Friday, July 31, 2009
Wednesday, July 29, 2009
I just wanted to share this with you - whether myself and my husband have a child or not is dependent on the Almighty, however I feel reassured we are coming to you for treatment. Whatever the outcome I feel we shall receive the best treatment from you.
I read your blog regularly and for comfort I read your website, and that alone keeps the light in my heart glowing...
Its difficult and often lonely when you enter the complicated world of IVF. You will not know this but already you are my friend and mentor. You give me strength and hope even though you are miles away and dont know anything about me other than what I have supplied via email.
I have high hopes and dreams of coming to India. I feel guilty to feel these emotions should I tempt fate in a negative way. I feel like I will be coming home. In this world where I am presently, no -one knows my husbands condition other than him but only in a basic way and the consultant who initially diagnosed. Our respective families are struggling to come to terms with the idea that one of us maybe infertile. In fact my inlaws were horrified at the mere idea their son could be infertile. They naturally assumed it was I with the problem They still believe this to this very day and I have given up trying to explain. Sometimes people's ignorance can be quite disheartening. All I have been getting is...drink this ...eat that....go to this Holy Man...pray this...have sex in this position..do it on this day of the month....blah blah...
My husband does not wish to talk about it. He relies on me to make all the necessary arrangements and to attend when required. I did all the research, I read the blogs, recommendations, reveiws, information of his infertility etc etc. All this information I have kept to myself and have stored away. And I know upon arriving at your clinic in Mumbai I will be able to share the information I have stored these past 8 months. It is like I am biding my time in a place which currently is ignorant, then I will enter another world where I will be able to talk the same language.
Jay Walsh, head of communications at the Wikimedia Foundation, says: 'Wikipedia shouldn't be taken as a 100% reliable source of medical information. ... But Wikipedia always strives for a degree of improvement.'
And as for physicians, there's no excuse turning to Wikipedia as a source when reputable medical resources are a few more keystrokes away. Although these other sites might require more time for a busy clinician, doctors need to eschew convenience to ensure their decisions are based on sound medical information.
Quality patient care demands no less."
12th Annual Survey on Consumer Reaction to DTC Advertising of Prescription Drugs Reveals | Rodale Inc
The Internet's growing user generated content websites prove to be a premium resource for online consumers as well. The survey reveals that 55% searched these sites for health-related information. This number suggests that consumers value personal health experiences of average individuals along with trustworthy medical websites."
The fact that so many patients do use websites as their first choice when trying to learn more about their medical problems and treatment options ( as compared to going to a doctor), I think it's just a matter of time that reliable internet healthcare portals will become port of first call for patients. It's much easier ( and cheaper) to access a website than your doctor !
We are using tools like our Free Second Opinion to offer patients a free online consultation for their infertility problems. We also use e-learning to help teach them about their treatment options .
It's good to know that we are at the cutting edge of health care delivery !
Q 1 What do you feel when you see your daughter go through IVF ?
A There are mixed feelings – of high hopes as well as anxiety. On a positive note, I feel good that with the advances in medicine today we have expert guidance in Infertility Treatment which was not available to the previous generation. So, a ray of hope crosses my heart that there is still a chance for my daughter to conceive and achieve her dream.
Anxiety, that my daughter has to take so many injections and medicines. I can see her emotional strains when two IUI cycles failed after all the efforts put in not to mention the financial loss incurred due to her taking leave without pay from her current company to attempt IVF as also the risk that she may not get her job back.
However, the biggest risk – “What if too much of these injections and medicines end up in pregnancy, but with a child suffering from Down’s Syndrome? Better not to have a child than give birth to one who will face difficulties for life.
Q 2 How does your daughter cope? How does she feel about it?
A I can see my daughter struggling to cope with difficulties and there are quite a few – the main being to reduce her weight.
I admire her commitment to have gone through it all. She could have chosen the easy way out and said ‘No’ to Infertility Treatment. After all, she has crossed 40 yrs. and she knows her chances are low. She has sacrificed her job, left her home in Pune to be under Dr. Malpani’s excellent care in Mumbai.
As a mother, I’ve encouraged her to do her Best and leave unto God the Rest.
It is said that some of our principal regrets in life are the opportunities we passed up and the chances we didn’t take.
Q 3 How do I feel about one child having children, one not?
A Each person has his own Destiny – Karma. My daughter got married at 41 yrs, while my son was quite young when he married , so by God’s grace he did not have difficulty vis-à-vis “infertility factor”.
According to me, the be all and end all of marriage is not just re-production. Sure, grand children are a source of delight and posterity is ensured.
However, I’d rather apply the analogy to marriage that “Oftentimes two people working together find easy that which seems un-surmountable to one alone.”
Tuesday, July 28, 2009
Go ahead - please ask me a question about endometriosis ! I'll be happy to answer !
Remember that the quality of my answer depends upon the quality of your question ! If I don't have an answer, I'll keep quiet - and patiently wait for your next question.
Monday, July 27, 2009
If you are well-informed ; have done all your homework; have explored all your options; and are quite certain of what you want from life and your medical treatment, then your best option is to treat your doctor as a technician and get him to do what you want him to do. This is a perfectly reasonable approach; and works well if you a compliant doctor who is willing to listen to your perspective.
However , some doctors can be very authoritarian, and will insist that their patients follow their rigid guidelines. Actually , having well defined medical protocols can provide a lot of structure and security, and is a good idea when tackling complex problems which require multidisciplinary teams , such as bone marrow transplantation.
On the other hand , if you are uncertain or confused; and need guidance and counseling, is best to treat your doctor as a professional. His first task will be to walk you through your treatment options and help you to decide what's best for yourself. Of course , not all doctors are good at this. Some doctors pride themselves on their technical skills and would much rather treat you as a disease which needs to be fixed , rather than a human being who needs hand-holding. This is especially true in certain specialties such as cardiac surgery , where many doctors would much rather be in the operating room , fixing blocked coronary arteries , rather than talking to their patients.
It’s also perfectly acceptable to use one doctor to provide you with guidance; and the other as a technician , to perform the surgery. This is why certain doctors , who may be technical wizards in the operating room, continue to attract lots of patients , even though they maybe very rude and have a terrible bedside manner. Of course , many doctors don't like this, because the amount they get reimbursed for providing counseling and showing you the right direction , is much less than they get paid when they are operating in the theater.
