Saturday, July 31, 2010

Should you consider doing IVF ?


IVF, or In Vitro Fertilization (also known as a test tube baby) is a medical treatment that fertilizes the egg cells by the sperm outside the uterus. IVF is currently the most successful treatment option for infertility .

IVF is usually used after other simpler treatments have been unsuccessful. The process requires the woman to begin hormone therapy for superovulation, to help in the production of multiple eggs. These eggs are then removed from the woman’s ovaries , and are combined with sperm in the IVF lab, where the fertilization process occurs. Once the eggs are fertilized, the resulting embryo is transferred to the woman’s uterus , and if it implants, then a pregnancy is established.

When IVF is used for treating male infertility (caused by sperm which are defective and are unable to fertilise the egg, a variant of IVF called intracytoplasmic sperm injection (ICSI) is used. ICSI is the process in which the sperm is inserted directly into the egg cell using a micromanipulator, allowing the sperm to fertilise the egg.

Healthy eggs; sperm ; and a normal uterus are the three key elements that must be present for a successful In Vitro Fertilization. In the past few years, pregnancy rates have greatly improved as a result of IVF treatment; and in good clinics, they are as high as 46% pr cycle. The key is to find a reliable clinic which has a high success rate ; and a dedicated and experienced IVF team.

Want to find out if IVF can help you to have a baby ? Ask for a free second opinion from Dr Malpani, a leading IVF expert, at www.drmalpani.com/malpaniform.htm .Taking treatment at a world-class clinic will maximize your chances of success and give you peace of mind you did your best !

Friday, July 30, 2010

The Best Way to Get a Second Opinion


Trust, but verify – This was undoubtedly one of the best pieces of advice I have ever received; and when it comes to your health, it’s absolutely imperative that you follow it. I don’t mean to imply that your doctor is incapable or inefficient, but when it comes to major medical issues, it’s always advisable to get a second opinion. This way, you not only prevent irreparable medical errors, you also gain peace of mind in knowing you made the right choice after taking into consideration all the factors at hand.

While most people know that a second opinion is important, they don’t know how to go about getting one. The most difficult part of this decision is finding a doctor or healthcare professional they can trust. Also, if both doctors provide contrasting opinions, how do they know whom to believe without going in for a third opinion? The answer to this differs from patient to patient – it varies according to various factors like cost, time, urgency, effort, opinions of friends and family, and others.

In general, a second opinion is desirable and even necessary when the diagnosis is complicated and not easy, when the surgical or medical procedure recommended by your doctor is risky and could have permanent or devastating consequences, when you don’t believe your primary doctor’s opinion or when you think you may have a condition that they have not diagnosed, when you believe that there are alternatives to your doctor’s suggested course of treatment that are less invasive, less painful, and equally effective, when your primary doctor is not a specialist in the disease you suffer from and other physicians are more qualified to offer opinions, or when you’re just confused and don’t know what to do.

Diagnoses of cancer, heart disease and the recommendation of a bypass or other kind of surgery, amputation of a limb, hysterectomy, termination of pregnancy for a fetal anomaly or danger to the mother’s health, removal of brain and other malignant tumors, and other such major life-affecting decisions are better taken with a second and even third opinion.
If you’re ready for a second opinion and want to get one, ask your doctor (if he or she is not going to be offended) or someone you trust to recommend a suitable specialist or healthcare facility.

Check with your insurance provider if your second opinion is covered in your policy or if you will incur an additional cost. If the second opinion varies significantly from the first, get a third and even fourth opinion to be sure, especially in the case of life-threatening or life-changing diseases and conditions. When you’ve decided on the course of treatment that you think is right for you, get your primary doctor to transfer your medical history and records to your new healthcare provider.

And finally, a word of advice; before you seek a second opinion, read up about your condition or disease through books and other sources that are validated and reputable. Don’t believe random Internet sites that are not authenticated or written by a specialist. This knowledge is just for information purposes alone, not something that you base your final decision on. Leave that to your doctor as he or she knows best when it comes to treatment and management of disease.

This article is contributed by Susan White, who regularly writes on the subject of surgical technician schools. She invites your questions, comments at her email address: susan.white33@gmail.com.

ZIFT and tubal transfer - even more options !

Tuesday, July 27, 2010

World's first IVF and infertility SMS channel !


Malpani Infertility Clinic, in partnership with MyToday, is pleased to announce that we have now started publishing the world's first patient education channels on IVF and infertility.

The mobile is a great tool for educating patients - and using SMS we hope to be able to remove a lot of the myths and misconceptions which surround this emotionally sensitive topic !

You can see all our SMS Infertility Channels here.

You can also subscribe free to our IVF channel here !

At present, this service is available in India only.
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Monday, July 26, 2010

Why do doctors bad mouth other doctors ?


Many patients find that the doctor you go to for a second opinion will often be very critical of the first doctor. When a new doctor criticises what the old one did, patients feel frustrated, because they feel it reflects badly on their choice of a doctor.

Why are doctors so happy to criticise their colleagues and peers at the drop of a hat ?

Some of this is simply a power game. Doctors do their best to try to look good for their patients, and by demonstrating the errors and shortcomings of the earlier doctors, they are emphasising how much good they are ! The hidden subtext is - You made the right decision when you came to me - I am the best !

Some of this is simple oneupmanship. Doctors are highly competitive and proud of their intellectual prowess and surgical skills. They take delight in highlighting the shortcomings of their peers, because this reinforces their belief that they are the best ! Medical students have always been competitive, and this immature streak persists , no matter how much they age !

Some doctors will do this as a subtle form of marketing, to cater to the patient's desire. When patients come for a second opinion, they want something new, something different ! Smart doctors are happy to comply , because this tactic offers their patients with new hope, and helps them to justify their consultation fees !

Thus, some doctors will order additional tests ( and the more expensive these are the better ! The really smart ones will say that the tests have to be sent abroad to a highly specialised lab , adding to their aura of omniscience ! ). Others will change the prescription ( often writing exactly the same drug, but with a different brand name , so it costs a lot more, or has to be "imported" !)

Unfortunately, this kind of critical approach has a backlash. For one, patients start believing that doctors are incompetent , and cannot be trusted. This will lead to more lawsuits in the future.
Even worse, remember your friend will return the favour when he gets a chance to do so !

