Wednesday, September 30, 2009

Teaching Indian children science the Agastya way !





The Agastya science mobile van is in Mumbai for 15 days, and is visiting various schools, to teach children science "hands-on". I visited them at B D Somani School today - and was very impressed by the great job they are doing.

All children are naturally curious, until schools and examinations kill their inquisitiveness. The great thing about Agastya is that it allows children to learn stuff for themselves, using simple inexpensive items.

What really impressed me is the fact that the teaching is done by the children themselves ! The Agastya staff train the students of the school - whom they call Young Instructors" - to actually perform the experiment themselves. Once they have understood the science behind the model land can demonstrate it themselves, the Agastya staff then allows the students to become teachers. Not only does this allow the children to become confident; it also encourages the other students to ask "stupid" questions ( which they are often reluctant to do in class).

For example, in one of the models, the Young Instructor rolls 2 balls down 2 different slopes - one of which is curved; and the other is straight ; and he asks the students to guess which ball will reach the ground first. Everyone clamours to guess the right answer - and then the Young Instructor lets the balls go - and then explains why the one on the curved track reaches the base faster. Once students see this in real-life, intangible concepts such as potential energy and kinetic energy come to life. Enthusiastic students will then race balls of different weights down the same tracks, to see what happens - thus creating their own experiments - and becoming young scientists !

I do wish every school would invest in these inexpensive teaching models, so they could have a Science Lab in a Box or their own schools, and not have to depend upon Agastya to inspire their children !

I wish they'd upload these demos to youtube - along with the questions children ask - and their answers !

Tuesday, September 29, 2009

Where to go for medical advice on the Web. (5) - Atul Gawande - Slate Magazine

Where to go for medical advice on the Web. Atul Gawande - Slate Magazine: "So perhaps you're right that patient-supported Web sites as opposed to physician-supported ones may ultimately have the most impact on the practice of medicine--in both positive and negative ways."

This article was published in 2000 - but unfortunately, not much has changed.

Web 2.0 is the flavour of the day, but there still aren't enough clever platforms which allow patients to collaborate and help each other. This is an area which is ripe for disruptive innovation !

Two Million People Using Kaiser Permanente’s Personal Health Record | Ted Eytan, MD

Two Million People Using Kaiser Permanente’s Personal Health Record | Ted Eytan, MD: " While many PHRs in the market are finding it difficult to attract users, Kaiser Permanente has long offered its members access to key features in managing their health online at kp.org.

The experience of Kaiser Permanente members challenges the idea that “patients don’t want PHRs.” They absolutely do – if the PHR helps people manage their health and connect to their health care team."

Patients can see the benefits of using the PHR. Their major problem is that entering their medical data is a non-trivial exercise - especially when the doctor is not similarly wired. The good thing about Kaiser Permanente is that everyone - patient, doctor and the medical facility are electronically connected . If doctors and hospitals could enter the patient's medical data for them automagically, a lot more patients would use PHRs very happily !

The doctor is in and logged on - Los Angeles Times

The doctor is in and logged on - Los Angeles Times: " E-mail can be as useful as a stethoscope in diagnosing, and electronic medical records are for the better.
By Dr Rahul Parikh|July 20, 2009

Wow. I've just taken care of three patients in 12 minutes, and I didn't do it by 'churning' them through my office as if it's some sort of factory assembly line. Rather, those patients (their parents, more specifically -- I'm a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms.

One mother attached a digital photo of a rash on her 3-month-old daughter's face; it turned out be nothing more serious than baby acne (it'll go away in a month or so). Another mom had noticed that her son was missing one of his pre-kindergarten immunizations (she had pulled up his shot records online) and requested that I order it. And the father of a 5-month-old boy told me that his son has been constipated off and on for the last month. I e-mailed him a questionnaire so I could determine whether the family should try something at home or bring the child to the office."

This is a win-win situation - for both doctors and patients; and works extremely well for IVF specialists like me. I tell all my patients to email me, rather than phone me - and this saves both them and me a lot of time, money and energy !

Monday, September 28, 2009

Medikidz - comic books for teaching children about health

Medikidz- - comic books for teaching children about health: "Follow the adventures of the Medikidz comic book superheroes. Blending fun with fact, the Medikidz help kids learn about health and disease in a humorous and engaging way. New titles every month, so check back regularly!"

This is a very clever way of involving children . It uses a comic book story format to teach them about their health and is an excellent example of edutainment . The comic books are packed with useful information, which I am sure even parents will find very helpful !

What I especially like about this series is the fact that it shows that it's possible to explain complex medical concepts in simple terms which even a child can understand ! I think if doctors take the trouble, it's possible to explain to every patient ( even illiterate ones !) what they need to know about their bodies. In fact, I think it would be a great project to try to adapt this same information to low-literacy populations !

I met Dr Kim Chilman-Blair today. She is the CEO and is very keen on distributing the comic books to Indian children. The challenge will be make sure they reach out to as many children as possible, without charging the children a lot of money.

I feel every pediatrician's clinic should have a complete set of these comic books for their patients - and hopefully , a generous pharmaceutical company will subsidise this !

These would be a great value-addition for every school library too - after all, children need to learn about their health and these books will encourage them to read and explore !

Any NGO which deals with children should also invest in a set for their library.

And every Pediatric Department in every hospital should have a complete set too !

Calling all infertile software engineers

If you are infertile, you know how difficult it can be to navigate the infertility maze. Handling your own emotions; those of your spouse; dealing with questions from family and friends; talking to your doctor; making decisions about treatment options; making sense of the IVF acronym potpourri; organising the finances; and preparing for failure are all processes which exact a considerable emotional and physical toll.

During your journey, did your ever wish there was a toolbox packed with useful information which would act as a guide during your journey ?

Why not use your personal experiences and your computer skills to create such a Toolbox for infertile couples ?

Maybe a google mashup which displays all the IVF clinics in India ?
An excel spreadsheet to track the treatment meds ?
A decision making template to help weigh the pros and cons of each treatment option ?
A mindmap, to ensure you've considered all possibilities ?
A flow chart to walk patients through the IVF cycle ?
Project management tools to help manage the IVF treatment project ?

I'll be happy to fund any of these !

IVF News - Experts attack 'fertility tourism' industry

IVF News - Experts attack 'fertility tourism' industry: "British couples travelling abroad to take advantage of commercial surrogate arrangements are engaging in a form of 'exploitation', Professor Naomi Pfeffer, an expert in the ethics and regulation of controversial developments in medicine, said at a fertility meeting this week.

Speaking at the 'Motherhood in the 21st Century' conference at University College London on Friday, she said: 'The exchange relationship is analogous to that of a client and a prostitute. It's a unique situation because it's the only instance in which a woman exploits another woman's body.'"

This is a typical worldview of an "expert" from the UK. Just because these women are poor does not mean they are stupid. If the surrogate offered to do this for free, I guess Prof Pfeffer would have no objections. Her only objection seems to be that money is changing hands, and this is what "contaminates" the transaction . I cannot agree with this viewpoint. Yes, the women are poor, but they are street smart enough to survive in Indian urban slums . They live in circumstances in which women like Prof Pfeffer and doctors like me would not be able to survive for even 2 days ! Does being poor mean they need to be protected by experts from the UK ?

I appreciate Prof Pfeffer's intention is to protect these women, but I am very disappointed by this lack of empathy . I wish these experts would talk to the surrogate to understand their point of view, rather than make such sweeping and unkind generalisations.

Let's look at a typical surrogate's story. She is poor; lives in a slum; has two children; and a husband who works, but cannot make ends meet. She can continue eking out a life of quiet desperation, and because she is not educated , can never exit this hellish life. One way out of this trap is to earn some money by being a surrogate. Not only does this earn her family some money which may allow her to get a better education for her children, it also ensures her some rest and pampering during her pregnancy. Is she being stupid by agreeing to opt for this ? The fact that so many women clamour to become surrogates - and that it's usually one surrogate who then brings lots of her friends as well , suggests that the surrogates are quite comfortable with this arrangement.

I agree surrogates can be exploited. But this is true of any transaction. Isn't it better to implement regulations and guidelines to protect them ? This is a constructive approach - rather than the "holier-than-thou" sanctimonious approach taken by experts who claim to speak for these women in order to protect them !