In the best of all possible worlds, you will find a doctor who is both a consummate professional and a skilled technician. While these are few and far between, it's well worth taking the time and effort to find such a gem.
Sunday, July 26, 2009
Most doctors are not very good at discussing possible bad outcomes. Actually I think this is the most important skill of a good doctor. There is very little point in discussing good outcomes. When everything goes well, both the doctor and patient are happy . They pat themselves on their backs - the doctor for good a job and the patient for selecting a good doctor - and then move on with their lives . However, things are completely different when the outcome as bad.
We need to look at this from 2 different perspectives – before the bad outcome ; and after the bad outcome.
When there is a complication, patients are understandably upset ; and doctors get very defensive. This starts becoming a confrontational situation. The patient feels that the doctor has done a bad job and has been negligent; while the doctor is worried that the patient may sue for malpractice. Rather than trying to work together to ensure a good outcome, they often spend their energies battling each other. Ironically, this means that when the patient needs the maximal support from the doctor , he is likely to get the least attention ! In case there has been a screwup, the medical staff will often try to cover this up, as a result of which the problem continues to fester , and future patients are also likely to be harmed.
This is why it so important to discuss possible bad outcomes before they occur. This is a central part of getting informed consent from the patient. However today getting an informed consent has become a mere legal formality, rather than being an occasion to discuss the possible risks and benefits of the procedure. Good doctor have always discussed the pros and cons well before informed consent became legally compulsory. Today , it is just seen as a form which must be filled out, before any treatment can be offered to the patient.
Doctors are understandably reluctant to discuss possible complications. They want to treat the patient; and are scared that if they tell the patient the unvarnished truth , the patient may back out of the procedure because he is worried about possible risks. This is why many of them gloss over possible complications; why others leave this unpleasant task to their juniors, who perform this very inadequately by ticking the check boxes on a long form , and getting the patient to sign this.
Patient are also often willing accomplices, because they too are quite reluctant to talk about possible complications. Patients are often scared and worried that they may die; and most human beings are not very good at confronting their own mortality. They just want a doctor who will make all their problems go away and make them completely well again. This is why bad outcomes are often not discussed adequately before the procedure is performed; which is why when the complication does occur, the patient is completely unprepared , both emotionally and mentally.
As an IVF specialist , I make it a point to emphasize to patients that while IVF treatment does have a high success rate , it also has a high failure rate ; and patients need to be prepared for this. I recommended that they prepare for failure; and have a Plan B ready , in case the cycle does not succeed. Some patients get very upset when I talk about failure. They have come to me for a baby; and they feel that if I discuss the possibility of failure, this means that I am not confident that I will be able to give them one. These patients will often find another IVF clinic, which is willing to present a much rosier picture , so they can go ahead with the treatment. Patients who are more mature and realistic, understand the importance of preparing a contingency plan before the cycle starts , and are quite happy to work with me. This is why, in case the IVF cycle does fail , our patients are much more prepared to take this in their stride, and move on. In other clinics , on the other hand , patients get extremely frustrated when the doctor stonewalls and refuses to discuss why the cycle failed, in spite of the fact that he assured them that it would work. Because we have such a transparent approach , we often end up treating a lot of these patients who have failed IVF cycles elsewhere.
Everyone is good at dealing with IVF successes. I think the hallmark of a good IVF doctor is how he manages the IVF failures !
Saturday, July 25, 2009
Medical News: Lower Blood Pressure Targets Offer No Benefits - in Nephrology, Hypertension from MedPage Today
Treating patients to reach lower targets did drop blood pressure by a modest average of 3.9 mmHg systolic and 3.4 mm Hg diastolic more than conventional goals (P<0.001), according to Jose Agustin Arguedas, of the University of Costa Rica in San Pedro de Montes de Oca, and colleagues.
However, the lower goals were not associated with significant reductions in any important outcome."
Unfortunately, doctors will continue insisting that " patients" maintain a low BP. This is better for the doctor
( more visits needed for monitoring and treatment , and more fees ) - but may not be best for the patient ( who often starts obsessing over his numbers and becomes a cardiac cripple !)
Medical News: Tight Glucose Control Raises Mortality Risk in Heart Failure - in Cardiovascular, CHF from MedPage Today
Modest glucose control with a hemoglobin A1c between 7.1% and 7.8% showed 27% lower mortality risk than tight control with an A1c of 6.4% or lower (P=0.001), David Aguilar, MD, of Baylor College of Medicine in Houston, and colleagues reported.
This high-risk population had a U-shaped mortality curve, they wrote in the July 28 issue of the Journal of the American College of Cardiology.
Several recent trials have also shown no macrovascular benefit to tight glucose control in general diabetes populations, Dr. Aguilar noted."
More is not always better ! As Gautam Buddha said, sometimes the best path is that of moderation !
Friday, July 24, 2009
The researchers’ objective was to estimate the extent of over-diagnosis. Screening for breast cancer is meant to detect lethal cancers earlier. Unfortunately it also detects harmless ones that will not cause death or symptoms. As it is not possible to distinguish between lethal and harmless cancers, all detected cancers are treated. Over-diagnosis and overtreatment are therefore inevitable."
Most doctors think of themselves as being professionals, and most patients will treat them as such. Not only do they expect the doctor to provide technical expertise, they also want their doctor to guide them as to which the best treatment option for them is. This is true for most doctor-patient interactions, when along with providing medical expertise , the doctor also acts as a friend , philosopher and guide.
However for infertility treatment , some patients take a much more proactive role, and use the doctor as a technician. They are very sure about what they want - and they simply use the doctor as a tool to gratify their personal desires. While some doctors are offended when patients make their own decisions for themselves, I find this a perfectly reasonable approach. In fact, for some patients , I find it's better to let them make their own decisions, so that they take ownership and responsibility for both the decision and the outcome. Since the outcome of any treatment is uncertain, taking the treatment they want to gives them peace of mind they did their best !
My job as a doctor is to ensure that this is a well informed decision, so I provide them with the facts and figures they need and explain the pros and cons of the various options. I try to be nonjudgmental and to give them the freedom to choose what is right for themselves. Thus, if I have a 45-year-old woman who wants to do IVF, I will explain to her that her chances of getting pregnant with her own eggs are very slim ; and that the chances of success are much higher if she is willing to use donor eggs. If she understands this and then chooses to go ahead with her own eggs, I am happy to support her decision.