Few doctors have the maturity to say - Yes, your doctor has done a good job and you are on the right track. Please go back to him !
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Saturday, July 24, 2010

Blocked fallopian tubes and infertility

Blocked fallopian tubes are one of the commonest causes of infertility. The fallopian tubes project out from each side of the body of the uterus and form the passages through which the egg is conducted from the ovary into the uterus. The fallopian tubes are about 10 cms long and the outer end of each tube is funnel shaped, ending in long fringes called fimbriae. The fimbriae catch the mature egg and channel it down into the fallopian tube when released by the ovary .

The tube itself is a muscular highly movable structure capable of highly coordinated movement. The egg and sperm meet in the outer half of the fallopian tube, called the ampulla. Fertilization occurs here, after which the embryo continues down the tube toward the uterus. The uterine end of the tube, called the isthmus, acts like a sphincter, and prevents the embryo from being released into the uterus until just the right time for implantation, which is about 4 to 7 days after ovulation.The fallopian tube enters the uterus at its cornual end.

The tube is much more complex than a simple pipe, and the lining of the tube is folded and lined with microscopic hair like projections called cilia which push the egg and embryo along the tube. The tubal lining also produces a fluid that nourishes the egg and embryo during their journey in the tube.


Fig 1. Normal tube and ovary, as seen during laparoscopy

Remember that a doctor cannot judge if your fallopian tubes are open or closed either by an internal examination; or a vaginal ultrasound scan. Unfortunately, this is a very common mistake many patients make, and they assume that if the scan is normal, this means their tubes are open. This is not true. Sadly, many doctors also make the assumption that the fallopian tubes are open, without bothering to test them. Thus, some doctors will assume that a young woman with polycystic ovarian disease must have open tubes, and they start treating her with clomid, without bothering to test the tubal status. This can sometimes be a very expensive mistake ! Just because you have had no symptoms of a pelvic infection does not mean that your tubes cannot get blocked; and if the tubes are blocked, this means the eggs and sperm cannot meet, no matter what medicines you take. This is why it is essential that you ask the doctor to formally test your tubal status before starting any treatment.

The only reliable ways of testing if your tubes are open or closed is by doing either a HSG or a laparoscopy. Personally, I prefer a HSG, because it is much less expensive and provides hard copy documentation.

If a tubal block is found, then what are the next steps ?

The first question is - Are both the tubes blocked ? If only one tube is blocked, then there is no need to take any action at all ! One normal tube is enough for normal fertility. If one tube is open and your doctor advises you to have surgery to open the other tube, please do not agree !

The next question is - Where is the block ? The block could be at the terminal ( fimbrial) end of the fallopian tube. This often causes the tube to get swollen with fluid, and form a hydrosalpinx. In the past, doctors would perform tubal surgery to open this kind of blocked tubes. However, the results were very poor. The tube would usually close down again; or would never function properly, because its inner lining was damaged - damage which cannot be repaired by surgery. Some of these patients would then go on to have tubal ( ectopic) pregnancies.

If the tube is blocked at the cornual end, it's sometimes possible to repair these tubes. Sometimes the block is not a real block, but just an apparent block because of tubal spasm . Sometimes the block is because of a mucus plug or debris, and this can sometimes be cleared with the help of FTR ( fluoroscopic tubal recanalisation). This is a bit like doing an " angioplasty " for the fallopian tube ! ?

Remember that it's impossible for a doctor to judge tubal function. While we know that a blocked tube will not work, it does not follow that an open tube ( which may look perfectly normal anatomically on the HSG or the laparoscopy) is in fact capable of functioning normally ! Sometimes the doctor says the spill of dye is "sluggish"; or that "the tubes filled slowly"; or that they have a beaded appearance. These are just descriptive terms, and often cause more confusion rather than clarity !

Finding out your tubes are blocked can be quite a blow. Because tubal disease is often silent, there is no way of suspecting tubal blockade prior to doing the tests. Blocked tubes will not affect your menstrual cycle, your health or your sexual life, but they will prevent you from having a baby !

While the results of tubal surgery to repair blocked tubes is poor, the good news is that it is possible to offer very effective treatment for this problem today, thanks to IVF, which allows us to bypass the problem completely ! In IVF, the test tube in the IVF lab performs the role the fallopian tube would normally perform in the bedroom !

If you have a hydrosalpinx , some doctors will want to surgically remove this prior to performing IVF. I do not think this is a good idea at all !
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Friday, July 23, 2010

Treating endometriosis in an infertile woman


I saw a patient who was at her wit's end. She had already had two laparoscopies for treating endometriosis. Since she was still not pregnant, she had gone to a third gynecologist. He did an ultrasound scan and found that the chocolate cyst had recurred; and was advising her to undergo a third surgery to "fix" the problem.

We find this is a very common tragedy which plays out frequently. The diagnosis of endometriosis is often done by the first doctor, while doing a diagnostic laparoscopy. He "treats" the problem by burning off the lesions, and dividing the adhesions. When the woman does not get pregnant after this, she gets a second opinion from an expert. This expert often pooh-poohs the surgical skills of the first doctor, and suggests that he needs to do another laparoscopy, in order to do a better job, to fix the problem once and for all ! The patient regrets having allowed the first doctor ( who appears to have not been very competent in hindsight !) to do the laparoscopy. She signs up for the second surgery and is now very hopeful. The doctor does the laparoscopy and "cleans" up everything - and shows her a beautiful video which demonstrates his surgical prowess. He then puts her on medications, and then tells her to "go forth and have babies " in her bedroom ! She is often quite happy for a few months, because her pain has now improved, and her symptoms are much better. However, when she still does not get pregnant, she goes back to him. Unfortunately, he has lost interest in her problem, because he is primarily a surgeon, and when you have a hammer, all you see are nails. He gives her some more medicines, and tells her to relax, go for a holiday and have more sex. When this also fails, she goes to a third doctor, who then finds the endometriosis has recurred; and suggests that he needs to do another laparoscopy, where he will compensate for the surgical shortcomings of the earlier surgeon, by using the " newest and latest " third generation laser and robotic equipment, which are available only in his clinic !