Why can't we trust poor women to make the right decisions for themselves ? Does the fact they are poor means that they need "protection from exploitation" or that they need Western experts to speak for them ? Just because they don't have a voice, can experts claim to speak on their behalf just because they are articulate and educated ?

I guess in a way I am being unfair to Prof Pfeffer. I do agree that some clinics can exploit surrogates, and they are more likely to do so because they can get away with it, since these women are poor and poorly educated. This means there is a grain of truth in what she says. However, to claim that it's the infertile women who are exploiting the surrogates is very unfair. Infertile women are unhappy and depressed. Surrogacy is often the last-ditch effort many make to have their own baby - and why would they want to exploit some other woman to do so ? In fact, it's in the infertile couple's best interests that the surrogate be well-nourished and well-cared for during her pregnancy, to ensure their baby gets the best prenatal care ! Most infertile couples are very grateful to their surrogates - and just because some unscrupulous doctors take undue advantage of some surrogates, to tar infertile couples with this brush of exploitation is unkind and uncalled for !

Sunday, September 27, 2009

How overtesting leads to overtreatment

Most good doctors know that an accurate diagnosis can be made 80% of the time by performing a clinical examination. Tests are usually done to confirm the diagnosis - and ideally should be used sparingly, and only when called for - when dealing with a complex or rare problem, for example.

Unfortunately, it takes time to do a thorough clinical examination. Taking a reliable history from the patient can easily take 15 minutes. In this day and age of 7 min clinic visits, doctors simply cannot afford the luxury of doing so ! The irony is that the patient's money is then wasted on ordering unnecessary tests.

This sets off a vicious cycle. Most imaging machines provide very high resolution scan images. The radiologist reports these - after all, that's his job. The problem is that even normal anatomic variants are reported , and when patients read this report, they are worried that they have a serious problem which needs correction. An excellent example of this is a prolapsed intervertebral disk seen on MRI scanning in a patient with backache; or a "torn cartilage" see on MRI scanning in a patient with knee pain.

The patient then demands surgical correction for this abnormality , without realising that there is often no correlation between the scan picture and his symptoms. Most doctors are happy to comply - they get paid a lot to perform procedures.

Thus, by refusing to pay primary care doctors for their time and expertise, and forcing them to "process patients " in an assembly line fashion, insurance companies and the government end up spending much more - and the patient is the loser in the long run !

Too much IVF ?

There has been a virtual explosion of IVF clinics in India recently. While this is great news for infertile couples, because they no longer need to travel long distances to take IVF treatment ( which was formerly available only in the metropolises), the tragedy is that this intense competition has led to IVF being done for patients who really don't need it.

Thus, patients who could get pregnant with simpler ( and less expensive treatment, such as IUI) are fast forwarded into doing IVF. This is what I call"treatment creep". Doctors can justify this quite easily, because IVF does have a much higher success rate. Ironically, clinics which do IVF for everyone who comes to them have a much higher success rate ( because many of their patients are young; have "unexplained infertility"; and have an excellent chance of getting pregnant, even without resorting to IVF !

When doctors cannot answer "Why ?"

The commonest question doctors are asked is - Why ?

As an IVF specialist, the questions I get include:

Why is my sperm count low ?
Why did the IVF cycle fail ?
Why am I not getting pregnant even though all my tests are normal ?
Why did I miscarry ?

Not being able to provide a good answer is frustrating - for both doctors and patients.

While we do understand some of the causes, the fact is that most of the time we are clueless as to what the real underlying reason is for an individual patient . Doctors are good at describing what happens - and we can often give these conditions a name. While providing a label can help to reassure patients that we have dealt with problems similar to theirs in the past, the honest truth is that medical technology is often not good at drilling down to find the answer to the Why ?

Some doctors, in order to placate the patient will often order a series of additional tests - some of which are very expensive . The results are often more gobbledygook - but because they are "scientific", they often provide patients with consolation that this new doctor is very "thorough" and well-informed - and he has been able to find a problem which all the earlier ( incompetent) doctors failed to find.

Unfortunately, many of these tests are completely useless, because they do not change the treatment options. In fact, they can often be actually harmful, because the doctor ends up wasting the patient's time and money pursuing and "treating" red herrings.

Unfortunately, most doctors refuse to take a critical look at their practise , and because of their personal biases, continue subjecting their patients to a battery of tests, even though they have not been proven to be helpful. Many patients are happy to toe the line, because they are fed up; frustrated; and are willing to clutch at straws !

Mature patients are willing to accept that life is full of mysteries; and that medicine is often an art, rather than a science. They willingly take the help which the doctor provides , but also understand that medical science has its own limitations. The sooner they come to terms with this, the easier it will be for them to move on with their life.

Pioneering Ideas: Tomorrow's New Vital Signs, PHR-delivered

Pioneering Ideas: Tomorrow's New Vital Signs, PHR-delivered: "Project HealthDesign has released a new e-primer that explores the importance of observations of daily living (ODL) in moving toward next-generation personal health records and health management. PHRs enable consumers and providers to incorporate routine health observations that go well beyond what data are captured at clinical visits. Some are more obvious than others – blood glucose readings for diabetics, did I take the right pills at the right time today – but others may play an equally important role in pursuing health goals and managing chronic health conditions.

Things like: Does my chronic pain spike when the temperature dips below a certain threshold? What effects might a particularly stressful month, with long hours at work and marginal sleep, have on my eating and activity behaviors, and hence my diabetes? Can the fact that a 17-year-old with a chronic illness is regularly self-reporting his or her mood to be bad or sad play a role in the self-management of his or her disease? And, if today’s pollen counts are really high, can my PHR device send me an alert in the morning to remember my inhaler, and then delete that point-in-time data capture because it may not be useful if conditions change tomorrow?"

This is information which only an electronic PHR will allow patients and doctors to capture and analyse.
If you have a chronic illness, then you should keep your own PHR. Don't wait for your doctor to suggest this . Your PHR will help you - and also help him to help you !

Saturday, September 26, 2009

Customer Disservice: Health Care #FAILs again and again « Crossover Healthcare

Customer Disservice: Health Care #FAILs again and again « Crossover Healthcare: "Our health care system is completely devoid of customer service. It is pathetic.

I took my son to have a simple tympanostomy (ear tubes) procedure this morning. I show up, sign in and take my seat amidsts the throngs of people in the surgical center waiting room. I brought my laptop and some reading materials to bunker down for the long wait ahead.

20 minutes later I get called up front to sign some additional paperwork. Instead of being greeted, 15 documents each complete with a full page of legalese is shoved my way regarding various aspects of responsibility, payment, agreement, arbitration, and host of other information. The grumpy lady has clearly done this a thousand times and she has absolutely no tolerance for any of my questions. She parries my first few skillfully, but I don’t let her blunt my questions regarding the finances."

These are problems everyone wants fixed - patients ; nurses; hospitals and doctors as well.If everyone wants to achieve the same goal, it's obvious that we first need to identify the common enemy - the medical insurance companies, who deliberately obfuscate this information, so they can remain profitable - at the expense of both the doctor and the patient !

How patients can help each other

It often breaks my heart when patients do not use their expertise and skills to help each other. Many of the infertile couples who come to me work in the Information Technology industry and are computer whiz-kids. Many of them also have horror stories of how badly they have been treated by their doctors; and how difficult it is to get reliable information about good IVF clinics.

The tragedy is that all they do is complain about the doctors - they do very little to try to help others who are in the same boat. They feel they are powerless, because doctors have all the power and expertise.

This is not true ! It would be quite easy for IT-savvy patients to create a platform which would allow them to rate doctors; and then share their first-hand experience and expertise with each other, so that other infertile couples could benefit from the experiences of the entire community. There is strength in numbers - and knowledge is power.

Bulletin Boards do allow patients to communicate with each other - but this is highly disorganised and unreliable. I am sure clever patients can think of a better way of sharing their knowledge !

I'd be happy to fund a Web 2.0 project which empowers patients to do this ! Any takers ?

Creating a patient participation platform to improve healthcare

I think the reason why the healthcare system is so patient-unfriendly is because doctors have all the power. The doctor has the medical knowledge , expertise and skills. In sharp contrast, the poor patient is worried and sick , and is dependent upon the doctor's help to get better.