After all this is her life. As a doctor , I can only provide a narrow medical perspective. I appreciate that when making important decisions like this , a lot of other factors come into play – intangibles such as emotions, religious beliefs and finances. These are areas in which the patient is the real expert - and my role is to empower her to make a decision she is comfortable with. Since she cannot do the IVF for herself in her own bedroom , she requires my help as a medical expert - and I am happy to serve as a technician in this role.
Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.
Yet the positive deviants do not seem to ignore the money, either. Many physicians do, and I think I am one of them. We try to remain oblivious to the thousands of dollars flowing through our prescription pens. There’s nothing especially awful about that. We keep up with the latest technologies and medications in our specialty. We see our patients. We make our recommendations. We send out our bills. And, as long as the numbers come out all right at the end of each month, we put the money out of our minds."
I've heard this asked or remarked upon many times before, and I must have just dropped any pursuit of the question, perhaps because I didn't have an audience to blog about it to. Now I do - and you're it!
In trying to formulate a response, I realize that the questions behind this question need to be answered first.
Did he really mean: Why don't physicians understand that making an upfront investment in something can sometimes make them way more money later on? i.e. What do they know about Return on Investment?
Or, was he really asking: Why do doctors handle money so poorly?
Or perhaps: Why are doctors so arrogant about knowing it all and not paying for good help or advice?
Or, could it actually be: Why are doctors so miserly?"
Thursday, July 23, 2009
This goes way beyond Google searches. PatientsLikeMe boasts that it's 'a new system of medicine by patients for patients.'"
The first is the infertile couple themselves. Having a baby is usually considered to be the woman's problem , and she is the one who seeks medical attention which means she usually goes to her gynecologist. Many men have a fragile ego, and while some refuse to go for sperm testing , others postpone this, because they are worried they will find that they have a problem. Many men still blissfully resume that if their libido is normal , this automatically means that their fertility is fine , and that they do not need to check their sperm count.
By default, it is usually the gynecologist who then becomes the primary care physician for infertile couples. Unfortunately, most gynecologists are clueless about male infertility. Many have never examined a man in their entire professional career . They usually ask for a semen analysis; and if this is abnormal, they refer the man to a urologist. However , sometimes they do not interpret the semen analysis report properly , and this causes its own set of problems. For example some gynecologists still believe that a count of less than 60 million is abnormal - which means that men with a completely normal semen report are overtreated with medication , wasting valuable time.
What happens when the infertile man is referred to the urologist ? While the urologist is a specialist , many of them do not have a special interest in treating the infertile man; and there are very few specialised andrologists ( male infertility specialists). This is why many urologists continue to provide many ineffective tests and treatments for the infertile man. They will often try empiric medical therapy to improve a low sperm count; and because this rarely works, patients get fed up and frustrated. The trigger happy urologists diagnose a varicocele for practically all men referred to them, by doing a color Doppler ultrasound scan. Once they find a varicocele , they are happy to treat it - and when this doesn't help to improve the patient's fertility status, they throw up their hands and say – Sorry – there is nothing else we can do ! The other problem with a referral to a urologist is that the care of the infertile couple gets fragmented. Often the gynecologist has no idea what the urologist is doing , and vice versa, which means the couple is not treated as a unit. This often causes them to lose confidence in medical treatment.
Another weak link in the medical system is the fact that many laboratories do not know how to perform a semen analysis properly. Since it is such a cheap test, they often do it badly, resulting in wrong reports - and therefore , the wrong treatment.
Compounding this problem is the underlying fact that the basic sciences understand very little about male infertility. We really still don't know enough about normal sperm production; and since we cannot pinpoint what the problem in sperm production is in the infertile man , there is very little effective treatment we can offer him. This is why the standard treatment for a man with a low sperm count today is ICSI ( intracytoplasmic sperm injection, www.drmalpani.com/icsi.htm) – a treatment which is conceptually crude, but works amazingly efficiently. We still do not have good tests for analyzing sperm function, so that a lot of our treatment consists of bypassing problems , rather than identifying them and solving them. This is a sad testimony to the fact that the infertile man has been relatively
About 15 years ago , it was felt that strict morphology testing using Kruger criteria would help us to identify which infertile men had functionally competent sperm. Unfortunately , we now realize that these criteria are not always reliable. The new generation of sperm function tests are supposed to check for DNA integrity. Unfortunately , these are equally unreliable, even though they are presently very fashionable. This is because while they do generate valuable information in research studies, they are not very good at providing clinically useful information for the individual patient. Thus , while we know in general that infertile men will have higher sperm DNA fragmentation levels than fertile men, there is no number at which we can tell the infertile man whether or not his sperm are capable of fertilizing his wife's eggs.
This sad truth is that male infertility treatment still leaves a lot to be desired. And this is why , ironically , the most effective treatment for the infertile man it to treat his fertile partner !
Wednesday, July 22, 2009
1. Inform Yourself.
Before you can inform your child about what to expect, you must learn what to expect. It is very important to learm about your child's surgery before the procedure by discussing it with the physician(s) overseeing your child's care. Among the key questions are:
- Can you walk me through the procedure?
- How long will the surgery take?
- How long can I be with my child before surgery?"
This is a great list of things every parent needs to know prior to their child's surgery.
Actually, it makes a lot of sense to know all this stuff before anyone's surgery - even your own !
Tuesday, July 21, 2009
Why more doctors are not the solution to India’s poor healthcare - The Peter Principle applied to Medical care
Why doesn't having more doctors improve the quality of healthcare ? Logically, one would expect that the best way to fulfill increasing healthcare demands is to increase the supply of doctors. Unfortunately , this does not work in real life , because doctors create a demand for their own services – the more the doctors , the greater the demand.
I think this is an example of The Peter Principle being applied to medicine. The Peter Principle states - “ Work expands to fill the time available for its completion. “ The medical corollary would be – “ Medical demand expands to fill the pockets of available doctors. “
This is because specialists , as contrasted to generalists, have a very narrow focus. They work hard to create more work for themselves. This increases their perceived value to society; their sense of self-importance; and their income.
