is there to draw you into buying the paper and reading the story. Would you read an article called “Coffee pretty unlikely to cause cancer, but you never know?” Probably not.
Before spraying your newspaper with coffee in the future, you need to interrogate the article to see what it says about the research it is reporting on. Bazian (the company I work for) has interrogated hundreds of articles for 'Behind The Headlines' on the NHS health news Web site, and we’ve developed the following questions to help you figure out which articles you’re going to believe, and which you’re not."
Commenting to media persons on occasion of the launch Mr. R Basil, CEO, Manipal Health Systems said that, 'with Manipal Symptom Checker we want to impart information regarding a particular symptom and help the person get the best possible treatment available. He further added that, through this initiative, we want to partner with the public in creating general health awareness in our society.'
Consumer Healthcare 2008 reports that 64% of online health seekers looked for a specific disease or medical problem and none of the popular search engines could deliver disease and diagnosis specific results. Clearly, there was a need gap identified and Manipal Hospital, always a pioneer in patient centric initiatives decided to launch Manipal Symptom Checker for convenience of persons who have concerns on their health. Manipal Hospital through this initiative will also promise personalized service and promote patient friendly practice.'"
It's great news that Indian hospitals are now starting to use the web to improve the quality of services they provide to their patients !
Thursday, February 05, 2009
In mid 80’s most of the hospitals in India were government owned and treatment was free of cost. With the advent of Private Medical Care the need for Health Insurance was felt and various Insurance Companies (New India Assurance, National Insurance Company, Oriental Insurance & United Insurance Company) introduced Mediclaim Insurance as a product.
According to recent news report Health insurance continues to be the fastest growing segment with annual growth rate of 55%. Health Premium has risen to Rs. 3300 crores in 2006-2007. As per the recent reports from various agencies the Health sector has the potential to become a Rs. 25000-crore industry by 2010.
On August 15, 2007 Prime Minister has announced Rs 2000 Crores for Health Insurance for poor citizens. We foresee that this amount will be partly in form of subsidy therefore during calendar year 2008 we can expect Health Insurance premium to touch figure in the range of Rs 10,000 Crores.
In 2001 with entry of various private Insurance companies now the customers have choice of buying this insurance from 14 Insurance companies.
http://www.healthinsuranceindia.org/riainsurance/healthinsuranceindia.org/ has more information on the rapidly growing health insurance market in India !
Until now, however, the movement has largely been fueled by patients paying out of pocket. Health insurers and corporations have stayed on the sidelines, talking endlessly about whether to get involved and, if so, how. There's reason to be cautious. How can the quality of care abroad be guaranteed? What if an employee has a surgical complication after coming home?
But the potential savings for employers are too large to be ignored forever, and Serigraph, which has about 1,200 employees worldwide and slightly fewer than 1,000 in the United States, is taking the plunge. The pilot program will be administered by Anthem Blue Cross and Blue Shield of Wisconsin, an affiliate of WellPoint, the largest U.S. health insurer in numbers of members (and the originator of the Serigraph initiative)."
For patients who travel overseas, a PHR ( personal health record) is invaluable !
Monday, February 02, 2009
A common criticism many Indians have of health information on the internet is that very little of it applies to India and to Indians. Indian medical websites are few and far-between - and they are often incomplete and outdated. Also, there is a major dearth of information in Indian languages. This means that it's extremely easy for someone sitting in Bombay to find tons of information from Mayo Clinic; or to read pages and pages on rare diseases such as cystic fibrosis; but very hard to get reliable information on common Indian diseases such as malaria or typhoid !
This is a shame - and we have taken the following initiative to address this challenge. We have setup India's first health wiki at www.myhealthpedia.in.
What we have provided at present is a bare skeleton. We hope that users will add flesh to this , so that this becomes a reliable and authoritative source of patient information for Indians.
The great thing about the wiki technology we have used is that it provides a very user-friendly platform for online collaboration, so that we can develop a repository of information which is online; available 24/7; and can be updated all the time. We hope to use the "wisdom of the crowds" to provide a useful service.
The next step is to translate this information into Indian languages. We have received a grant from the Sir Ratan Tata Trust to do so, and are looking for volunteers and experts who will help us to make this project a success !
Please do sign up at www.myhealthpedia.in !