This is sometimes why doctors can be so arrogant and rude. Patients need them more than they need patients - and this is especially true of very busy doctors who have packed schedules and long waiting lists.

One way of redressing this imbalance would be to give patients more power. If patients could organise themselves into communities and compare notes about doctors; their bedside manners; how much they charge ; and their clinical outcomes, this would allow patients to select the best doctors for themselves.

But wouldn't doctors feel threatened by such a system ?

I think this would actually help doctors a lot ! Because of the positive patient feedback, good doctors would do even better ; while the bad doctors would have to quickly improve and shape up - or be left with no patients at all !

It will also help to balance the workload amongst senior doctors and their juniors. Senior doctors who are good are often so busy, that they have no time for themselves ; and they are so caught up in their patient workload, that they may not have enough time to devote to every patient they see. They may often burn out because of the excessive workload.

On the other hand, junior doctors who are good and have all the time in the world to devote to their patients, are often left twiddling their thumbs , because they do not have any patients to see. This encourages them to take shortcuts and indulge in malpractises such as giving commissions and cuts - all of which slowly and progressively poison the medical system and damage the doctor-patient relationship.

A patient participation platform will allow these young doctors to become busy and rise quickly in their profession , without having to indulge in corrupt practises !

" What will happen to me if I don't grow eggs at all, doctor ?"

I recently had a young woman who was very worried about doing an IVF cycle. She had a low AMH level which suggested that she might have poor ovarian reserve and might not produce any eggs at all, inspite of superovulation.

She was very scared about starting IVF treatment . " What will happen to me if I don't grow eggs at all, doctor ?"

I feel patients need to confront their worst fears - and a useful way of doing this is by thinking about - What's the worst which can happen ? It's true that if she did not grow eggs during her IVF cycle she would be devastated, as this was her last option for having a baby with her own eggs. However, even if she did not grow any eggs, at least she would have peace of mind she tried her best - and she could then move on with her life and consider alternative options.

Medically, she would be no worse off for having tried - and while it's true that she would still remain childless , doing the IVF treatment would not harm her or damage her health. Not trying because she was scared that the outcome would be bad was the worst possible decision to make - and I had to explain to her that she could not allow her fear to paralyse her into inactivity.

Why are Indian patients so passive ?

There is a lot of talk on healthcare reform in the US today - and what is exciting is the fact that the discussion is being powered by enlightened consumers, who want a greater say in what kind of medical care they get.

By contrast, Indian patients are practically asleep. The Indian healthcare system also need an overhaul - but while Indians are great at complaining to each other about how terrible their doctors are, they seem to do very little to try to fix the problem.

Why is this so ? Aren't Indians smart enough ? We have enough IT skills to be able to use IT to dramatically improve the basic doctor-patient interaction ! This is something which will benefit everyone - doctors as well as patients.

I think Indians are just so used to complaining, that we can't seem to find the energy to fix the problem. What a shame !

The e-patient white paper: Seven Preliminary Conclusions | e-Patients.net

The e-patient white paper: Seven Preliminary Conclusions | e-Patients.net: "The authors – mostly doctors, remember – said “Our most helpful insights came from a growing awareness that e-patients use the Internet in three fundamentally different ways:
1. to access content,
2. connect with others,
and
3. collaborate with others in ways never possible before.

Wake up to the new world of participatory medicine: equip, enable and empower patient participation."

I believe this is true in India as well. The trouble is that the number of e-patients is still very small. However, they are influential , and will catalyse a change in the way healthcare is delivered in India. This is already true in certain communities like Gurgaon, which has a very large number of young affluential Indians who live on the internet - and use the web extensively to help themselves get the best medical care.


“Common Sense Is Not So Common” (What We All Need to Remember)

“Common Sense Is Not So Common” (What We All Need to Remember): "Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.”2 I would add knowledge of the patient's ability to pay for the medicines prescribed."

This is useful for both doctors and their patients to remember. Your doctor may be the expert on your disease - but you are the expert on your body and your illness. Doctors without common sense can be hazardous to your health , so please use yours !

Thursday, September 24, 2009

How to sell to doctors

Most of the drug companies that I used to deal with often used very pretty young women fresh out of college who bought in lunch, break food and more. In fact most doctors offices have calenders where they arrange these people to bring things in ( in advance) . Plus they wait and wait and wait in the waiting room to see the doctor for a few minutes, they leave a lot of samples of their products, they give away gift certificates and other free items to staff and doctors.

No wonder people have a low opinion of doctors !

The price you pay for not doing IVF

Many patients are very worried about doing IVF. They are scared that they will put on weight; or that the hormones will make them lose hair; or that the treatment will cause them to run out of eggs. In reality, the truth is that IVF treatment when done in a good clinic is very safe; and the medical risk is very low.

In fact, the primary risk with IVF is financial and emotional. IVF does cost a bomb, and if the treatment fails, this leaves quite a financial dent. Similarly, every couple doing IVF is sure in their heart of hearts that the cycle is going to work for them, and if it fails, they are often devastated.

However, there is also a price couples pay for not doing IVF ! This is the regret that by not doing IVF, they did not explore all their treatment options, and thus deprived themselves of a chance of having a baby. It's a general rule that you usually regret the things you did not do - not the things you do. Not doing IVF may mean that you may always be left with the haunting doubt that you did not give yourself the best shot at getting pregnant.

I tell all my patients to take the past of least regret - and while the outcome of any treatment is uncertain, taking IVF treatment at a world-class clinic will give you peace of mind you did your best !

Why aren't Indian doctors better organised ?

One of the commonest complaints patients have about doctors is that they do not remember anything about them. For many doctors, the patient is just another number - and patients are often fed up that they have to repeat their medical history all over again every time they visit their doctor - even if it has just been a few days.

One of the reasons for this is that Indian doctors are notoriously poor at keeping medical records. At the end of a visit, most just write down a prescription - they do not even bother to document the clinical examination findings or their tentative diagnosis !

This is why they often have to "start from scratch" every time they see a patient ( unless they are blessed with a phenomenal memory).

The truth is that most Indian doctors see a large number of patients daily. Also, many will travel from hospital to hospital and clinic to clinic, which means they really don't have a well-organised mechanism for keeping and storing the patients' medical records.

This poor organisation hurts both doctor and patient. The best solution is for doctors to use an electronic medical record ( EMR) system on their laptop - but the older generation of doctors is still very computer-phobic ! Hopefully the new breed will use computers extensively - not only to improve the quality of the medical care they provide to their patients , but also to make their own life a lot easier !

Monday, September 21, 2009

The Fertility Challenged - A Cartoon Film for Infertile Couples - Part III

In the Face of Swine Flu, Common Sense and Science

1. Swine flu is very contagious. But the severity of swine flu is much lower than the seasonal flu (the flu of normal winters).
2. Swine flu demands common sense and calmness, as for seasonal flu. Contact your physician only in severe cases, such as coughing up blood or significant difficulty breathing.
3. Medications for swine flu such as Tamiflu and Relenza do not prevent the disease, and they are not useful for treatment in healthy people, They have common side effects some of which are serious causing admission to hospital. These medications might be useful in severe cases, but this is unproven.
4. Vaccine against swine flu is experimental. Nobody knows how effective it will be in preventing the disease or how safe it will be.
5. Swine flu does not have any different consequences for pregnant women than seasonal flu.
6. Previous flu pandemics do not produce high mortality since we have had antibiotics to cure pneumonias which complicate flu. Previous flu pandemics have no “second wave” and if it takes place it is not likely to be more severe.
7. Health services must always take care of thousands of acute and chronic patients, and it is important not to waste time and resources for mild cases of swine flu.

When you should fire your doctor

It always amazes me as to what abuse patients will put up with. I understand that patients are scared and desperate - and they want a doctor who will be their God and make all their problems go away. However, this desperation does not mean that patients should put up with rudeness or insults.

A good doctor will always respect his patients - and if the doctor cannot be bothered to do so, then he does not deserve the patient's respect either !

Sometimes the best course of action is to find a better doctor, rather than to remain stuck with the same bad old doctor. Just because he has treated you in the past and you have a relationship with him does not mean that you are married to him - and even bad marriages are better off being ended by a divorce !