Let's see how this plays out in real life. Consider a Tier 3 city in India. This has a population of one million people who are being served 10 physicians. These physicians will also take care of heart problems , such as hypertension , angina and heart attacks - the bread-and-butter problems which every internist sees in daily practice. Now a cardiologist decides to set up practice here. Because he is a “ specialist”, and does have special expertise and equipment such as echocardiograms, the physicians are quite happy to refer their complex cardiac cases to him - and this is exactly the way things should be. Since he is busy and is doing well , a second cardiologist decides to set up shop in the same city. However , since there aren’t enough complex cardiac cases to keep two cardiologists happy, these specialists now start scouting for work and soliciting cardiac patients with simple problems. While these problems could easily have been handled by the physicians much more inexpensively, because the cardiologists cleverly project themselves as being better experts, patients with deep pockets prefer going to them rather than their regular doctor. Since cardiologists charge more than internists, they are seen as being better doctors in the public perception. Hospitals are quite happy to employ them, because they generate more income; and to protect their turf, the cardiologists start insisting that cardiac patients can only be admitted under their care, and not under the care of general physicians. Hospitals are more than happy to comply, because they need to keep their specialists happy - and the fact that this increases their income , is an additional incentive.
Over a period of about 10 years, the status quo changes. Because the new generation of young internists no longer sees cardiac cases, they are no longer capable or competent to handle these patients, who are then automatically sent ( or self-referred) to the cardiologist. As time goes by , the cardiologists become busier, and they end up monopolizing all the cardiac patients.
However, there aren't enough cardiac patients to keep all the cardiologists happy. This is when the Peter Principle kicks in, and cardiologists start creating more work for themselves. Rather than manage patients with angina conservatively, they start superspecializing, and performing invasive procedures such as cardiac catheterizations for angiography. At one end of the spectrum , they start doing more complex procedures such as angioplasty; while at the other end , they redefine normal cholesterol levels and normal blood pressure levels, so that practically everyone is either pre-hypertensive or hypercholesterolemic , and requires medical attention from a cardiologist.
By increasing the demand for their services, they setup a vicious cycle, so that no matter how many cardiologists are churned out, there will always be a need for more ! In fact, cardiologists often play a game of “one-upmanship” with each other, because they need to compete for patients and prove they are better than their colleagues. Thus, they will buy the nth generation stress test machine or the newest 64 slice colour CT scanner for visualising the coronary arteries – and then will hunt for patients who “need” these tests, to justify their purchases ! As George Bernard Shaw wisely said many years ago – Every profession is a conspiracy against the laity !
A specialist is one who knows more and more about less and less until he knows everything about nothing. Woe betide the man with chest pain because of a pulled muscle who goes to a cardiologist. Rather than make the correct diagnosis with the help of a careful history, he will subject the patient to a “ routine heart disease workup” involving an ECG, stress test and echo – not because the patient needs it, but because he is a cardiologist and needs to “rule out” a heart disease ! The real tragedy occurs when he finds an abnormality on one of his tests – an abnormality which may just be a normal variant, unrelated to the patient’s problem, but which then needs to be explored in greater detail, just
because “ it is there” !
Please note that I am not criticising cardiologists. They are just behaving as rational human beings, responding to the perverse economic incentives society chooses to provide them.
Monday, July 20, 2009
Sunday, July 19, 2009
There is a new building coming up next to ours. There is a 50 year old tree in this compound, which is being hacked down even as I write this - in broad daylight ! The work is being done by a worker from the Bombay Municipal Corporation, even though the avowed policy of the Corporation is to protect trees and create a green city !
We called the BMC hotline at 1916 - but no one picked up for over 30 minutes.
We called the Colaba Police Station, who sent a constable, who then promised " to look into the matter" !
The tragedy is the trees continue to be mercilessly hacked down in Mumbai, while the authorities look the other way - and we call ourselves a civilised society !
While the cutting has been stopped for sometime, it's my prediction that the tree will be cut down in the next 2-3 weeks, to help in the
beautification of the new tower" which is coming up !
Wednesday, July 15, 2009
The gynecologist is a logical first choice. Most women have a long-standing relationship with their gynecologist , and are comfortable with him. Since gynecologists are specialists in tackling women's health problems , most can competently diagnose the cause of infertility ; and provide basic medical treatment. They are usually quite conservative; and would be the first choice for simple problems . However , they are often poorly equipped to deal with complex infertility problems.
Since a man with a hammer only sees nails, they will often subject the patient to unnecessary surgical procedures , such as a laparoscopy; or perform intrauterine inseminations for men with low sperm counts , simply because they do not have anything else to offer. They are often extremely poor at handling male infertility problems , and will usually refer these to their friendly urologist. This often means that care gets fragmented; and ends up of being poor quality.
Most gynecologists are also not aggressive enough when dealing with older women. Since most of their women are fertile, they often forget to remember the impact which aging has on the ovarian reserve of infertile women.
Also since they rarely have a special interest in treating infertility , waiting rooms are often quite infertile-patient unfriendly. There are often full of expectant mothers , and this can cause unnecessary emotional distress. Also some of them are not compassionate or empathetic enough when dealing with the impact which infertility has on the woman's psyche.
Infertility specialists would be the first choice, if you have a complex problem. Not only are they experts at dealing with infertility they have a lot of experience; and are armed with the advanced reproductive technology to solve most problems. However they are often quite expensive ; and some of them will often resort to unnecessary , complex costly treatment, even to tackle simple problems.
This means the patient has to choose between the risk of wasted time with the gynecologist, versus overtreatment with the infertility specialist. Since the infertile couple doesn't know how simple or complex their medical problem is , this often leaves them in a quandary.
What we do in our clinic ? If I am the first doctor the infertile couple is seeing, I will complete the workup for them , so we have an idea as to what the reason for the infertility is. This takes about 7 days and costs about US $ 200 only. If it's a simple problem , we will suggest that they find a gynecologist for their treatment. This allows us to concentrate on infertile couples who have complex problems , so that we can provide them with a higher quality of service, without diluting our focus.
In the best of all possible worlds , gynecologists with take care of the simple problems ; and if they have failed to achieve a pregnancy within 6 months , they would refer these patients onto an infertility specialist. Unfortunately, since most doctors have a proprietary attitude towards their patients , they are often reluctant to refer these patients to infertility specialists , because they do not want to lose them. This often means that they waste the patient's time , money and energy in pursuing ineffective treatments.
One useful tip is to create a clear plan of action with a well defined timeframe in
partnership with your doctor , so you have a clear sense of what your treatment options are. This way, you retain control of your medical treatments as well as your life so you have peace of mind you did your best.
