Tuesday, June 30, 2009
Monday, June 29, 2009
Let's take a patient who is terminally ill.
When should the doctor tell him ? Tell his relatives ? How should he tell them ?
Good doctors learn how to tell bad news with grace - while others mess this up or delegate this job to their juniors, doing both their patients and themselves a major disservice.
Good doctors tell patients the truth because they respect them and they feel it's in the patient's best interests that he knows the truth. Others will simply follow a "tell the unvarnished truth policy" to protect themselves, because they need to protect themselves from a possible malpractice suit.
And it's not just when patients are terminally ill that doctors face these dilemmas. It can be a problem in all specialties, including IVF. For example, I saw a patient today who has testicular failure and who cannot have a baby with his own sperm. How do I break the news gently to him, without causing him harm or hurt ?
How much truth can he accept ? How do I judge this for each individual patient ?
I don't want to be cruel and take away his hope ? But don't I have a responsibility as a professional to tell him the unvarnished truth ? If I don't he may end up wasting time and money pursuing ineffective treatment from quacks. I agree having to deal with a hopeless situation can be cruel - but false hope can be even crueller. Often it's better to know the truth no matter how bitter it is, so patients can deal with it and move on with their lives. Many of them are much stronger than they realise - and a crisis can be a challenge and an opportunity as well !
Saturday, June 27, 2009
My Pulmonologist 1 -
o Non stop talking
o No interest in listening to the patient
o Pre determined on the prescription
o Talking too much medical jargon
o Scaring the patients - if u don’t do as I say “bla bla“
o No greeting/No smile
o As if taking out all his frustrations on the patient
o Over medication for a temporary allergy, sneezing and breathing problem
• My Pulmonologist 2-
o Very good communication, empathetic listening, considering patient history, current ailments and treatments
o Stage by stage treatment according to the severity
o Invest time to listen to patients very cordially and collects all possible information for the treatment.
• My Gynecologist 1
o One of the well knwon consultants
o Consulted with lot of hope
o Never could meet the main Doctor during my 7 visits
o Very rude attitude of the hospital staff and doctors
o Too many people, no communication, no apparent linkage of consultations with the different doctors
o The staff expects the people to know everything from medical terminology to process to procedures
o No language/cultural sensitivity to communicate.
o Important decision without consulting the patient’s opinion
o Unhygienic clinics and scanning centre; scanning is a must every time
• My Gynecologist 2
o Very well behaved and empathetic
o Technical knowledge to use the modern methodologies was lacking and hence ended up in a hasty decision to do laparotomy ( surgery) for my ectopic
• My Gynecologist 3
o Well behaved and empathetic listener
o High use of medical jargon and expects patients to know those words
o No realistic answer to patient queries
o Very expensive
o Good medical staff and very supportive
o First attempt didn’t work out for me.
• My Gynecologist 4
o Well known and acclaimed doctor who is said to have God’s touch
o We went for medical advice and a second opinion before starting the next round of treatment
o Before seeing the doctor, we were advised to take a scan
o The assistant doctors were very rude and unkind and asking do you have “xyz” disease and shouting because I was ignorant about medical jargon
o There was a printed prescription waiting for us when we met the doctor who asked us to take the medicine and advised us to come back after 3 months, if I didn’t get pregnant.
o In our 5 minute consultation the Doctor spent more time making fun of my previous treatments and the procedures my earlier doctors had followed.
o Answers were very point blank and on all my queries, there was no answer except that – “ everything is possible”.
o To our surprise, a very expensive test was prescribed at the end of the consultation. The cost of this ran into 5 digits ! (The relevance of this was very suspicious , since we were told to return to the clinic only after 3 months)
o Patients are taken for granted and expected to obey everyone from staff to the main doctor
o End result : We never felt the need to go back to the clinic
Friday, June 26, 2009
Increases the emotional bank balance
Gives the care & warmth expected
Smile can cure the anxiety of the patient
Ray of hope radiates from the smile!
• Effective communication
• Active Listening
• Cultural/Language Sensitivity
• No gender/social bias
• Entrust to speak
• Build the Trust
• Avoid Deliberate Critical Comments
• Be curious
• Avoid Peer criticism
• A good listener truly wants to know the speaker
• Focus on mental health rather than just the physical ailment
• Counseling enhances the mental power
• Understand the social and mental stigma
• Do not undervalue the problem with a mechanical cause
• Biological or mechanical reasons are part of treatment procedure
• Counseling kills the ills without the pills
• Listen, listen and listen
• Note down the discussion
• Encourage to reveal rather than perceive
• Patient is the priority
• Do not use medical jargons
• Probe for past history
• Do not expect the patient to be medically savvy
• Every patient is different, only symptoms match
• Key to opening the magic box of information is with you !