A cartoon film for infertile couples - Part 2

Saturday, September 19, 2009

Doctors as miracle workers

Patients come to doctors with a lot of hope. This is especially true for infertile couples, who are hungering for a baby.

When an infertile couple gets pregnant with IVF after 10 years of infertility, they often treat their doctor as a miracle worker - and feel the doctor is God !

I wish I was a miracle worker - it would make my life so much simpler ! Patients would not even need to come to me - I'd give them as many babies as they wanted at home.

The truth is that while good doctors can do a great job with helping patients, we are still limited by human biology - and a good doctor will try to help the patient to have realistic expectations.

In fact, I worry when patients come to me expecting miracles .This is an unrealistic expectation, and often causes a lot of heartburn and despair, if the cycle fails - as it may do, no matter how good a doctor I am and how skilled my treatment is !

How to identify a good IVF clinic

It can be very hard for patients to differentiate between a good IVF clinic and a bad IVF clinic because they all seem to be the same - and patients are not sophisticated enough to be able to make out which offers a better service.

For example, many IVF clinics will tom-tom they have bought the newest machine and have the latest technology . However, these are often marketing gimmicks to get media publicity - they do not really help the patient or improve success rates in any way. In fact, many of these "high tech wonders" often end up collecting dust in the lab, because they are never used after the first flush of excitement over their novelty value dies down.

A better way of judging how good an IVF clinic is by talking to patients who have failed an IVF cycle there.While successful patients are happy to sing the praises of whichever clinic they went to, if a patient who has failed an IVF cycle still has good things to say about the doctor, this means a lot. This suggests that the patient was treated with consideration - and a clinic which treats patients respectfully will do a good job of providing high quality medical care also !

How many patients are willing to repeat the IVF cycle in the clinic is a good index of how good the clinic is !

Is the problem with my eggs ? or with the IVF clinic ?

When patients get few eggs or poor quality embryos, their key worry is -

Is the problem with me ? ( Do I have "old eggs" ?)
Or is the problem with the IVF treatment ( Maybe the doctor is not doing a good job with monitoring superovulation or timing the HCG ?)

It's a very valid concern - but most patients are reluctant to discuss their concerns with their doctor. When the outcome is poor, doctors often get defensive. This causes communication to break down, and patients start worrying that the doctor is not being frank and forthright; or is concealing vital information. They get fed up and frustrated, and then decide to try with another IVF clinic.

Unfortunately, most doctors take a perverse pride in badmouthing other doctors; and the new doctor will often criticise the treatment protocol of the old doctor. This ignites new hope in the patient's heart, and she is encouraged to try again with a new clinic. However, if the outcome is bad again ( because the problem was the fact that the patient has poor cytoplasm), then there is even more heartbreak - and patients who have failed multiple IVF cycles at different clinics will often badmouth all IVF treatment

Friday, September 18, 2009

Signs of a bad IVF clinic

IVF has become a big business today.

How can you protect yourself from poorly equipped inexperienced doctors, who set up IVF clinics just to make money ?

Unfortunately, there is no simple answer to this question. Just going by a clinic's reputation does not help ( some big name clinics are just money making mills) - and neither does checking its "success rates", because it's so easy to game these.

I feel the only effective solution is to be well-informed about what an IVF treatment cycle involves, so that you know the clinic you select provides state of the art technology.

Do they cryopreserve embryos ? Do they offer vitrification ?
Do they offer blastocyst transfer ?
Do they provide photographic documentation of your embryos ?
Do they offer PGD ( preimplantation genetic diagnosis) ?

Here are some of the red flags which should warn you the clinic may not be very good.

They depend upon a doctor who travels to the clinic for a few days every month to do the clinical procedures
They perform less than 100 IVF cycles every year
They do not have a full-time embryologist
They "batch patients" because they don't have the required expertise in-house and need to "import" qualified people for the treatment
They do not document their medical treatment protocols
They do not provide you with a medical treatment summary
They do not answer your questions
They do not provide you with photographs of your embryos

I feel the last is critically important. While the clinical outcome of an IVF cycle is always uncertain, since doctors cannot control embryo implantation, producing good quality embryos is a function of the IVF clinic, and correlates directly with the skill and expertise of the IVF lab Good IVF clinics take pride in their skills - and by documenting the embryos they produce in their lab, they can show their patients that they are transparent and skilled !

Doctor, why did my earlier IVF cycle fail ?

As a senior IVF specialist, I see many patients who have failed IVF cycles in other clinics. One of the first questions they ask is - Why did my earlier cycle fail ? Why did the embryos fail to implant ?

In order to answer this question, I first need to review their medical records, to find out what was done in the IVF treatment. Unfortunately, most IVF clinics are terrible about documenting their treatment. Many clinics simply refuse to handover the medical record to the patient, claiming that it is their property. Others just provide a bare summary ( for example, " Embryo Transfer done" ), without even bothering to specify how many embryos were transferred or what their quality was !

( This is true of IVF clinics in India. US clinics are quite meticulous with their documentation , and doctors in the US are very careful about keeping records ( there are some medical benefits to living in a litigious society !) However, many US clinics still make patients work extremely hard in order to retrieve a copy of their records !)

Without this medical documentation, it's very hard to analyse the reason for the failure.
Broadly speaking , there are two possibilities

1. Biological problems with the patient ( for example, poor quality eggs because of poor ovarian reserve)
or
2. Problems with a poor quality clinic ( old malfunctioning laboratory equipment , causing fragmented embryos).

If the problem is because of a poor quality clinic, then this is easy to fix, by providing good quality treatment in a good clinic. However, if the problem is poor egg quality ( for example, in older women), then no matter how good the clinic, the success rates will be low.

I always remind patients that while the outcome of any treatment is uncertain, taking treatment at a world-class clinic will give you peace of mind you did your best !

Is IVF being overused ?

The simple answer is - Yes !

As an IVF specialist, I am sorry to have to say so, but I think too many IVF clinics offer IVF as a treatment option, when simpler treatments are also likely to be effective.

I am not trying to criticise IVF clinics - I am just trying to protect infertile couples !

While IVF is a great treatment, many couples ( especially those who are young) can often be helped with simpler and much less expensive treatment options. However, just like many gynecologists keep on repeating IUI treatment cycles ( instead of referring the patient for IVF, like they should optimally do), many IVF clinics will do IVF directly , instead of trying IUI first. Doctors can be quite possessive about their patients !

So what is the poor patient to do ? There's a simple answer ! Be well-informed, so you can take the right decision for yourself, and don't get taken for a ride.

What do patients want from their doctors ?

Being ill is scary. Trying to find the right doctor at this time can be a very stressful experience !

Patients want to find a doctor who
- they can trust
- who is technically competent
- who is available
- who will not over-charge them

I advise patients to make a sort list of doctors - and then interview them all, so they can find the one who they like the best.

However, over the last two days , I have been making the "doctor rounds" while accompanying a friend who needs an angioplasty , so I got a first hand view of what the process can be like.

In reality, most patients don't have the time or energy to do this. Also, they just don't have the skills to judge a doctor's competence , which is why most use a short cut or convenient rule of thumb. For the vast majority, this would consist of talking to doctor friends or colleagues, so they can get recommendations as to which doctor they should go to. Most will then select a doctor based on geographic proximity - and then hope for the best.

It is true that "word of mouth" is very important and this is often what makes ( or breaks) a doctor's reputation. Most of us will depend upon friends and relatives for recommendations as to which doctor to go to; or which lawyer to select.

Unfortunately, this is a very inefficient and unreliable process to make such a vitally important decision.

The good news is that the internet can make this much more efficient. While doctor-rating websites still leave a lot to be desired, well-informed patient communities provide a great resource which can allow patients to judge which doctor is right for them. These communities allow patients to cut through a lot of marketing hype - and also help to keep doctors and clinics honest, because bad reviews can easily damage their reputation and practise.

Empowered patients can help to heal a sick healthcare system !

Baby Chase - Chap 8. The story of how one couple completed their family

Thursday, September 17, 2009

Googlewave for improving healthcare

There are several potential uses for Google Wave in the healthcare context. The first, most powerful use is the ability of the health community to implement patient-centered communication. Doctors and patients are able to initiate communicate around a condition and all things related to the patient's condition are captured within a wavelet (individual conversations/collaborations). Things like MRI's and test results can be appended to a wave and doctors and specialists can collaborate through the wave. Since the communication is server-based, these conversations can be captured, secured, tagged, searched.