The sad truth is that endometriosis recurs, no matter how good the surgeon. We can never cure it - and even our treatment leaves a lot to be desired, because of our limitations ! This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Let's go back to my patient.

" What do I do now , doctor ? I am completely fed up ! How do I manage my pain ? And what about having a baby ? "

I explained to her that she needed to set her priorities. " Which is more important right now ? managing the pain ? or having a baby ? We can't do both together - we need to do this one step at a time !"

" For me, having a baby is my first priority doctor".

" Fine, then let's focus on getting you pregnant. Let's forget about the pain and the endometriosis for now . The reason you are not getting pregnant is because your eggs and sperm are not meeting in your fallopian tubes. We need to get the eggs and sperm to do so; and we need to use assisted reproductive technology in order to do this."

The next step is to check the AMH level, to determine what the ovarian function . For young patients with a normal AMH level, the next step would be 3 cycles of superovulation with IUI. However, for older women; those with low AMH levels; and if the IUI fails, then the best course of action is IVF. After all, we need to find solutions , not waste time looking for problems !

Is there any need to surgically remove the endometriosis prior to doing IVF ? No ! The endometriosis is outside the uterus and will not affect embryo implantation, so it's best left alone.
If there is a chocolate cyst, we can always aspirate ( puncture) it under ultrasound guidance, when starting the IVF cycle.

The good news is that an additional bonus with this approach is that once you get pregnant, the endometriosis will also automatically improve !

Thursday, July 22, 2010

Why infertile couples need to look for solutions - and not worry about problems !!


Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! The quality of a doctor’s answers depend upon the quality of the patient’s questions !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !
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Wednesday, July 21, 2010

Google books and social media

Google books is a great concept and I love the idea that the content of these books is available for anyone to browse.

A simple way to add value to Google books would be to allow users to highlight selected portions of the text; and then annotate them and share them with others. This would make the book come "alive" and would add much more value to the online book.

An e-book can be far more than just a digital version on a print book and allowing readers to
" mark up " books and discuss them will create much more traffic on the site ( which I am sure google will be happy to monetise !) and add more value for both authors and readers.

Tuesday, July 20, 2010

Buyer communities on Ebay

KLEINMACHNOW - DECEMBER 17:  A sign for Intern...Image by Getty Images via @daylife

I buy lots of stuff on ebay. I like the convenience they offer and find their prices are very competitive. I can judge the reliability of the seller thanks to the fact that ebay allows buyers to rate sellers. However , I wonder why ebay does not allow users to comment and provide feedback about the products they buy, like amazon does.

This would be a very useful service to prospective buyers, because I could learn a lot more about the product ( and alternative options) at the "point of purchase" !


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Friday, July 16, 2010

Embryo Transfer - the graphic guide

How old is too old to have a baby ?


Right now the world record for the oldest mother has been set in India and the oldest woman who has given birth is 73 ! At an age when most women have become great-grandmothers, is it sensible for a woman to want to have a child ?

Let’s explore this in more detail. Let’s suppose we decide , like some countries have done, that the age cut-off should be 45 and that women who are more than 45 should not be allowed to have IVF treatment, because they are “too old”. Then what happens if a 46 year old woman who is otherwise very healthy wants to have a baby ? Is it fair to say no to her just because she is one year past the cut off age ? Why ?

It’s quite likely that older women are going to make very good mothers. They are mature – and have spent a lot of time and energy in making this decision, which means they are likely to be thoughtful and caring parents ! While they may not have as much physical energy, they are likely to have many more financial resources ! And they are much more likely to make better parents than 14 year old unmarried girls ( who society allows to have babies , just because they are capable of doing so biologically and do not need our permission to do so !).

I agree this does raise a number of ethical issues ! Are IVF doctors being irresponsible ( in order to earn more money ) by agreeing to such requests ? Is it fair for the child ( who is likely to become an orphan at a young age, because his mother is likely to die in a few years) ? Should society lay down guidelines ( like it does for adoption ) ? Or is it a decision which the woman should make for herself ? Are we being ageist by not allowing older women to use this technique, just because we think it is “unnatural” ? Isn’t it sexist as well ? When a 70 year old man gets a 20 year old woman pregnant, society applauds his virility and manhood ! Why shouldn’t we be happy to encourage older women who want to have kids as well ? After all, this is their personal decision, and we should be happy to honour their autonomy. They are not harming anyone and if they are well off enough to afford IVF treatment with their own funds, presumably they are well off to be able to provide for the child’s well-being, even after their death. Maybe in an Indian joint family, the child will be well-cared for, whether the birthing mother is infirm or not ? One option would be to make independent counseling mandatory for older women, before they go in for donor egg or donor embryo IVF , so we can help them to make the right decision.

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Thursday, July 15, 2010

Physician-Patient E-mail Improves Quality, Study Finds

Physician-Patient E-mail Improves Quality, Study Finds. " Some doctors have been reluctant to communicate with patients via e–mail, in part because of reimbursement and medical liability concerns. But a new study in Health Affairs provides a compelling case for opening up the inbox to patients: It may improve the quality of care.

Researchers at Kaiser Permanente followed 35,423 patients with diabetes, hypertension, or both, over a two–month period. Those that used e–mail to communicate with their doctors saw a statistically significant improvement in measures from the Healthcare Effectiveness Data and Information Set, a group of performance measures used by the managed care industry. "

This is exactly what you'd expect. Patients need to be able to talk to their doctors - and email is cheap, quick, efficient and effective . Even better, it allows everything to be documented, so there's no scope for confusion or misunderstanding !

Patience With Patients


There is a reason doctors and nurses are called "caregivers" and it's been proven time and time again that when putting patients in a caring, positive environment, healing time is decreased significantly as opposed to a sterile, strict atmosphere where doctors and nurses exude arrogance and are insulted when questioned.