• Past is past, what is next?
• Prescribe for the patient and ailment
• Educate and explain
• Do not conceal, or presume
• Explain process and procedures
• Do’s and Do not’s in procedure
• Steps to follow
• Cost involved and payment options
• Clarity will make the patient follow your advice
• Every step of treatment should increase the trust
• Treatment procedure and data available to all related staff to avoid misinterpretations
• Educate the team and staff on behavior
• For many patients, their doctor is a savior. Value this !
• Include the patient in major decision making
• Cure= medicine + trust
Be successful to triumph
Your designation doesn’t make you successful, how you follow it matters
Trustworthiness and capability make you a successful doctor
A successful doctor will have high social responsibility
Success is the measure of happy patients
Thursday, June 25, 2009
However, I feel an increasingly important type of patient education will be education by patients, where patients educate doctors ( and other healthcare professsionals) about their illness.
While doctors are disease experts and a know a lot about pathology, the patient is the one who has the illness - and it's the patient who is an expert on himself ! Since he is the one who has to live with the disease 24/7, expert patients are treasure houses of information . In the past, grandmothers were the traditional dispensers of home medical remedies and the court of first resort when any one was sick. Unfortunately, most of this knowledge was either locked up in the expert, who had no effective way of sharing it with others ( except by word of mouth); or this wisdom was undervalued, because the patient was not a doctor and therefore not considered to be an expert.
The good news is that it's become much easier for expert patients to share their expertise. For one, doctors have learned to value the contribution of the patient and they respect the central role patients play in managing their own disease and in getting better. Equally importantly, the internet provides a great tool which allows patients to share their wisdom !
How can expert patients educate doctors ? Some steps are simple. They can provide feedback about the medical services and facilities on offer, so that doctors can improve their clinics. After all, how will doctors improve if patients don't tell them what they want ?
Patients can be one of the best sources of CME, or continuing medical education for the doctor. They can offer to share what they have learnt about their disease . Patients have a lot more time to research the internet about their medical problems; and with the help of a doctor, patients can often do a much better job in finding out about new advances. This could include locating clinical trials; experimental drugs; or getting in touch with the world authority on a particular medical topic.
Observant patients provide feedback about what the effects of the medical intervention have been. Medicine is an inexact science - and telling the doctor about what works and what does not is extremely valuable. It's only when an empathetic reseacher observed that patients who were enrolled in a clinical trial of viagra ( for treating their hair loss) refused to return their surplus medications that he realised that the viagra was helping them improve their sexual life - and a billion dollar block buster was born - thanks to observant patients - and an observant doctor !
Good doctors have always known that patients are their best teachers. Traditionally, expert doctors ( for example, professors in medical schools) learnt from their patients and then shared this knowledge with other doctors by publishing the results of their research ( in the form of case
studies or controlled trials) in medical journals. Even today, a good doctor knows that every patient has something valuable to teach. After all, biology is an inexact science, and life is full of surprises and twists. Senior doctors learn to value the exceptional patient and the unusual one, because of what they can learn from them.
Sadly, some doctors still feel threatened by the well-informed patient. These are typically doctors who have low self-esteem; or whose knowledgebase has become outdated because they do not have time to keep up with medical advances.
Good patients will not only spend time in educating their doctor, they will also spend a lot of time educating other patients. Patient education of patients by patients if often far more affective and useful, because it's peer to peer ! Patients speak the same language; share the same concerns; and establishing rapport is muc easier, because they have "been there, done that !"
All of us are going to be patients some day; and illness is a fact of life. We all learn to live with our illness - and the smarter and more enlightened amongst us realise that one of the best ways of coping with this crisis is by helping others. Expert patients are generous with their expertise and knowledge - and use this to help others. This could be simply by publishing a blog, to help others with practical tips ; and to provide emotional support, so that they know are not alone in their struggles. Other patients are more ambitious and will start support groups; or publish a book; or even raise funds for patient advocacy and medical research.
You cannot choose your illness. But how you battle it is in your hands ! Learn to share - this is good for you - and for others as well !
Wednesday, June 24, 2009
It's always hard to break bad news. This useful protocol helps doctors to prepare before talking to patients and their family - and helps them to do a good job !
The sad truth is that most doctors know the most medical science when they sit for their postgraduate examinations. Once they start practise, their knowledge becomes outdated quickly because they just do not have the time to keep up. Their medical textbooks get outdated very quickly – and very few subscribe to medical journals, because these are so expensive !
Most depend upon colleagues and consultants for specialist advise when they encounter a patient with a rare or complex problem.Some attend medical conferences for CMEs ( continuing medical education), to overcome this lacuna. For the vast majority ( especially in smaller towns) , the only source of medical knowledge is the "friendly medical representative" . Sadly, all these are very unreliable means of remaining well-informed – as a result of which they often become outdated very soon.