This is great way of improving doctor-patient communication as well as patient-patient communication !

Virtual reality and second life for medical training

At Imperial College London, medical students navigate a full-service hospital where they see patients, order X-rays, consult with colleagues and make diagnoses.
An avatar approaches a virtual patient in a hospital inside the  online world Second Life.

It's an interactive, hands-on learning experience -- and none of it is real.

These prospective doctors are treating virtual patients in Second Life, the Internet world where users interact through online alter egos called avatars. The third-year med students are taking part in a pilot program for game-based learning, which educators believe can be a stimulating change from lectures and textbooks.

Social media for patient communities

FacetoFace Health is your trusted site for connecting one-on-one with others who share similar health experiences. Share your story, and find others, quickly and privately. Humanizing Healthcare - that's what we do.

I like the idea that you can "match yourself" with patients with similar diseases.This way, expert patients can help newbies deal with the medical care system !

Wednesday, September 16, 2009

How do you market something which is free ?

HELP is a free consumer health library we have been running for over 10 years now. The website is at www.helpforhealth.org.

While I am happy to fund the library ( which means we do not need any financial assistance), we do need help to increase awareness about the unique services HELP offers, so that more people will make use of our services. We do not have a marketing budget; and are having a difficult time marketing HELP.

Logically, one would expect this would be easy to do. We offer a unique service, which no one else offers; and because we help patients to talk to doctors and provide free Information Therapy, to empower patients to get the best medical care, one would expect people to be very happy to use our free services. We have no hidden agenda; are not looking for money; and are trying to improve the doctor patient relationship and to heal the sick Indian healthcare system by making sure patients are well - informed - all of which are laudable goals !

While the media does write occasional article about HELP, the fact still remains that we have not done a good job in marketing HELP, because not many people know about the services we offer.

Part of the problem is that because our services are free, they are not valued ! ( After all, if you get something for free, you don't think it's of any importance). I am quite certain that we do not want to charge for our services, because I believe patients need to have all the information they need and want, if they want to get the best medical care; and this is part of our mission.

We offer free online Ask the Librarian services as well, where we provide reliable authentic information to users by email, thus acting as infomediaries who are Information Therapy specialists.

I would like suggestions as to what we can do to market HELP ! We need help in marketing HELP !

Monday, September 14, 2009

Computer Maker Dell to Jump in Electronic Health Record Pool - Health Blog - WSJ

Computer Maker Dell to Jump in Electronic Health Record Pool - Health Blog - WSJ: "Another player is getting into the health IT game. Today it will be computer maker Dell who’s going to partner with hospital groups to offer electronic medical records, according to the New York Times.

Dell plans to target small practices with 10 docs or less, set-ups where the majority of U.S. docs practice. It will offer the hardware framework for these services, and partner with electronic health records software makers like eClinicalWorks to offer services. But docs in small practices largely continue to rely on paper records stuffed in manila folders."

This will dramatically improve EMR penetration !

Modern medicine versus alternative medicine

Many patients are confused as to whether they should try alternative medicine; or stick to conventional ( Western, allopathic) medicine.

I think the best option is to use a sensible blend, depending upon your problem.

Step one would be to go an allopathic physician, so he can make sure you don't have a serious problem. The diagnostic technology Western medicine offers is far superior, and allows you to make sure you are not overlooking a serious illness.

If you do have a serious illness, then I feel Western medicine is better organised to deal with it ( even though the results may not always be good, because doctors cannot always influence the natural history of a disease, which marches on to its outcome, no matter what we may try)

If it's not a serious illness ( for example, back ache; chronic headaches or hypertension) , then I'd suggest you give alternative medicine a try first. Many of these medicines work very well , because many of these chronic problems are lifestyle related - and western medicine unfortunately rarely addresses this aspect !

Sunday, September 13, 2009

Twin pregnancy for Bangalore couple after successful IVF

I am 32 years old and my wife is 29 years old.



We had been married for 4+ yrs, and had been trying to get pregnant ever since but no luck. In these 4 years we tried almost everything under the sun to fulfill our dream but nothing worked. We live in Bangalore, and consulted many infertility specialists in Bangalore. Since all our reports were normal it was more terrible since we did not know the root cause of the problem.. However, we started taking treatment in Bangalore and in three years underwent numerous assisted natural cycles, stimulated cycles, 7-8 IUIs, 2 IVFs but nothing worked and we almost decided to give up any further treatment as it was too traumatic to live life on a monthly basis..After every unsuccessful cycle we would hope that next month we will be lucky. We were extremely stressed & dejected and started avoiding our friends and relatives whose only question was when are we going to give the good news. We were spending most of our income on our treatments and obviously this took financial toll on us too. Apart from that, doctors whom we met all these years were too commercial and somehow I thought infertility has become a money spinning business for IVF clinics without any human touch.



My wife was so fed up with all these useless treatments that she refused to take any further treatment and almost decided to live without a child. We almost accepted childlessness as our destiny. But I persuaded her to undergo one last IVF cycle and she agreed. We decided to take some time off before starting next cycle. So I started to search for a doctor for whom infertility is not a mere profession but also the passion. I spent several sleepless nights browsing internet looking for infertility specialists and found Dr Malpani's website where tons of really useful information was available.. One of my relative also recommended him along with few other famous doctors in Mumbai. Finally we planned 1 week of leave and went to Mumbai in Nov 2008. We met Dr Malpani and explained our problem to him. We found him very heart warming, very compassionate and extremely passionate about helping childless couples. After meeting him, we thought he is the one we were looking for. He joked with my wife that "You are young and I can guarantee you a baby, give me lots of follicles!!!". For a moment, we thought we have found a trusted friend and a doctor in one person which is so important in infertility treatments. We met other doctors in Mumbai too and found them too busy for their patients. After meeting Dr Malpani, We always knew Dr Malpani is the only choice for us. Unlike other doctors, after seeing our reports he did not blindly asked us to repeat all the blood/urine/sperm tests and suggested only one Thyroid test at the beginning of next cycle. That was very impressive to us because every doctor blindly recommends numerous expensive tests even if they are not needed. His clinic was very well maintained and staff was so cordial and friendly. We came back to Bangalore and decided that next cycle we are going for IVF in Dr Malpani's clinic.



We kept in touch with Dr Malpani through Emails and he was always prompt in responding to mails. We never felt we are 1200 Kms away from Dr Malpani as he was always reachable by phone and email. I sent an email to Dr. Malpani with my wife's blood reports. Within 4-5 hours I received a reply from Dr. Malpani advising us about the treatment, Cost, and all requested information. We are quiet impressed with the professionalism and prompt response. My wife started taking injections in Bangalore itself and landed in Mumbai on 10'th day of he cycle in June. We stayed near the clinic so commute was not a problem. But there was some bad news in store for us. Dr Anjali Malpani did the scan and told that there were not many follicles on 10'th day and we may have to cancel the cycle. We were heart broken and thought that all our efforts have gone waste. But then she suggested doubling the injection dose and seeing how ovaries respond in next 3-4 days and then she will take a call. We agreed and decided to continue and wait for 3-4 days more. We hoped that follicle count will increase in next 3-4 days..We visited Siddivinayak temple in the evening and prayed for successful IVF. After 4 days of increased medication, miracle happened and Dr Anjali Malpani told that she can see many more follicles now and they need few more days to mature before retrieval. We were scheduled for retrieval on 29'th June and Dr Malpani told me that they collected as many as 30 follicles and 24 was mature. I was stunned and little afraid also that this might cause OHSS. But he calmed my down and explained it properly to me. He said there is nothing to worry and everything looks perfect so far. Embryo transfer was scheduled for 2-July. It was little disappointing when he told that there was only 6 good quality embryos out of 24 matured eggs. Dr Mapani again comforted us and showed us the embryos in the lab. It was great to be able to see the embryos which were ultimately going to become the babies. This shows that Dr Malani really believes in empowering the patient by providing as much information as possible. No other doctor I visited earlier cared to tell what they were doing. Many a times we would ask him stupid questions and he would address them with patience. I found this a very rare quality among today's doctors.