Family Matters

Last year, as I sat in the hospital with my mom who was very sick with cancer and couldn't take care of herself, for the sixteenth time waiting to see which type of nurse and doctor we were going to get: Jekyll or Hyde, I realized how nervous I had become when it came to who was going to really take care of the most beloved person in my life. I wanted the best for this wonderful person and knew she deserved the best, but I had become extremely defensive each time we went to the hospital due to the spectrum of health care personalities we had experienced. Not wanting to over step my boundaries with a dozen questions about why and what the staff would do to help my sick mother, but I struggled with the fact that she needed treatment physically, but also emotionally and when we were blessed with a friendly nurse and doctor that went a little out of their way to show that they cared, we held onto them with both hands as they led our terrified family in what we trusted was the right direction.


Life and Death

I've heard several horror stories about arrogant doctors who got a little too cocky and make mistakes that could have killed their patient due to their overconfidence. These types of mistakes happen more frequently than most people realize but are overlooked or covered up. So question your doctor or nurse, don't be afraid to stand up for your rights as patients, after all, it's your body and if you are uncomfortable, find someone else. It's hard enough to go through a painful time or watch someone who is sick and needs help, but trusting your care giver and feeling confident that they are also looking out for the one you care about or your best interest is imperative in the healing process both physically and mentally.


This is a guest post from Alexis Bonari , who is a freelance writer and blog junkie. She is currently a resident blogger at onlinedegrees.org, researching areas of online universities. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.
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Wednesday, July 14, 2010

How technology helps doctors save time!


This is a guest post from Aditya Patkar, Marketing Director, Plus91.

Doctors need to incorporate technology in their daily life to increase their efficiency. Let’s look at how Dr. Thakkar can use everyday easily available off-the-shelf inexpensive technology intelligently, to help him become more productive. .

1. A website and and Email Id
2. A smart Mobile Phone
3. A pen drive
4. A laptop or PC with Internet
5. An EMR solution

1. Website and Email Id:

a. Dr Thakkar’s contact Information with a google map is readily available , so that his staff does not have to waste time giving directions to patients as to how to reach the clinic !

b. Important patient information captured on the website: Dr. Thakkar likes each patient to fill in a comprehensive form before he sees them. In the past, patients would have to fill the form in the clinic, and this caused long lines of upset patients clogging his clinic. . Now he can ask his patients to fill this form online , and it comes to him as an email which he can read just before the patient comes in. This saves both his patients and him time, and allows him to see more
patients !

c. Patients from all across the world can now easily email their queries to Dr. Thakkar. This can help him to provide services remotely to his patients, improving his service levels and connectivity with his patients, and allowing him to attract patients from all over the world !

d. Dr. Thakkar does procedures where he needs to give instructions to his patients for pre-procedure preparation and postoperative precautions . Often patients forget the details, and keep calling him when he is busy in his clinic. These interruptions upset his workflow and concentration. Now he can re-direct them to his website , where all the instructions are written down in great detail , in multiple languages!

2. Mobile Phone:

a. Dr. Thakkar can now check his daily schedule on a mobile phone. The latest smart phones come with many calendar features and schedulers with alarms. Also by using Google Calendar or innovative EMR solutions , he can get reminder SMSs on the phone for appointments and operations.

b. Dr. Thakkar can access his Email on his GPRS enabled phone , which can let him see the latest blood report of his patient and take decisions quickly.

c. The latest phones also come with high quality cameras, so that he can now store X-Rays and reports as images at the click of a phone button.The latest EMR solutions now allow you to directly attach these images to the patient’s records also!

d. The phone also comes with GPS navigation systems. Dr. Thakkar can get where he wants to go quickly and safely, especially if he is doing a house visit .

3. Pen Drive: A pen drive is a small and low volume file storage system.

a. Dr. Thakkar can carry all his patient reports and word documents in his pen drive, which means he no longer needs to lug a brief case around to all the hospitals.

b. Dr. Thakkar can plug his pen drive into any PC and access his notes and presentation on the
go. This saves him time , as he does not need to burn CDs , or search through many papers. The data all the drive is all well-organised neatly into folders.

4. Laptop or PC with Internet

a. Dr. Thakkar can optimize the use of all this technology by having his own PC or laptop. Now all his data can be soft copy, easily transferable, viewable, and most importantly , searchable with ease!

b. Dr. Thakkar can now access his emails and patient documents quickly and anywhere on his laptop.

c. Dr. Thakkar sometimes has queries on new medicines and procedures. Now he doesn’t need to wait to read a journal or attend a conference. He can simply go onto the internet and search MDConsult ( www.mdconsult.com), the world’s largest online medical library. Why wait when all the latest medical information is all at your fingertips ? This saves you time, impresses your patients – and ensures you are at the cutting edge of medical science !

d. Dr. Thakkar need not wait for hard copies of patient reports and test results. Now he can have the soft copy emailed to him so he can check them in his office or on his laptop on the move. This saves him time later – and his patients are grateful, because he does not need to make them wait for a diagnosis.

5. EMR solution: A software which helps him with his patients and clinic

a. An intelligent EMR such as KlinCare saves Dr. Thakkar time and improves accuracy in retrieval of patient records. He can also analysemedical statistics keep his accounts, check his inventory and even manage referrals .

b. He can email reports and send SMS reminders to patients directly from theEMR . Now Dr. Thakkar is always on time and so are his patients, so they do not waste time waiting.

c. Dr. Thakkar likes to send his patient’s case reports to the referring doctor. He can now instantly email the report to his colleagues – who are very impressed with his promptness, and are happy to refer more patients to him !

These are just some inputs on how technology can help doctors make better use of their time, so that clever doctors like Dr Thakkar have more time to spend with their family !

Can you afford to lag behind ?

To know more about how we help you save time and improve your productivity , please visit www.plus91.in. If you need hand-holding and guidance, Plus91 offers free seminars for doctors, to help you learn how to master this technology as well !

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Tuesday, July 13, 2010

How to fool IVF patients


Infertile patients are very vulnerable, and it's quite easy to fool them. Sadly, many IVF clinics will do so ruthlessly.

Here are some of the ways IVF clinics provide a sub-standard service to their patients.

1. They do not have the required training or expertise. It's shocking, but one of India's "leading" IVF clinics is run by a doctor who is a skin specialist ! ( Check out the resume and biodata of the doctor carefully - and ask to see his medical degree, if you do not want to be taken for a ride !)