Tuesday, July 14, 2009
Monday, July 13, 2009
A normal endometrium requires adequate blood flow ; and high estrogen levels. Thus , if the lining is thin there are 3 possibilities: the estrogen levels may be low; the blood flow is poor; or the endometrium is damaged. We need to systematically examine all these 3 possibilities , so that we can pinpoint what the problem is in the individual patient , and then try to correct it.
If the doctor finds the endometrium is poor during the IVF cycle , often the best option is not to transfer the embryos but to freeze all of them. The patient can then be treated with high doses of exogenous estrogens, to see if this causes the endometrium to become thick. If the endometrium grows well , it’s then possible to transfer the frozen embryos after thawing them into an estrogen primed endometrium.
However if the lining remains thin in spite of high doses of estrogen, this means the problem is either one of poor blood supply ; or a damaged endometrium. Some doctors have used color Doppler ultrasound to measure uterine blood flow, but the results with this have been mixed. Others have tried using vaginal viagra to try to improve endometrial blood flow. Since there is no reliable method to assess uterine blood flow , the next step is to determine whether the endometrium has been damaged or not. There are two possible causes of end-organ damage when the endometrium is nonresponsive. One is that the endometrium has been anatomically distorted because of intrauterine adhesions ( a common cause for this in India is uterine tuberculosis. This condition is called Ashermann syndrome; and this can be diagnosed either with a hysterosalpingogram , which shows filling defects within the uterine cavity ; or with hysteroscopy , during which procedure the scars can be surgically removed. However in some patients , even though the uterine cavity is anatomically completely normal ; the uterine blood flow is normal; and the estrogen levels are high, the endometrium remains persistently and frustratingly thin. We then hypothesize that the endometrium has suffered end-organ damage as a result of which it does not respond to estrogens. This condition has never been adequately studied; and it does not even have a name ! Most doctors just call it – “ Thin endometrium” . The Latin equivalent for this would be leptometrium ( lepto = thin) . Maybe we should coin a name to describe this condition , so that we can study it properly. Today, this can be an unsatisfying diagnosis to make, because we cannot prove this diagnosis ; and neither can we correct this problem. The only solution for some of these patients is surrogacy.
Sunday, July 12, 2009
If there had been a lot of eggs and a poor non-receptive endometrium , the simplest option would have been to freeze all the embryos ; and then work on improving the endometrium so that the frozen embryos could be transferred in a subsequent cycle after thawing them when the endometrium was ripe.
However if there are only a few eggs , we are likely to get only a few embryos , and often these may be of poor quality so that they may not survive the stress of a freeze and a thaw. Is a bird in the hand worth two in the bush ?
One option is to cancel the cycle and then consider alternative options such as using donor eggs.
Another option is to accept the fact that the chances of implantation are poor because of a poor endometrium , but to go ahead with the transfer anyway in the fresh cycle.
The other option is to proceed with the egg collection ; and then make a decision whether to transfer or not , depending upon the number of embryos obtained and their quality.
These are all difficult decisions which tax both the patient's emotional stamina and the doctor’s clinical judgment. I feel the best approach is to make a list of all the options ; to try to quantify the probability of success with each option, using the doctor’s best guesstimate; and then to allow the patient to make the final decision. Patients should follow the path of least regret , so they have peace of mind they did their best , even when the odds were stacked against them.
Unfortunately , sometimes it does seem like that . Human reproduction is not a very efficient enterprise – whether it's being done in the bedroom or an IVF clinic. While we are very good at making embryos in the IVF lab, embryo implantation is still a complete black hole, and we still don't know why every embryo doesn't become a baby.
When the patient has finished 4 IVF cycles and still has not become pregnant even after the transfer of gorgeous-looking embryos , both she and doctor are faced with difficult questions which we unfortunately still cannot answer. The honest answer is that we often just do not know why the embryos did not implant ! However, what we do know is that even embryos produced by healthy young fertile couples have numerous genetic defects , even though they may look perfectly normal under the microscope. Sometimes patients just need to be patient until they get lucky !
However , patients do not want to hear that their IVF specialist does not have all the answers. After spending so much time , money and energy , they feel the least they are entitled to are answers – and an honest “ we don’t know “ just does not suffice.
Desperate situations call for desperate measures. After a failed IVF cycle, doctors are usually on the defensive because one of the things patients may feel ( but fortunately are polite enough to rarely say outright ) is – Did the cycle fail because the doctor was not good enough ? Did the doctor goof up ? And sometimes, the doctor also feels that he has let the patient down.
This is why some doctors will resort to expensive and experimental treatments such as immune therapy, which have been never been proven to work, but are still used widely , because of the great demand from desperate patients.
What is our approach ? We try to analyze the problem scientifically . There are 3 possible variables: the embryos ; the endometrium ; and the embryo transfer. If there has been a problem in one of these areas, we try to figure out whether this was a one-off problem ; or if it is a recurrent problem. Some problems are correctable, and we try to fix them, so that the next cycle as a better outcome. Thus if the embryo transfer was technically difficult because of cervical stenosis , we can transfer the embryos directly into the fallopian tube , by doing a ZIFT. However if the problem recurs , we then need to move to Plan B. Options include : changing the eggs ( donor eggs) ; the sperm ( donor sperm) ; the embryos ( donor embryos) ; the uterus ( surrogacy) - or the doctor !
Saturday, July 11, 2009
I have great sympathy for these poor resident doctors. I was a resident doctor myself in KEM Hospital about 25 years ago, and can vouch for the fact that the residents work under conditions which are degrading and sub-human. Resident Quarters are cramped and dirty; and they do not even have basic hygienic facilities. These are conditions which no parent would tolerate for their children – one of the reasons I did not want my daughter to become a doctor . The real tragedy is that the government does have enough funds to provide better conditions for its resident doctors - but it stubbornly refuses to do so, because it can get away with paying them a pittance.
Are these doctors asking to be paid a fortune ? Not at all ! They only want to be paid exactly the same amount which other State governments pay their resident doctors. Maharashtra is a rich state , and can easily afford to do so if they want to do. Unfortunately , because the resident doctors are not supported by their seniors, it's very easy for the government to break the strike. This is another excellent example of how politically naïve doctors are ; and how their lack of unity leads to their being treated as second class citizens.
It is easy for the rest of the world to take a moral high ground and say that doctors should not worry about petty matters such as money . They should be devoting their lives to taking care of their patients – and the money should not matter to them at all.