He transferred 4 good quality embryos and after 3 days of rest, we came back to Bangalore. After 15 days, we did our first bHCG test and oh my god!, IT WAS POSITIVE. We first could not believe it and we were waiting for this moment from last 4.5 years. I called Dr Malpani immediately and gave him the good news. He was also very happy to hear this. Then he suggested repeating the tests after 3 days. When we repeated the test after 3 days, bHCG doubled which indicated that this is viable pregnancy. In first ultrasound, radiologist told that it's TWINS and our joy knew no bounds. Now my wife is 12 weeks pregnant and expecting our child in Feb 2010. We still call/mail Dr Malpani if we have any concerns related to pregnancy and he is kind enough to responds to email or return our calls.



Dr Malpani proved god-sent to us and I would recommend Dr Malpani to every couple having difficulties in getting pregnant. He is doing a great service to childless couples and may god always bless him.



We will be happy to discuss our experiences further. Feel free to contact us at ivf_bangalore@yahoo.com.

Saturday, September 12, 2009

What is your IVF success rate ?

This is the commonest question most patients ask IVF doctors. It's a very important question, because patients understandably want to maximise their chances of success - and would like to select a clinic which has the best success rates.

However, such a simple question unfortunately does not have a simple answer. While clinics can quote their overall success rates - such as 40% per cycle; or a take home baby rate of 35% per cycle, for example, these numbers mean very little to the individual patient.

The number needs to be individualised for each couple because it depends upon a number of variables - the most important of which are the woman's age and her ovarian reserve.

Even more importantly, the fact is that 40% means nothing to the individual patient. For an individual, the rate is either 0% or 100% !

Going one step further, suppose the number the doctor quotes is 5% or 20 % ? The question you need to ask yourself is - " Will I still go ahead, because any chance is better than the zero chance I have in my own bedroom on my own ?"

If the answer is yes, then there's really no point in asking the question, as it will not affect your decision !

Why IVF is a lot like gambling

Everyone knows that the outcome of an IVF cycle is often a matter of chance. In this respect, going in for an IVF cycle is very similar to gambling. Let me explain.

Firstly , whether to go in for an IVF treatment cycle , like deciding whether or not to bet at roulette is a decision which is electively made, by choice – it’s never compulsory ; and many couples may prefer to select childfree living or adoption, rather than pursue an IVF cycle.

Secondly, the outcome of both is always uncertain. Just like you can increase the odds of winning the roulette by buying more tickets, you can increase your chances of IVF success by doing more IVF cycles; or transferring more embryos. If you are lucky, you can hit the jackpot after buying just one ticket – but if you aren’t, then even buying lots of tickets may not help !

Thirdly, smart patients, like smart gamblers, know what to do to maximize their chances of winning. Thus, a good poker player will work hard at learning the game and practicing it, so he becomes good at playing it. Similarly, smart infertile couples understand that doing their homework can help them to select the best clinic and opt for the treatment which is right for them.

Finally, the luck element plays a big role in both winning a lottery and in getting pregnant with IVF. Fortunately, the odds of getting pregnant are far higher – but it can still be a crap shoot.



In our clinic, we offer a very useful option to help patients improve their chances of winning considerably ! This is the guaranteed pregnancy option, which helps patients to maximise their chances of success, while reducing their financial burden .

Friday, September 11, 2009

The difference between health and healthcare

Everyone seems to be debating what the US can do to reform healthcare because it's become too expensive and unwieldy. I think we need to define our terms clearly.

What all of us want is to remain healthy. However, we do not need doctors to do so. We all know the simple things we need to do to keep our health - such as eat right, sleep well, and exercise. Doctors add very little value to remaining healthy - and most of us we don't see our doctors when we are healthy !

We need doctors to take care of us when we fall ill - and this is exactly as it should be. Doctors provide illness care ; and help us to fight our illness and become healthy again. However, because illness care has a negative flavour, the medical profession has put a spin on what they do, and believe they belong to the healthcare industry.

While we are all worried about the overspending on healthcare; and understand the need to make sure medical care is provided sensibly to prevent wastage, the problem is that when we ( or one of our loved ones) fall ill ourselves , we want the doctor to do everything possible for our personal illness care - the money be damned.

It is this dichotomy between what we feel we deserve personally; and what society should do for the rest of the unwashed masses, which is what causes the tension and polarised views in this debate.

Wednesday, September 09, 2009

How many IUI cycles should I do ?

I always cringe when I see infertile women who have had more than 4 intrauterine insemination ( IUI ) treatment cycles. This is way too many - and while there maybe no medical downside to doing so many IUI cycles, when patients have done so many IUI cycles, they are usually fed up and frustrated. They have lost confidence in themselves - and their doctor, which means that they are often not willing to consider more effective treatment options, such as IVF.

Medical studies have confirmed that most women who are going to get pregnant after IUI will do so within 3 treatment cycles. If 3 cycles have failed, they have reached the point of diminishing returns, and need to move on with more effective options, such as IVF.

However, why do so many doctors ( and patients) do so many IUI cycles ?

The primary reason is financial. IVF is much more expensive than IVF, so patients often cannot afford to doIVF. While this is a very valid reason , it also does not justify doing the wrong treatment, just because it is cheap. It's better to not do anything at all ! False hope can be very depressing and stressful.

Another reason is that most IUIs are performed by gynecologists, who would rather "hang on" to their patients, rather than refer them to IVF specialists for IVF treatment. This wastes a lot of valuable time and money ( the patient's) .

The final reason is the fact that patients ( and their doctors) often fail to formulate a treatment plan - or to eve think about what to do if the IUI cycle fails. Treatment is always on an ad hoc basis - let's do one more, and see what happens. Not preparing for failure is sometimes the surest way of ensuring you will fail !

How American Health Care Killed My Father - The Atlantic (September 2009)

How American Health Care Killed My Father - The Atlantic (September 2009): "Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

I’m a businessman, and in no sense a health-care expert. But the persistence of bad industry practices—from long lines at the doctor’s office to ever-rising prices to astonishing numbers of preventable deaths—seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results—a reason my father and so many others are unnecessarily killed.

Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value."

Tuesday, September 08, 2009

Indian Healthcare going thru a paradigm shift

There is a need to develop a Healthcare-IT platform specifically for India. A platform that will include HIS+EMR+ERP and will be hosted, so that every clinician, administrator or manager can use it over the web. Software as a service [SaaS] model can become a reality now in India because internet bandwidth is becoming available everywhere through fixed lines, mobiles and DTH. The SaaS moel is economically viable because it converts the Capex into Opex. Also there is no entry or exit barrier.


I agree completely. Barriers to adoption of EMRs are coming down rapidly, so this space is ripe for a "disruptive innovation". The key question is - how many hospitals and doctors feel the need to use IT to improve healthcare processes ?

The three ages of modern womanhood: don't get pregnant, won't get pregnant... can't get pregnant…

Women in early adulthood are in control of their reproductive health, personal and working lives. But the concerns of today are beginning to focus not only on failed contraception/family planning but recognition that family planning to many women, really means anti-family planning leading to worrying delays in starting to have children.

All young women should read this post ! You need to pay a price for all decisions you take - and a woman's biological clock does not have an alarm on it, unfortunately.

The irony is that the introduction of modern contraception, which was hailed as a major advance for women because it allowed them to safely postpone childbearing, has become a major stimulus for the boom in the fertility industry 20 years later. This is a grim example of the law of unintended consequences in action.

Monday, September 07, 2009

Where are your medical notes ?

I often see patients who have had many IVF cycles in other centers, and the first thing I need to do is to review their medical records. Like many other doctors , one of the first questions I ask is - Where are your medical notes ?

At this point, patients will show me their medical treatment summary which their earlier doctor gave them - or complain that they don't have any information at all, because the "doctor did not give this to us" !

However, I don't just want to see a summary of the medical tests and treatments the patient has had so far. What I really want to review are the notes which the patient has prepared herself of her medical journey to date. While some doctors are very " possessive" of their medical records, and refuse to give these to their patients ( for reasons best known to them) , every patient can keep a simple summary of what they have done ( in chronological order), so it's easy for the new doctor to get a overall summary of what has been done so far.