2. They do not have the required staff members . Many IVF clinics do not have a full-time embryologist, which means the IVF lab is often poorly run and the equipment not quality controlled or tested on a regular basis.

3. They quote success rates which are inaccurate and inflated.

4. They do not share information with the patient during the cycle - or even afterwards. They just mouth platitudes, saying - everything is fine , without providing any details

5. They do not provide photos of embryos, which means there is no hard-copy documentation of what the end-result of the IVF treatment is !

Many patients have burned their fingers by selecting poor quality IVF clinics. The only way you can prevent this problem and protect yourself from being fooled is by asking questions on a proactive basis !


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Monday, July 12, 2010

Irregular cycles and infertility - is it PCOD or poor ovarian reserve ?

Medical Ultrasound Scanner By Daniel W. Rickey...Image via Wikipedia

Many infertile women have irregular cycles and they know that the reason for their infertility is related to their irregular cycles. However, many are quite confused as to the relationship. Some naively believe that if the cycles are regularised, their fertility will also automatically improve ! This is why they waste months taking birth control pills, without trying to address the underlying problem !

Today, we know that the commonest cause for irregular cycle is PCOD - polycystic ovarian disease. Unfortunately, many gynecologists blindly diagnose every patients with irregular cycles as having PCOD , without bothering to rule out other possibilities !

Let's look at some basics.

Women who ovulate regularly get regular periods. The reason a woman's periods are irregular is because she does not ovulate. This is called anovulation. While it is true that the commonest cause of anovulation is PCOD, it's equally true that this is not the only cause. A good doctor will do a careful workup to evaluate ovarian reserve, in order to determine what the reason for the anovulation is.

Thus, in some women the reason for the anovulation is poor ovarian reserve - a condition called the oopause. However, if this is mis-diagnosed as PCOD, precious time is wasted and the patient never gets a chance to get the right treatment !


If you have irregular cycles, please insist that your doctor do the following simple medical tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs).

2. A vaginal ultrasound scan on Day 3, which should check for the following.

a. ovarian volume
b. antral follicle count

Patients with PCOD typically have a high LH:FSH ratio; a high AMH level; large ovaries; and increased ovarian stroma with many small antral follicles.

Patients with poor ovarian reserve, on the other hand, have a high FSH:LH ratio; low AMH levels; small ovaries and a reduced antral follicle count.

If you are not sure how to interpret your reports, please send me your medical details by filling in the free second opinion form , and I'll be happy to help !



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Sunday, July 11, 2010

What tests should I do after a failed IVF cycle ?


There's lots of pressure on IVF doctors when an IVF cycle fails. Patients want a baby - and since they have not succeeded, they want answers as to why the cycle failed !

Doctors will take one of 3 approaches.

Many are nihilistic. They know that the tests we have today do not help much. Our technology is still fairly crude, because the commonest cause of failed implantation is genetically abnormal embryos, and we still cannot detect or prevent these, given the fact that human reproduction is a very inefficient enterprise. The best option for most patients is to just try again, and this is what they will advise.

Unfortunately, this straight-forward forthright approach is very difficult for most patients to accept . They want answers to their questions !

Unfortunately, the truth is that our technology is still not good enough to provide these answers.
After all, how can you track the fate of a microscopic ball of calls after they have been placed in the uterus ?

Some doctors are very aggressive. They will run lots of tests and often have pre-printed " panels of tests" for testing for everything under the sun - whether it's relevant or not ! Many of these tests are very expensive and can only be done in selected laboratories, which the doctor has a " special tie-up " with ! Most of these results are just lots of gobbledygook , and it's not possible to to make any sense of the results, because they have never been validated ! However, many patients are very happy with this approach. They feel the doctor has been " very thorough" - and now that a problem has been found, it can then be " fixed" , so they now have a better chance of having a successful IVF ( even though this is just a delusion !)

Some doctors are conservative. They will perform tests selectively, as needed, based on a careful analysis of the IVF cycle, and explain why these tests are needed; and what information they can provide, which can be used to modify the treatment plan for the next cycle.

Until patients learn to ask the right questions, they are unlikely to get the right answers !



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What 'Patient-Centered' Should Mean: Confessions Of An Extremist - Health Affairs

What 'Patient-Centered' Should Mean: Confessions Of An Extremist -- Health Affairs: "Three maxims. Others have struggled to find a proper definition of patient-centeredness. Three useful maxims that I have encountered are these: (1) 'The needs of the patient come first.'(2) 'Nothing about me without me.'(3) 'Every patient is the only patient.'

Unfortunately, most doctors learn to become patient-centric only after they ( or their loved ones) fall sick and are traumatised by the "healthcare system" !

What’s Making Us Sick Is an Epidemic of Diagnoses - New York Times

What’s Making Us Sick Is an Epidemic of Diagnoses - New York Times: " For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system. You might think this is because doctors make mistakes (we do make mistakes). But you can’t be a victim of medical error if you are not in the system. The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses. "

Overdoctoring, overdiagnosis and overtreatment are a major threat to your health !

Saturday, July 10, 2010

After a failed IVF cycle - what's next ?


I just got this email from a patient.

Doctor, I am now at my wit's end ! I have failed 4 IVF cycles at 2 different clinics. The doctor transferred 2 beautiful blastocysts each time ! What do I do next ? My doctor is advising surrogacy, since he believes my uterus is rejecting the embryos.

IVF failure is reproductive medicine's most frustrating problem ! When beautiful embryos fail to implant in a perfect cycle , it's often impossible to determine "what went wrong" ! A knee jerk reflex is to then consider surrogacy.

However, surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos , rather than a uterine problem.

Just because the embryo transferred was a perfect looking blastocyst does not mean that it was genetically normal ! We still do not have the technology as yet to determine if the embryos are genetically fine. Even though PGD technology is improving, it's still going to take time till it becomes an established part of routine clinical practise. And even if the new PGD technology
( using CGH, or comparative genomic hybridisation , for example) will allow us to check all the 23 pairs of chromosomes, it still only provides a crude check that the chromosomal number is normal - not that there are no genetic defects in the embryo !