Unfortunately , the resident doctors have done a very poor job in mobilizing public support for their cause. If they published more photographs online about what their living conditions are like and how poorly they are treated , most citizens would be much more sympathetic to their cause. Unfortunately most of us are blissfully unaware of how difficult their life is. Society at large no longer treats doctors with the respect which it used to , and is quite happy to brow beat them.
I can confidently predict what the outcome of the strike is going to be. It is going to end up exactly the same way as all the other strikes. The resident doctors will buckle under pressure when forced to do so by the government and will resume duty. In order to save face , they will declare that the government has agreed to sympathetically listen to their demands - but in reality , nothing will change.
The biggest tragedy is that senior doctors have refused to come out in support of the resident doctors. By not supporting their cause, the medical profession has once again taken a beating. However the real sufferers are not going to be the resident doctors – it is going to be the next generation of patients. If we want our doctors to be compassionate and empathetic; if we want to train doctors who are kind to their patients; if we want our doctors to improve their bedside manners and treat their patients with respect, then the least we need to do is to treat our future doctors with respect and compassion. If we treat them badly , they are going to end up treating their patients badly too. Every good manager knows that if you want your employees to treat your customers with respect , the employees need to be treated with respect themselves. By failing to give our resident doctors a fair deal, not only have we failed them , we have failed ourselves , because these are the same doctors who will take care of us when we are ill in a few years. Rather than complain about the deteriorating doctor-patient relationship, we need to accept that a large part of this deterioration is because of the shabby way we treat our resident doctors.
Let's analyse their rhetoric. When you form a partnership, who is it formed with ? The government continues to ram its advise down its citizens' throats, based on "expert advise" from its policy makers, and multinational organisations, most of whom have a hidden agenda.
This is a typical "top-down" approach, which is beloved of demographers, politicians and bureaucrats. It's completely divorced from reality, and has little bearing on what's important to citizens !
Government experts cannot continue to sit in their ivory towers and tell people how many children to have , based on what they feel is " good for the country". For one, the experts are often wrong . Any good economist knows that India's strength today is its people - and the only reason India attracts billions of dollars from foreign investors is because we are now in a demographic sweet spot , thanks to our growing numbers of young citizens. These are our strength - not our weakness ! We know longer need to go out with a begging bowl, and are considered to be a developing superpower, rather than less developed country, thanks to our people !
Our focus should be on playing to our strengths and capitalising on them, rather than treating them as a weakness. Unfortunately, Indian experts are very easily manipulated by foreigners, who has a vested interest in seeing that India remains controlled and controllable.
A true partnership is formed between equals - where both sides respect each other, and consider the other's welfare, to create a win-win situation. Citizens choose to have babies for their own reasons , to maximise their personal wellbeing , and we need to learn how to tap into this basic biological urge, so that everyone benefits.
I feel the best slogan would be - Every Child, A Wanted Child ! ( Har Baccha,Chhaha Baccha,in Hindi). This would respect each individual citizen's right to choose for themselves - and create a country of empowered citizens who can lead India into the future. Thus, I might want to have just two children; whereas a poor farmer may want six. As long as each of us have children whom we desire and love, we will bring up these children well, and strengthen not just our families, but the country as well ! The government should facilitate this process of allowing people the personal choice to plan their own families - only then will it really contribute to family welfare ! It should learn to respect the "bottom of the pyramid" and trust that its citizens are capable of making their own decisions for themselves, rather than trying to force its agenda down their throats !
Friday, July 10, 2009
Some women with poor quality eggs have poor eggs because they have impaired ovarian reserve. Every woman is born with all the eggs she is ever going to have in her life; and as she gets older, she keeps on depleting her ovarian reserve until she becomes menopausal. However , for at least 10 years before reaching the menopause , her egg quality declines, so that she has enough eggs to produce enough hormones to get regular menstrual cycles, but not enough to make a baby. This is called the oopause. Since her cycles are regular , this lulls her - and her gynecologist - into a false sense of security. The good news is that we now have accurate tests to check ovarian reserve. These include a high-resolution vaginal ultrasound scan to check the antral follicle count; and a blood test to check the levels of AMH , or anti-Mullerian hormone. A low antral follicle count and a low AMH level both suggest poor ovarian reserve. In these cases the problem is that we have to technology to make the diagnosis but the diagnosis is not made properly because of a lack of awareness.
There is an other group of women , who have apparently normal ovarian reserve, but poor quality eggs. The group is much more frustrating to deal with. It is only when we do IVF or ICSI for these women , that we find out that they have an egg problem. Let me explain.
Some of these women will grow eggs poorly in response to superovulation. Such a poor ovarian response is a marker for poor ovarian reserve. Unfortunately, they have a normal antral follicle count and normal AMH levels, which means this diagnosis is made only after the IVF superovulation has started.
The third group is perhaps the most difficult. These are women who grow a sufficient quantity of follicles in response to superovulation ; and have high estradiol levels as well. Egg collection is usually uneventful ; and the doctor often retrieves 8 to 16 eggs for them. If IVF is done, when the fertilization check is performed the following day, much to the embryologist’s surprise and the patient’s dismay , it is found that the fertilization is very poor even though the sperm are fine and actively motile. If ICSI is being done, the embryologist often finds that the eggs are morphologically normal ; or are very fragile. For example, these eggs have granular cytoplasm ; or vacuoles in their cytoplasm ; or dark areas within the cytoplasm. Since normal eggs are simple spherical formless blobs, these subtle cytoplasmic abnormalities are often missed or overlooked. The embryologist may also noticed that the eggs are fragile, and the cell membrane offers little resistance to the injection pipette. Many of these eggs may die during the ICSI process.
Unfortunately , because egg morphology has not been adequately studied , we still do not have good descriptive terms , when talking about these abnormalities. Since the eye only sees what the mind knows, often these abnormalities are not picked up. The patient is often subjected to repeated IVF or ICSI cycles , with the same poor results each time.
Why is abnormal egg cytoplasm such a difficult problem ? In order to understand this, let's first review the important role the egg cytoplasm plays in embryo development. The most dramatic events during fertilisation occur in the nucleus, when the male and the female pronuclei fuse. However, the energy to drive this fusion comes from the mitochondria in the egg - the energy powerhouses of the cell, which power cleavage and cell division. One major problem is that there is no way of testing egg cytoplasmic quality - either clinically, or in the research lab at present. While electron microscopy studies have confirmed these eggs have cytoplasmic abnormalities, this is still an area which has not been adequately studied.