While it's possible to practise medicine based on 10 year old medical text books, the quality of this practise leaves a lot to be desired. This is why many doctors are insecure; and they often end up losing their patients to well-equipped specialists in corporate hospitals.
Not only is this bad for a doctor’s self-esteem, this can prove to be embarrassing when patients with internet printouts know more about their disease than the doctor does !
Also, this failure of the doctor to update himself with the latest medical knowledge can result is lawsuits for medical negligence – the doctor’s biggest nightmare.
It's not that Indian doctors are lazy or don't want to keep up with recent advances - it's just that it's very hard for them to do so ! Not only are medical books and journals exorbitantly expensive, most of them simply do not have access to a well-equipped medical library.
While some doctors do try to use the internet to keep updated, the sad truth is there is very little high quality medical information available on the net !
The good news is that now for less than Rs 30 per day, Indian doctors can subscribe to the world's largest online medical library, at www.mdconsult.com ! MDConsult allows doctors to remain uptodate by providing online instant access to the FULL-TEXT of over 40 respected medical books and 50 prestigious medical journals which are constantly updated. This means they will never need to buy another medical book in their life !
MDConsult provides convenience and peace of mind – at the doctor’s desktop - for only Rs 9995 per year !
They can also try out a risk-free 30 day demo – free of charge !
To subscribe, please contact: HELP - Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400 001
Tel. No.: 65952393/ 65952394/22061101
Saturday, June 20, 2009
The Medical Group Management Association is promoting the use of these smart cards through its new Project SwipeIT. The association aims to persuade payers, software vendors, and practices to “initiate processes to adopt standardized, machine-readable patient ID cards by Jan. 1, 2010.”"
Tuesday, June 16, 2009
Patients with ovarian failure now have 2 options: donor egg IVF
( www.drmalpani.com/donoregg.htm) or
embryo adoption ( www.drmalpani.com/embryoadoption.htm).
Many patients find it difficult to decide between egg donation and embryo adoption. The treatment plan is similar and the pregnancy rate with both options is equally high - about 50% per cycle. However, each has its pros and cons.
Embryo adoption is less expensive ; and easier to do because we are using frozen embryos. There is no waiting list involved and the treatment can be done whenever you are ready. However, both the eggs and sperm will be coming from unknown young people, so you will be providing no genetic contribution to the baby.
Egg donation is more expensive; and it takes us 2-3 months to arrange this, as we need to find an egg donor for you; to synchronise her cycle with yours; and to superovulate her for you. With egg donation, the sperm used will be yours.
In summary, if providing your genetic contribution is important, then egg donation is a better idea. If not, then embryo adoption is better.
1. If we can do IVF for you
2. What kind of IVF treatment would be best for you ( IVF ? ICSI ? ZIFT ? donor eggs ?)
3. What your chances of success will be
For the husband, all we need is a simple semen analysis ( www.drmalpani.com/semen-analysis.htm) , to check sperm count , motility and morphology.
a. If it’s normal, then we plan to do IVF.
b. If it’s abnormal, then we plan to do ICSI. If there is an element of doubt ( for example, if the counts vary a lot), then ICSI is a safer option, as fertilization is guaranteed
c. If it’s zero, then we need to consider sperm retrieval through TESE or PESA
The wife needs more extensive testing.
1. blood tests for the following reproductive hormones : FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of the eggs). This needs to be done from a reliable lab such as Specialty Ranbaxy ( www.srl.in). If these tests are normal, then the standard superovulation regimen can be followed . However, if there is a problem, then this will need to be corrected.
a. A high prolactin ( www.drmalpani.com/prolactin.htm) can be corrected by treatment with bromocriptine or cabergoline
b. Abnormal thyroid levels ( www.drmalpani.com/thyroid.htm) can be treated with medications
c. An abnormal LH:FSH ratio suggests PCOD. This may need to be corrected with metformin prior to starting IVF. Also, the superovulation will need to be gentler
d. A high FSH level or a high FSH:LH level suggests poor ovarian reserve. This means that the response to superovulation may be poor and reduces the success rate. Poor ovarian reserve ( www.drmalpani.com/oopause.htm) . Additional testing may be needed, such as a clomid challenge test; tests for AMH ( anti-mullerian hormone levels) and an antral follicle count. Options may include trying to improve ovarian reserve with empirical treatment and using more aggressive superovulation for IVF. An alternative would be to consider donor eggs or donor embryos
2 . a HSG ( hysterosalpingogram, X-ray of the uterus and tubes) on Day 8 of the cycle ( to confirm the uterine cavity is normal and the fallopian tubes are open. You can read about this at www.drmalpani.com/hsg.htm. An HSG can be painful and this is not always essential prior to doing IVF. However, it is a very good way of documenting that the uterine cavity is anatomically normal ( especially in towns with poor medical facilities). Alternatives to HSG include vaginal ultrasound scanning , but this should be high quality. If the HSG is normal and the fallopian tubes are normal, then an additional treatment option which can be offered is ZIFT ( www.drmalpani.com/zift.htm), where the embryos can be transferred directly into the fallopian tubes, instead of the uterine cavity, to improve the chances of implantation.