Until we can routinely screen all embryos for genetic perfection, the best option is to follow Sutton's Law - to go for where the gold is. If you have failed 4 IVF cycles ( where the embryos looked perfect , the uterine lining was excellent and the transfer was easy), the odds that this is an embryo problem are far more than it being a uterine problem. This is why the chances of success with donor egg IVF or embryo adoption are much higher than with surrogacy.

Of course, most patients want to pass on their own genes to their children, which is why these alternative can be much more difficult options to consider, but they are much easier than surrogacy - and much less expensive as well !
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Friday, July 09, 2010

From medical practitioners to medical entrepreneurs


This is a guest post from my friend, Dr. Shalini Ratan, MD, Founder , Nirvan Life Sciences Pvt. Ltd. at http://nirvanlifesciences.blogspot.com/.

Health care today is unlike health care yesterday.

The healthcare market is growing by leaps and bounds. According to reliable sources, the market size for the private sector in healthcare has shot up from Rs 85,500 crore in 2006 to Rs 1, 48,050 crore now. This accounts for 80 per cent of the total market—the highest share in the world. About 15 hospital projects are slated to open this year. The number of doctors and nurses enrolled in medical colleges and nursing schools will have to triple over the next 10 years. An additional 520,000 students physicians will be required by 2012.

In this scenario there is enormous scope for clever medical professionals. However, with this demand come new challenges! Doctors need to learn new skills in order to keep their patients satisfied, because the modern breed of patients are evolving as consumers and demand much more attention from their doctor. At the same time one has to overcome the hurdles to achieve higher goals in practice. Doctors in private practice will need to develop themselves to compete with the corporate hospitals which have a marketing team for their service promotion, huge marketing budgets and well groomed medical practitioners. So at the end of the day, to provide complete healthcare experience to the patients the doctor has to play the role of a medical expert as well as a medical entrepreneur.

The role of a medical practitioner today is not only of a clinician and an academician, but also a manager and implementer for providing excellent medical services. And this requires a “Mindset Shift” of the medical professionals.

A doctor invests almost a decade in becoming a trained professional through technical education and internship. However the formal medical education fails to train the doctors in some key skill areas. A doctor to be highly effective need to learn art of communication with their patients, build a compassionate doctor – patient relationship and be highly efficient in operational skills. As doctors are not groomed in a corporate environment they need to polish their skills to become Medical Entrepreneurs.

Enhancing Doctor - Patient Relationship is an area of importance today. There is a need to empower and engage patients in today’s technology driven era. Knowledge and understanding of the needs of patients and their families now is more crucial than ever in providing exceptional patient service. Today a doctor’s reputation is driven by the combination of patient experience and perception of services provided to them.

The medical professionals would need to re-think about enhancing doctor-patient relationship, should be able to understand the basic principles of medical practice management, develop familiarity with the language of healthcare marketing and acquire various soft skills like communication, handling team and understanding the online digital world. This would help them handle medical practice effectively.

A doctor would need to combine multiple talents - technical expertise in their specialty; understanding the importance of hospitality in the hospital ; and above all, developing a compassionate and empathetic approach in order to create loyal patients.

So the need for a doctor today is to have a patient centric approach, practice medicine effectively as a professional, not a trade and earn profit smartly.



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A place to bond for infertile couples - dnaindia.com/mobile


A place to bond for infertile couples - dnaindia.com/mobile

Mumbai: Infertility, to those faced by it, can be as emotionally
debilitating as the loss of a loved one. Most people find it extremely hard to accept that they are infertile andthe stress of denial can even lead to serious psychological problems.

After dealing with scores of couples who approached them with such issues, Dr Aniruddha Malpani and wife Anjali formed a support group called Infertility Friends where men and women who have overcome their circumstances help counsel those still coming to terms with it. The group has been around for 15 years and is still going strong. Infertility Friends is the first such support group in the country for infertility. It is a registered charitable trust run by infertile couples and provides a forum for infertile couples where they can get together to discuss their experiences with each other, and derive strength from their collective experiences.

“Infertility is not just a medical condition, it has emotional and psychological ramifications. Speaking to others who have been through a similar experience is like an emotional catharsis for others with the same condition,” Dr Malpani says.

“However, these days, with commuting becoming a huge problem, the group meets very rarely. So, we have moved the group online, where couples find the anonymity reassuring,” Dr Malpani adds. For those interested, the website is called infertilityfriends.org. Dr Malpani says, “The forum also helps bust some myths related to infertility like: Infertility is a woman’s problem; my spouse might leave me if we can’t conceive a child; this is God’s way of telling us we cannot be parents, and so on.

While well-meaning friends and relatives will offer advice, those who have actually had infertility treatment are better equipped to bust such myths.

Dr Malpani says among the frequently asked questions are — is IVF painful? Does it cause excessive hair growth? And, doctors’ answers are generally taken with a pinch of salt. It is only those who have gone through the treatment who will inspire confidence in others, Dr Malpani adds.

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Overcoming the fear of IVF failure

The fear of failure is perhaps the commonest reason why most women do not have the courage to try a second IVF treatment cycle when the first one fails.

But playing it safe has risk as well. If you never dare to fail , you will never succeed !

Here's a great post on how to overcome the fear of failure !

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Thursday, July 08, 2010

How to Ensure IVF/ICSI Success


This is a guest post from an expert IVF patient !

The title of this post is misleading to say the least, because if there’s one thing no one can guarantee you, it is a 100 percent chance of success in getting pregnant through any assisted reproductive technique. All your doctor and medical team can do is to set up the best possible environment in your uterus to hold the embryo, ensure that everything possible is done to get the best quality of eggs, sperm and embryos, and transfer the growing embryos into your uterus at the right stage. After that, it’s up to a higher power to decide if the embryos implant or not. No matter how much medical science has advanced in creating life, there are still some mysteries that remain. And this is why your doctor cannot assure success in an IVF cycle.

If that is so, then why write an article about ensuring success? Because when it comes to IVF, ICSI and any other assisted reproductive technique, success is relative. Some people take home healthy babies a year or so after they’ve started treatment, some take home more than one baby because of multiple pregnancies, others come back more than once before they’re able to become proud parents, yet others get pregnant only to lose the baby midway, and yet others go through multiple cycles without ever testing positive. Most people would consider success in an IVF cycle as taking home a healthy baby at the end of your pregnancy, but having gone through five unsuccessful cycles myself, this is what I have to say about relative success.