Of course, part of the problem in some labs is that the failed fertilisation is not because of an intrinsic egg problem,but because of poor lab conditions. How can you as a patient find out if the problem is a lab problem ; or a biological problem with your eggs ? This is why, if there are fertilisation problems, it's very important to ask the lab to document egg morphology with photographs and videos, which can then be reviewed later. It's also a good idea to repeat the treatment cycle in a better clinic, to eliminate the possibility that the poor results maybe an artifact created as a result of suboptimal lab conditions ( such as infection; poor quality culture medium; or an unskilled or inexperienced embryologist).
I also think it's time doctors coined new medical terms to describe these egg problems. We could borrow some of the terms we use at present to describe sperm problems ! Thus, if a patient has few eggs ( impaired ovarian reserve), this could be called oligo-ooctyosis ( = few eggs). If the eggs are abnormal, this would be terato-oocytosis ( = abnormal eggs) ; and if the eggs do not fertilise because of cytoplasmic problems, this would be astheno-oocytosis ( = weak eggs).
How do we tackle this problem in our clinic ? We trouble shoot, by checking if the problem is localised to just single patient; or if it's affect more than one ( which would suggest a lab problem rather than a patient problem). If we think the patient has abnormal eggs after egg retrieval, we take photographs of all these eggs , so the patient has adequate documentation. We prefer doing ICSI as compared to IVF for these patients. However it requires a skilled embryologist , because these eggs need to be handled with care and respect . If ICSI is done in the routine fashion , many of these eggs will die during the cytoplasmic aspiration.
If at the end of the ICSI cycle , we feel the patient has a problem with fragile eggs ; poor quality eggs; all eggs with cytoplasmic abnormalities, we explain this to the patient; and discuss their treatment options.
One possibility is that this was a one off phenomenon for unexplained reasons; and may not recur , if we try again. However , because we feel that the risk of recurrence is high , we change the superovulation protocol, with the hope that a change in medication may help to improve egg quality .
If this also fails , then the only realistic options are to consider either donor eggs or donor embryos. These can be very hard choices to make , especially for a young woman who felt she had normal eggs prior to starting the IVF treatment, because she had regular menstrual cycles , and a normal FSH and AMH level.
This is why we emphasize to patients that while the primary purpose of an IVF cycle is therapeutic , IVF cycles often reveal valuable diagnostic information , which can help us to pinpoint possible problems and create effective treatment solutions. These problems could never have been diagnosed unless IVF had been done !
Wednesday, July 08, 2009
So what is the poor infertile couple to do ? After spending years and a small fortune on IVF treatments, they are now forced to wait once again for as long as 3 to 4 years on waiting lists. For non-resident Indians , the wait can be much longer. The influential ones use shortcuts to bypass the waiting list; while others consider adopting a child from less- developed countries.
It is ironic that while the technology of contraception and abortion has reduced the availability of adoptable children, assisted reproductive technology now offers a new option to infertile couples. This is the option of embryo adoption.
Biologically , embryo adoption is exactly the same as a traditional adoption , in that the child and the parents have no genetic linkage. However , here the resemblance ends. Whereas with traditional adoption it is a child who is adopted after birth, in embryo adoption the infertile couple adopts an embryo before pregnancy.
There are many advantages to embryo adoption. There is no waiting list; and the infertile woman gets to experience the pleasure of pregnancy and birth. This obviously enhances bonding between the infertile couple and the child. Another major advantage is that there is no social stigmata involved ; and the couple does not need to get permission from family members or disapproving in-laws. Also , since these embryos are usually of high quality, the success rates are better than 50% per cycle. The only disadvantage is that the treatment can be quite expensive.
You can read more about this option for family building at
Monday, July 06, 2009
Sunday, July 05, 2009
Most people have no clue what infertile couples go through.
The hunger and longing for a baby – and the frustration and pain of having to deal with failed IVF cycles is something which most infertile couples learn to deal with in the privacy of their bedrooms.
This is why many people end up saying stuff to infertile couples which is inaccurate and unhelpful – and they often add insult to injury by saying hurtful things, even when they don’t intend to cause pain ( for example, “ Just relax and you’ll get pregnant ! “ )
In order to bridge this gap between the fertile world and infertile couples, we have produced an animated cartoon film called, Making Babies – Everything you wanted to know but didn’t know whom to ask ! You can watch it free at
Friday, July 03, 2009
On the other hand, most patients feel that doctors charge too much. They envy the Mercedes many doctors drive ; and the fact that they take Wednesday off for playing golf. Many resent the fact that they have to pay hundreds of dollars for medical procedures which may just take a few minutes.
Also, it’s a well-known fact that the fees charged can vary considerably – not only from doctor to doctor – but from patient to patient as well ! Patients would be much happier if the medical costs were transparent.
The truth is that the amount which doctors charge is often a mystery for doctors themselves. Most doctors are not very good businessman; and fees are usually set for reasons which are beyond their control.
Since they are used to working for free during their the medical training and residency , young doctors often quite uncomfortable collecting fees for their professional services when they first start weighing hundreds of thousands of dollars in debt. Most use market criteria to set their fees – and charge what other doctors are charging. While this is a useful rule of thumb, in many cases it can be too much- while in others it’s too little.
Many, who are idealistic when they are young, charge enough to make a comfortable living , so that they can cover their expenses , and still have enough to keep the family happy. This is easier to do in smaller towns in India for example , but extremely hard to do in the US , where doctors will start their practice often owing hundreds of thousands of dollars in debt to cover their loans to pay for their educational tuition fees.
Other doctors , who are hard-nosed businessman ,take a much more pragmatic viewpoint . They do an informal market survey to study how much patients in their community are willing to pay for their services – and price these accordingly.
Some doctor will deliberately charge a higher fee than the competition. This is especially true for senior doctors , who feel they have earned the additional income because of their experience and expertise. Others do so because they want to create an air of exclusivity about them , because they know that patients often misinterpret high fees as being equal to a better quality of service. After all , if a doctor charges more, it must be because he is better !
This is especially true for fields such as cosmetic surgery, where patients pay directly for their services, and there is intense competition for patients. Some doctors deliberately charge a premium, not just in order to maximize their income , but to convey that they are better than the rest. However, remember that higher is not always better. On the other hand, lower fees are not always a bargain either !