3. a vaginal ultrasound scan on Day 10 or 11 , which should check for the following.
a. ovarian volume
b. antral follicle count
c. uterus morphology
d. endometrial thickness and texture
Because ultrasound interpretation is so subjective, it’s important to do this at a good quality center. The better centers have digital ultrasound machines, which allow them to give you the scans as a jpeg file which you can save on a DVD or a flash drive.
In case there is an abnormality, then newer ultrasound techniques, such as 3-D vaginal ultrasound provide more information. If there is a polyp, then this will need to be removed by doing a hysteroscopy. Intramural fibroids ( in the wall of the uterus) do not need to be removed prior to IVF, as they do not affect embryo implantation. You can read more about this at http://www.drmalpani.com/fibroids-and-infertility.htm. Submucous fibroids ( which are in the uterine cavity) need to be removed. These can be best removed with an operative hysteroscopy ( www.drmalpani.com/hysteroscopy.htm).
You should always insist on a copy of all your medical records.
What other tests are needed ? All clinics will also test you for infectious diseases, such as HIV, Hep B and VDRL. Other tests include checking your rubella immunity, in case you have not been vaccinated against rubella. If the test show there is a problem, then this can be treated prior to starting IVF!
Other clinics will perform much more extensive testing. These include tests for esoteric conditions such as: immune testing; testing for TB ( including blood tests for TB antibodies and PCR on an endometrial biopsy) ; routine hysteroscopy to check the uterine cavity; and TORCH tests.
Many patients are very impressed by doctors who order so many tests. They feel these doctors are very careful and thorough ! However, the truth is that most of these tests are pointless and just waste time and money. Before doing all these tests, just ask your doctor one simple question – How will the results of this test change my IVF treatment ? Remember, that if the result of the test will not change your treatment, then there’s no point in doing the test !
Friday, June 12, 2009
Patients know that knowledge is power - and this is especially true when you are infertile and are considering IVF treatment, which can be expensive and time consuming.
What are the risks of IVF ?
Is IVF the right option for you ?
Which is the best doctor ?
However, reading can be very boring - and many couples find it difficult to absorb and assimilate the information they are bombarded with.
We have developed an interesting way of learning everything you want to know about IVF at
http://www.ivfindia.com/IVF/IVF.htm. This is free.
This is the world's first e-learning course on IVF , and feedback is welcome, so we can improve it !
Become a well-informed patient, so you get the best possible medical care !
Tuesday, June 09, 2009
I recently received an email from a patient who had had a hysteroscopy. This is a procedure where the doctor inserts a fine telescope inside the uterine cavity, to confirm the uterine lining is normal. She was not happy with her doctor's interpretation of the findings, and wanted me to review the video. I was happy to do this - but she wasn't sure how to send the video file to me. It was too big for an email attachment - so she uploaded it to youtube , and sent me the link, so I could look at the video. I was happy to reassure her that the hysteroscopy confirmed her uterine lining was normal !
Minimally invasive surgery has changed the practise of medicine - and endoscopy is now routine is many fields of medicine. The findings are documented as digital videos, which doctors can review when creating a treatment plan. Youtube can be a great way for doctors and patients to share medical videos inexpensively and efficiently !
Monday, June 08, 2009
A few doctors took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."
Friday, June 05, 2009
In order to facilitate travel for patients who come from other countries to India, many medical tourism companies have been established. They help patients to identify a good clinic and assist them with their paperwork and travel. This is a useful service, as it helps patients who are not comfortable with travelling to India with a lot of peace of mind, as they have a "local person" they can talk to.
Many of these companies approach us, and expect to be paid a commission for referring patients to us. This is not something I am comfortable doing, so we have refused to do so. While I am quite happy with their charging patients for the services they provide to them, I am not comfortable about their lack of transparency ; and that patients are not aware that these companies are taking a portion of the medical fees. Isn't this simliar to giving a cut or kickback ?
However, this means we are losing patients to competing IVF clinics who are happy to pay these commissions. Are we being stupid ? Is there anything wrong in giving these companies a
" service fee " or "facilitator fee" ?
Thursday, June 04, 2009
The numbers are increasing because foreign clinics cost less than British ones, treatment is available within weeks and more older women are seeking to become mothers when their fertility is declining."