• Every successive cycle you go through teaches you patience and tolerance, qualities that are required in large amounts if you want to stay sane when you face failure time and again.
• Sign up for the next cycle only if you are realistic about your chances of success – it’s important that you stay positive even as you know in one corner of your mind that there is a chance for failure too. So in the event of no pregnancy, be prepared with positive reinforcement in the form of friends, family and other things that you love so that you don’t fall apart.
• Do your homework – you may be forgiven for being ignorant of the IVF process during your first cycle. But if you’re coming back for the second or even third time, it is imperative that you read all about it, know what you’re in for, what your doctor must or must not do, what you must or must not do, and choose the clinic that offers you the best chances (Clinics that have a complete IVF setup and do not rely on outside specialists for their expertise are better options because you don’t experience unforeseen delays and inept treatment).
• Failure in multiple cycles may open a new door for you – most people start to consider other options like adoption, surrogacy, donor eggs, donor sperm, and other unconventional ways to have babies. Talk to your doctor about all the options open to you before you decide to put your body through the whole rigmarole again.

An IVF cycle is just another method of treatment that medical science has invented - it is liable to both success and failure. And when you realize this simple truth, it’s easier to go through the process and come out smiling, irrespective of whether you succeed or fail.

This article is contributed by Ashley M. Jones, who regularly writes on the subject of online pharmacy technician certification. She invites your questions, comments at her email address: ashleym.jones643@gmail.com.

Wednesday, July 07, 2010

Why I am a doctor

This is based on an interview I did for a cover story for Heal India magazine.

1. Why did you choose to become a doctor ?

Medicine is a service profession and I decided to opt for medical practice because this provides an opportunity for direct patient interaction. The emotional income in medical practice is unmatchable – and it’s a great feeling when patients thank you changing their lives by giving them a baby !

2. How easy or difficult was the transition from residency to practise ?

I have always enjoyed academics and won over 20 gold medals during my medical training. I continue to read medical journals and present papers at medical conferences, which means we are at the cutting edge of medical technology. In fact, our IVF clinic is more advanced academically than most departments of OB/GYN in teaching hospitals in India, because none of these offer IVF treatment. The Professors here only know and teach the theory while we actually do IVF in real life ! Yes, I do miss teaching medical students and residents, because interacting with juniors and young students is a lot of fun. This is why, instead of teaching medical students, we focus our attention on teaching our patients – which can be a lot of fun academically, as patients ask a lot of very intelligent and stimulating questions which keeps me on my toes ! I feel we have been able to get the best of both worlds in our clinic!

3. What drives you ?

I like getting up in the morning because I know that I can help to improve the life of my patients by giving them a deeply desired baby ! I love exploring new technology – both in the IVF lab; and Information Technology. This is why I am an angel investor in startups which deliver technology to doctors to help them improve the care they provide to patients !

4. Are you satisfied with the academic framework that we have in India ?

No – I think it can be improved a lot ! I feel academic departments in teaching hospitals have become outdated and stale. They do not have access to the latest technology, because of funding constraints. I feel it’s a crying shame that so–called teaching hospitals in India which provide postgraduate training in MD for gynecologists do not teach their residents how to do IVF because they do not offer IVF treatment for patients ! This is very sad – doesn’t Family Planning and Welfare also mean helping infertile couples to have a baby ? IVF is not expensive – and I feel that a Dept of OB/GYN which does not offer IVF in this day and age should not be recognised by the Medical Council of India. How can a gynecologist who has never seen a single egg collection during his residency consider himself to be well equipped or qualified to practice OB/GYN today ?

5. There is mass migration of medical students ? Why so and how can
this be curtailed if not contained.

The Brain Drain has always been a fact of life . After all, in a capitalistic society, bright students will look for the best opportunities for themselves , and there is no reason why they should restrict themselves to India. I do not think that trying to curtail this by making residents sign bonds is a good idea. It makes far more sense to provide young doctors with stimulating opportunities to practise high quality medical care in India, so they no longer feel the need to go abroad. In reality, most students who migrate to the US are just blindly following the herd mentality and being quite short sighted. For the bright medical students, India offers the best opportunities in the world today. We have a young and growing population – and for ambitious doctors who are willing to work hard, the sky is the limit. I often feel sorry for my classmates who have settled in the US – my quality of life is far better than theirs !

6. What inspired you to set up a clinic ? How do you find it different from others already existing ones ?

Most IVF clinics in the world are free-standing ambulatory care facilities. After all, infertile couples are not “sick” and do not need hospitalization. By operating an independent clinic, we offer a much higher quality of customized and personalized care to our patients, without all the hospital red tape. Not only is this much better for our patients, it’s much better for us as well. We provide a very cost effective service because we do not have any hospital overheads – and we do not need to give the income we earn away to the hospital management.

7. How do you envision..... (heart / cancer/ fertility,,,,) hospitals/ centres in India in days to come ?

I feel we will see a boom. Specialty hospitals ( between about 50 - 100 beds) , which are focused on a particular specialty are the best way of providing high quality medical care. They are focused factories – and can prove to be centers of excellence !

8. How do you divide the time between medical practice and academic
preparations ?

I feel this is a very artificial distinction. All practise is based on theory – and a good doctor needs to be proficient in both ! I learn by reading about my patient’s problems, so I can provide them with the best possible solution for their problem. By converting the theory ( in medical journals and text books) into practice, we remain at the cutting edge of both !

9. Combining medical practice and academics or on the job learning - which of the two do you think is preferable.

I think all good doctors will agree that the only way to learn medicine is by actually treating patients ! The only real learning which occurs in medicine is at the bedside – so all medical learning has to be on the job ! As Sir William Osler put it so eloquently, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
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Tuesday, July 06, 2010

COMFORTING patients


A new set of interactive guidelines have been created to help clinicians more effectively communicate when they deliver bad news to patients.

COMFORT is an acronym that stands for Communication, Orientation, Mindfulness, Family, Ongoing, Reiterative, and Team.

Communication- Clinicians need to learn to how to use clear and familiar language
when breaking bad news. Patients are people and have the basic right of receiving information in a manner that makes sense to them. Communication between doctors and patients should strive to be person-centered and nonverbally direct.