What I doctors who charge less ? Some doctors are financially quite comfortable , and because they have low overheads , they are willing to charge just enough to cover their costs. They charge enough to cover their staff salaries and electricity costs for example , but they often end up underpaying themselves. Ironically, though the doctors charges less because he doesn't need much money to be contented, the disadvantage of charging low fees is it often conveys to patients that the quality of services may not be as good !
This is why it's quite common to see an escalation of prices. Once one doctors increases his fees , the others often have to do so , in order to toe the line. Fortunately , this is true in the other direction as well, and of one doctor drops his prices , many others will do so as well , in order to stay competitive.
In places like the US where third party payers dominate the market, the ability of the doctor to set his own fees is practically zero. He pretty much has to charge what the third party is willing to pay. As medical insurance becomes prevalent in India, this is going to be true here as well , where the insurance companies are soon likely to call the financially shots.
In countries like the UK, which have a nationalized health service, doctors do not have to worry about how much to charge , because this is a decision which is taken out of their hands . For many doctors, this can be a blessing !
While many doctors pride themselves on their professional skills , and take pride in the fact that they couldn't be bothered about money, the fact of the matter remains that medical private practice is also a business , and unless doctor learns how to charge the right amount for his services, he will often end up underpaying himself. In the long run , this may mean that he may not be able to invest in either updating his professional skills or buying state-of-the-art equipment , both of which can lead to poor quality medical care. He will then end up losing his patients to corporate hospitals, which are extremely good at maximizing their profits. Doctors need to find the right balance, so that they can both enjoy their financial income, as well as their emotional income. Earning money is not a sin just because you are a doctor; and if this money is utilized to improve patient care, this is good for everyone involved.
Thursday, July 02, 2009
Both ovaries are normal in size and shape. There is a well defined hypoechoic cystic lesion in both ovary measuring RT - 11x12.5x10.3 mms with volume 0.7ccs and LT - 12.8x14.3x15.4mms with volume 1.5ccs. It shows marked low level internal echoes and small focal calcification. No evidence of free fluid in pelvic cul-de-sac.Hence bilateral small ovarian lesion -endometrioma.
Their gynecologist had advised them medication to resolve the cyst; and a repeat scan after 6 weeks to confirm the cyst had disappeared.
They wanted a second opinion, as to whether this was good advise.
Please read the report carefully again. Don't worry about the gobbledygook or the medical jargon. My point is that medical scan reports are often deliberately full of this, in order to worry patients and send them scurrying to their doctors. The cyst is about 10 mm in size - this means it's only about 1 cm ! It's extremely small - and the only reason it can be detected is because the ultrasound machines today are high resolution machines, on which the images can be zoomed, till normal anatomical structures can be interpreted as "lesions" which need treatment ! Unfortunately, most people are innumerate ; and not sophisticated in enough to interpret the report. Others trust their doctor blindly - and expect him to do what is needed. This is why George Bernard Shaw said that all professions are a conspiracy against the laity !
The beauty of this scan is that the doctor has done everything by the book ! He has simply reported everything he saw - in excruciating ( and unnecessary ) detail ! So why am I finding fault with him ?
Many reasons ! For one, this report is "pseudo-accurate" ! It's simply impossible to measure structures in terms of 0.1 mm ! While it's possible to position electronic calipers and read off their readout, this simply shows that the doctor is not applying his mind ! This is false accuracy and precision which misleads the patient.
Secondly, the interpretation is highly suspect. The ovary is normally a cystic structure, and this tiny "cyst" could just as well be a normal ovarian follicle, which contains a mature egg , rather than a "lesion".
Thirdly, he has deliberately reported his measurements in mm rather than cm - thus making the "lesion" appear larger. This can mislead poorly informed patients !
So is the radiologist not very bright ? On the contrary - he is very smart - he is a willing accomplice in the game being played by the referring gynecologist !
Doctors often send patients for scans. This is often to rule out problems - and to show patients how careful and thorough they are. Most patients are happy do these scans - after all, what's the risk of doing just a test ?
The trick is that the radiologist then "finds abnormalities" - even though he knows they are of no importance, and may be just normal anatomic variants. The patient reads the report - and then worries because of all the abnormalities which have been picked up. Off he goes back to the gynecologist, for treatment. The doctor is happy to comply , because this means more follow up visits - and additional income !
It's possible to milk this for many months because the new ultrasound machines can pick up tiny fibroids and cysts for practically all women, because these are such common findings ! The woman has now been converted into a patient - and she is now stuck on a game which shuttles her back and forth from radiologist to gynecologist, and it's extremely hard to escape this.
The danger is not just that of the money being wasted on the overdiagnosis and overtreatment - or on the unnecessary anxiety which is created. The bigger risk is that sooner or later some trigger happy gynecologist will decide that the cyst is not responding to medical treatment - and needs to be removed surgically. This unnecessary surgery will actually reduce the woman's fertility - thus making her an infertile patient who will need to come and see me !
I have discussed gynecological scans in this post - but the tragedy is that this charade is played out in practically all fields today !
Wednesday, July 01, 2009
The advantage of this system is that is maximizes throughput for the consultant, who can then see about 10 patients in an hour. It also ensures that all the information in the form is completely and systematically filled out .
While many consultants will swear by this system because it's one they have used for many years, the sad truth is that this is not the best method for the patient. The quality of the patient's history depends to a large extent on the clinical expertise of the doctor asking the questions - and an experienced clinician is far better at this as compared to a junior doctor or a preprinted form. In fact I feel the distinguishing factor between an experienced doctor and a junior is that a good doctor knows how to take a history ; which questions to ask; and how to interpret these questions . Unfortunately , this is not something which can be taught easily ; and is not efficiently done with the check box system.
This is why in real life , when a patient is referred to a senior consultant, the one thing which this doctor will do ( which was often not done properly before ) is sit down and talk to the patient. Many more puzzling clinical problems are solved by a carefully taken history , rather than by ordering more lab tests or scans.
Not only will taking the history personally improve the care the patient gets, this history taking session is a great opportunity for the consultant to establish rapport with the patient and build trust and confidence in the doctor’s skills. It also gives the clinician a chance to connect with the patient and display empathy and compassion. This can be hard to do nowadays, when clinic visits have to be compressed within 10 minutes. Unfortunately , by not giving patients the time and respect that they deserve, we end up doing everyone a disservice.