I always feel there's no point in blaming a doctor who does not give you your medical records. However, by taking more interest in your treatment, and accepting responsibility for being your own primary caretaker and custodian of your medical records, you can always provide a meaningful story of your medical journey to your doctor !

As Clemenceau said, " War is too important to be left to the generals." Your medical records are too important to be left to your doctor !

Check out our new website

Malpani Infertility Clinic now has a new and updated website at
www.drmalpani.com !
Please do take a look and tell me what you think of it.

drmalpani.com offers comprehensive coverage on infertility - and we have much more content as compared to any other infertility website . I like to think we are world leaders in exploring new ways of trying to teach and educate infertile couples about their treatment options !

Sunday, September 06, 2009

Second Life Programmer wanted

I need a Second Life Programmer to set up a Virtual IVF clinic on Second Life which will allow users to learn about IVF by watching videos; and to interact with an IVF expert.

Am looking for someone who is experienced; and who will work independently

Intensive Care or Insensitive Care

Death with Dignity

Is swine flu vaccine worth it ?

The swine flu epidemic has created a huge scare, and some clever people are happy to capitalise on this ! Sales of masks and medications have shot up - and the next huge market is for vaccines. Lots of researchers and manufacturers are lining up to sell millions of dollars worth of vaccines to the Indian government . Health departments will most probably buy huge supplies because there's money to be made for everyone in these purchases - but this is likely to be money which is wasted.

After adjustment for other disease and frailty, vaccination reduced pneumonia rates by a nonsignificant 8% during the flu season and increased risk by 4% during season peaks, reported Michael L. Jackson, Ph.D., of the Group Health Center for Health Studies here, and colleagues in the Aug. 2 issue of The Lancet. These findings from a rigorously controlled case-control study of both inpatient and outpatient cases add to controversy over the true magnitude of the benefit from flu shots, the researchers said.


Saturday, September 05, 2009

Is it worth doing IVF again ?

One of the most frustrating problems in infertility today is IVF failure - also called implantation failure. This refers to infertile patients who have undergone an IVF cycle and produced beautiful embryos - but the embryos have failed to implant for unexplained reasons.

Many patients who fail an IVF cycle often give up. Not only are they disappointed, they are also upset about the fact that their doctor does not usually give them a clear explanation for why the IVF cycle failed - or what they can do differently the next time, to improve their chances of success. While some stop for financial reasons, others come to the conclusion that they are destined to never have a baby; and admit defeat prematurely.

It's important to remember that while the reason for the IVF failure maybe a biological problem which cannot be corrected ( for example, a thin uterine lining which is not receptive), it is equally true that the reason for the failure maybe a medical variable ( for example, the wrong superovulation protocol; or a poor quality laboratory), which can be fixed in the next attempt.

Our pregnancy rates in patients who have failed IVF cycles elsewhere is very high, because we can transfer more embryos in difficult patients ( unlike fertility clinics in UK and Australia, where the number of embryos which can be transferred is limited by law). While transferring more embryos does increase the risk of high-order multiple pregnancies, this risk is negligible in difficult patients ( for example, the older women or women with previous failed IVF cycles). In our fertility clinic, we customise the number of embryos we transfer for each patient we treat, rather than just blindly follow a guideline ( which has been laid down for the general population, without considering each individual's specific problem).

The other common reason for a failed IVF cycle is a poor ovarian response, which means patients get few eggs and few embryos. For these patients, we offer the option of aggressive superovulation, with high doses of HMG, in order to help them grow more eggs, so we have more embryos to transfer.

Sometimes the reason for IVF failure is because the embryo transfer was technically difficult, because of cervical stenosis. This means that the transfer is often traumatic, and is associated with bleeding. For these patients, if their fallopian tubes are open, we prefer doing a fallopian tube transfer ( ZIFT ( ZIFT Video ) , zygote intrafallopian transfer) so that we can bypass the cervix and place the embryos directly in the fallopian tubes. This ensures a very high pregnancy rate.

Another group of patients who often do poorly in other IVF clinics are those who have PCOD. Because many doctors are so worried about the danger of OHSS ( ovarian hyperstimulation) in these patients, they often end up superovulating these patients badly, and retrieve few poor quality eggs, compromising the pregnancy rate. In our fertility clinic, we prevent OHSS by carefully aspirating each and every follicle at the time of egg retrieval , and flushing it repeatedly with a double-lumen needle, until it collapses completely. By removing the follicular cells which are responsible for producing VEGF and causing OHSS, we have been able to prevent OHSS in PCOD patients very successfully in our fertiliy clinic by using this novel technique.

If the first IVF cycle fails, it's always a good idea to get a second opinion, so you know what your options are, and what you can differently, in case you decide to try again.

You can get a free second opinion at
www.drmalpani.com/malpaniform.htm !

Friday, September 04, 2009

HealthHiway gets $4 mn investment

HealthHiway gets $4 mn investment: "HealthHiway, an initiative by the Apollo Hospitals Group providing software solutions for the healthcare sector, has received an investment of $4 million from Silicon Valley-based venture capital firm Greylock Partners. The funds will be utilised by HealthHiway to enhance its technological capabilities and strengthen the service infrastructure for healthcare providers, said Ashvani Srivastava, CEO, HealthHiway.

HealthHiway was launched in 2007 by the Apollo Group in collaboration with IBM with a capital base of about Rs 5 crore. Investment by Greylock Partners is the first round of fund-infusion into HealthHiway. The company is looking for more such funds and strategic collaborations from technology players in the next three months, Srivastava told reporters here on Thursday.

HealthHiway’s software solutions provide service infrastructure for hospitals, practitioners, pharmacies and health insurance providers to facilitate better collaboration within the healthcare ecosystem and collate patient data on a unified platform. The solutions are built on software-as-a-service (SaaS) model. “The SaaS model allows the adoption of IT solutions previously not accessible due to complexity and high cost. We offer web-based, easy-to-use and easy-to-pay solutions. HealthHiway is the first in the country to bring in SaaS into hospital administration as well as clinical systems,” Srivastava added."

I am very pleased that VCs are now investing in health Information Technology in India . We need to leverage Indian IT skills so that we can improve healthcare delivery in India. This is a huge opportunity; and since there are no legacy issues, Indian doctors and hospitals can use cutting edge Web 2.0 solutions (
such as cloud computing ; user-generated content to create communities ; and software enable services) to deploy this technology inexpensively.

Wednesday, September 02, 2009

Swine Flu, 1976 - "The Epidemic That Never Was,"

________________________________________
1976: Fear of a great plague
By PAUL MICKLE / The Trentonian
On the cold afternoon of February 5, 1976, an Army recruit told his
drill instructor at Fort Dix that he felt tired and weak but not sick
enough to see military medics or skip a big training hike.

Within 24 hours, 19-year-old Pvt. David Lewis of Ashley Falls, Mass.,
was dead, killed by an influenza not seen since the plague of
1918-19, which took 500,000 American lives and 20 million worldwide.

Two weeks after the recruit's death, health officials disclosed to
America that something called "swine flu" had killed Lewis and
hospitalized four of his fellow soldiers at the Army base in Burlington County.

The ominous name of the flu alone was enough to touch off civilian
fear of an epidemic. And government doctors knew from tests hastily
conducted at Dix after Lewis' death that 500 soldiers had caught
swine flu without falling ill.

Any flu able to reach that many people so fast was capable of
becoming another worldwide plague, the doctors warned, raising these questions:

Does America mobilize for mass inoculations in time to have everybody
ready for the next flu season? Or should the country wait to see if
the new virus would, as they often do, get stronger to hit harder in
the second year?

Thus was born what would become known to some medical historians as a
fiasco and to others as perhaps the finest hour of America's public
health bureaucracy.

Only young Lewis died from the swine flu itself in 1976. But as the
critics are quick to point out, hundreds of Americans were killed or
seriously injured by the inoculation the government gave them to
stave off the virus.

According to his sister-in-law, John Kent of President Avenue in
Lawrence went to his grave in 1997 believing the shot from the
government had killed his first wife, Mary, long before her time.

Among other critics are Arthur M. Silverstein, whose book, "Pure
Politics and Impure Science," suggests President Gerald Ford's desire
to win the office on his own, as well as the influence of America's
big drug manufacturers, figured into the decision to immunize all 220
million Americans.

Still, even the partisan who first branded Ford's program a fiasco,
says now that it happened because America's public health
establishment identified what easily could have been a new plague and
mobilized to beat it amazingly well.

To understand the fear of the time you have to know something about
the plague American soldiers seemed to bring home with them after
fighting in Europe during World War I.

The Great Plague, as it came to be called, rivaled the horrid Black
Death of medieval times in its ability to strike suddenly and take
lives swiftly. In addition to the half million in America, it killed
20 million people around the world.

It got its name because it was a brand of flu usually found in
domestic pigs and wild swine. It was long thought to have come, like
so many flus, out of the Chinese farm country, where people and
domestic pigs live closely together.

Recent research has shown, however, that the post-WWI flu was brought
to Europe by American troops who had been based in the South before
they went to war. Medical detectives, still working on the case in
the 1990s, determined that a small group of our soldiers took swine
flu to Europe and that it spread to the world from there.

How the swine flu got to Fort Dix in 1976 still hasn't been tracked
down. At the time, Dix military doctors knew only that a killer flu
had made it to the base and that they were lucky more men hadn't died
or been sickened seriously.

Weeks after Lewis died, doctors from the Centers for Disease Control
and other federal public health officials were meeting in Washington,
trying to decide if they should recommend the government start a
costly program of mass inoculations.



One doc later told the authors of "The Epidemic that Never Was" that
he and others in on the meetings realized there was "nothing in this
for the CDC except trouble," especially because a decision had to be
made fast to get the immunizations manufactured by the fall.

"...The obvious thing to do was immunize everybody," the doctor said.
"But if we tried to do that ... we might have to interrupt a hell of
a lot of work on other diseases."

The doctors knew they faced complaints if the epidemic broke out and
vaccines weren't ready, as well as criticism if they spent millions
inoculating people for a plague that didn't happen.

"As for 'another 1918,' 1 didn't expect that," the doctor continued
in the book. "But who could be sure? It would wreck us. Yet, if there
weren't a pandemic, we'd be charged with wasting public money, crying
wolf and causing all the inconvenience for nothing ... It was a
no-win situation."

By mid-March, CDC Director Dr. David J. Sencer had lined up most of
the medical establishment behind his plan to call on Ford to support
a $135 million program of mass inoculation.

On March 24, one day after a surprise loss to Ronald Reagan in the
North Carolina Republican presidential primary, Ford decided to make
the announcement to the American public.

Congress still had to appropriate the money, of course, and that
wasn't going to be easy. Even before official congressional
consideration of the plan was taken up, there were forces arguing against it.

Another big hurdle was the drug makers, who were insisting the
government take liability for any harmful side effects from the
vaccine. During congressional hearings in the spring and early
summer, lawmakers heard some naysayers who noted that the swine flu
of last winter never got beyond Dix and that only one death had been reported.

The president and his experts prevailed, however, and on Aug. 12
Congress put up the money to get the job done. The mighty task was
put into the hands of a charismatic 33-year-old physician for the
Department of Health, Education and Welfare, Dr. W. Delano
Meriwether, a world-class sprinter who still competed in track meets.

Now he was in a race for life, or so he thought. Meriwether was given
until the end of the year to get all 220 million Americans inoculated
against swine flu.

By Oct. 1, the makers had the serums ready and America's public
health bureaucracy had lined up thousands of doctors, nurses and
paramedics to give out the shots at medical centers, schools and
firehouses across the nation.

Jim Florio, then an ambitious rookie Democratic congressman
supporting Jimmy Carter for president, didn't use the situation to
take a shot at Ford. He lined up and was the first Jersey resident to
take the inoculation.

Within days, however, several people who had taken the shot fell
seriously ill. On Oct. 12, three elderly people in the Pittsburgh
area suffered heart attacks and died within hours of getting the
shot, which led to suspension of the program in Pennsylvania.

Jersey pressed on with inoculations, however. Through the fall, even
as more bad reports about the side effects of the vaccine came out,
thousands of mostly older people in Greater Trenton lined up outside
health centers, schools and firehouses to get the shot, sometimes
waiting for an hour.

One of them was Lawrence's Mary Kent, a 45-year-old mother of two
teenage boys who couldn't tie the ribbons on Christmas presents only
days after she got her shot at the Trenton War Memorial in early December.

On Dec. 16, increasingly concerned about reports of the vaccine
touching off neurological problems, especially rare Guillain-Barre
syndrome, the government suspended the program, having inoculated 40
million people for a flu that never came.

By year's end, Jack Kent knew his wife was seriously ill and started
reading all about the side effects of the president's flu
inoculation, especially nerve problems like those his wife was experiencing.

Even before Mary Kent died an invalid at age 51 in January 1982, Kent
had joined the hundreds of Americans who filed suit against the
government on behalf of children left without a parent due to fatal
side effects from the swine flu vaccine.

Kent's sister-in-law, also named Mary Kent, recalled the other day
that Jack Kent died in 1997 still angrily blaming the government for
giving his wife Guillian-Barre, leading to her death.

The swine flu case of 1976 forever reduced confidence in public
health pronouncements from the government and helped foster cynicism
about federal policy makers that continues to this day.

Citing the swine flu fiasco, for instance, one scholar recently
authored a report suggesting the threat of AIDS has been similarly overblown.

Yet Joseph Califano, one of the earliest to use the word "fiasco" in
describing the swine flu affair, came to the conclusion that it all
couldn't have been avoided. Califano, whom President Carter appointed
Secretary of Health, Education and Welfare after beating Ford in the
November election, said the doctors had no choice but to err on the
side of the caution.

In "The Epidemic That Never Was," Califano said that faced with the
threat of another killer plague with the potential to end millions of
lives, the doctors were right to seek an inoculation program

--------------------------------------------------------------------

It's amazing how little we seem to learn. Doctors seem to have a short memory - and we seem to be over-reacting to swine flu in India in 2009, just like the US did in
1976 ! Will we end up making the same mistakes and wasting a lot of time, money and energy ?

Baby Chase - Chapter 7 in the story of how a couple completed their family !

How to cut your healthcare costs

Here are some great tips from Dr. Erika Schwartz, Medical Director of Cinergy Health.

O M E N S – Five Simple Steps
1. Observe Preventative Measures
2. Manage Your Prescriptions
3. Educate Yourself
4. Negotiate Doctor’s fees
5. Scrutinize Medical Bills
• Observe Preventative Measures: Simply stated, take care of your body and mind. Eat a healthy diet, take daily nutritional supplements, choose the stairs instead of the elevator, and stay away from junk foods, alcohol and smoking. You’ll see the doctor a lot less and feel much better. It’s your life after all, so be in control of it.
o Listen to Your Doctor’s Advice: Make sure your doctor does more than just diagnose illness and prescribe medication. And assuming he/she is helping you maintain a healthy diet, exercise regimen and overall healthy lifestyle, follow the advice (but also use the internet to get a second or third opinion as necessary), and you will have more money to spend on things you enjoy.

• Manage Your Prescriptions: Prescription medications are very costly. Be sure to ask you prescribing physician or pharmacist for the equivalent, generic brand of the medication they are ordering. If a generic comparable medication is not available ask your physician if they can find a substitute from your insurance plan’s preferred drug list.

• Educate Yourself: The internet is a web of knowledge. Do your own investigating before running to the doctor’s office every time you have the sniffles. When you go to the doctor make sure you bring the information with you and ask questions. Make sure the doctor gives you acceptable answers.

• Negotiate Doctor’s Fees: Never assume the first price is set in stone.
Call your insurance company and ask for the rates they pay their doctors for the specific procedure you need (hint: it is usually lower than the price the doctor charges the patient). Approach your doctor with this information and ask them to lower their price. You may be surprised at their willingness to negotiate. If the doctor is unwilling to negotiate their fee, find another doctor who will. The same strategy applies when you are seeing an out of network doctor or seeing a doctor while uninsured.

• Scrutinize Your Medical Bills: Don’t presuppose that hospital and medical office accounting departments always pay close attention to the bills they send. Be sure to double check everything you receive and if there are any discrepancies, contact the hospital or medical offices to clear up the bill, then send the information to your insurance company promptly.
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