Orientation- Low health literacy leaves most patients and their families with little choice
about their care. A patient receiving bad news will be overwhelmed, and will often respond to any clinician recommendations, even if they are ineffective. Treatment outcomes should be clearly articulated in language that is appropriate for both the age and education level of the patient.

Mindfulness- Doctors need to learn to treat each patient interaction separately. When
delivering bad news, the patient should be at the center of the doctor’s attention.
Focusing on a patient’s individual experience requires doctors to avoid basic scripts and protocols.

Family- Families should be included in conversations when doctors break bad news
to patients, since families provide support to the patient. Families are also affected by illnesses, and clinicians need to address both the patient and their family.

Ongoing- Clinicians must emphasize that the patient will not be abandoned after a
diagnosis, or while they receive ongoing treatments. By continually communicating with patients, clinicians can provide more clarification about the diagnosis, especially if the recovery will not be quick.

Reiterative- When interacting with a patient, clinicians need to keep the meaning behind
their messages the same, even if the message delivery takes different forms over time. The message must always adapt to fit the needs of the patient.

Team-Patients receive care from a team of medical professionals, including physicians,
nurses, chaplains, psychologists, and social workers. Communicating as a team will help reassure patients and their families that they will be receiving proper care.

This study appears in Volume 59 of Communication Education, a publication of the National Communication Association. For more information about NCA or its journals, please visit www.natcom.org.

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Monday, July 05, 2010

The role of masterly inactivity in treating patients !

The Doctor, by Sir Luke Fildes (1891)Image via Wikipedia

Today I saw a 28 year old woman who was worried because a 1.0 cm size uterine polyp
had been diagnosed on a vaginal ultrasound scan, and two gynecologists had advised that she needed to have surgery to remove this . She wanted a third opinion, because she was understandably reluctant to go through this surgery. A polyp is a benign finger-shaped outgrowth of the uterine lining, and is quite commonly found in young women.

The patient had no complaints . The polyp had been detected while doing a routine vaginal ultrasound scan during her annual health checkup ! This was an incidental finding, which was not causing her any problems, but when most doctors are confronted with an " abnormality " the "knee-jerk" reflex response is - "fix it ! After all, if you have a hammer, you are likely to see nails everywhere !

I am a conservative doctor, and I told her that no action needed to be taken at this time. The best course of action would be - masterly inactivity or watchful waiting. Now I am a senior doctor, and am comfortable advising patients that they do not need "treatment" for everything which a scan picks up, but I seem to be in the minority these days !

I feel the problem is that doctors only see patients with problems ! They do not see healthy people at all, and sometimes I feel most doctors would not be able to diagnose a healthy person if they saw one ! Infertility specialists only see infertile women, which means that they unthinkingly assume that every problem they find during their diagnostic testing is the cause of the patient's infertility and needs to be " fixed" . However, this is flawed thinking. The truth is that we we do not know the natural history of many of these conditions. Thus, we do not know how many fertile women have polyps - after all, most normal women have enough sense not to go to a doctor !

This means that we tend to over-diagnose and over-treat. Sadly, taking a second opinion does not solve the problem because most doctors will give the same advise - treat it ! After all, it's much more more profitable to treat it than to leave it alone. Incidentally, this is perfectly acceptable medical practise, and would not be considered to be unnecessary surgery, because most textbooks do advise that polyps need to be removed and most doctors are quite happy following these textbook recommendations ! For one, they can just follow the protocol blindly, which means they do not have to apply their mind or individualise their advise for the patient's unique circumstances - something which takes time and energy ! Modern medicine believes in protocols and guidelines, which leaves individual doctors with very little freedom to make decisions for special cases. Everyone has to be squeezed into the protocol, no matter what ! It's much safer for doctors to do this, as they cannot be criticised for following accepted guidelines. Sadly, there is no incentive for doctor to not do anything !

I think we need to remember that we do not treat ultrasound images - we treat humans ! The exact same polyp seen on an ultrasound scan in a 34 year old infertile woman needs to be managed completely differently as compared to a 29 year old asymptomatic woman !

Aggressive over treatment can have a downside , because it can end up creating more problems ( for example, operative hysteroscopy for polyp removal can result in infection or bleeding). The trouble is that our machines for making a diagnosis have become much better , and because the technology is so good, it's very easy to pick up normal variants and label them as an abnormality ! It's also easy to offer to treat, because modern treatment is minimally invasive , and does not involve scars or hospitalisations , which means that doctors are more willing to intervene !

However, remember that no surgery is minor for the patient which means patients are often confused. They are fine, so they are reluctant to do under the knife. However, their mind starts playing games with them; and when two different doctors advise surgery, most are happy to toe the line. They often feel - thank God the doctor diagnosed the " problem " early , before it became a major issue - let's fix it now when it's small !

Sometimes it's best to leave well alone - but it requires a mature doctor - and a mature patient - to be able to do so !

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Sunday, July 04, 2010

Informed Consent: How technology can help both doctor and patient !

Panama Health Care - Surgery 1Image by thinkpanama via Flickr


This is a guest post from Mr Parag Vora, CEO, Infoseek, in which I am an angel investor. Infoseek makes patient educational videos in India.

Getting Informed consent from the patient remains a very tricky area in medical practice today . Failure to obtain valid consent is one the commonest reasons patients go to court when they are unhappy with their doctor.Unfortunately, no standardised guidelines have ever been published by the Medical Council of India, Indian Medical Association, or any other ‘reputed’ medical body. This is a huge lacuna, and the importance of taking consent has never been taught to most doctors properly, even though there has been a huge rise in medico-legal and malpractice claims in the past decade or so.

All over India there is a lot of diversity in the way consent is taken and interpreted. There have been instances where consents have been highly inadequate; and in some cases, the doctor has completely forgotten to take a consent altogether ! What makes a consent an ideal consent is still a grey area in India. The ambiguity in the consent document leads to variable interpretations that have resulted in damages to medical fraternity in the form of malpractice claims and litigations.

The Supreme Court of India has laid down certain guidelines in its various judgments for what makes a consent valid; and how it should be taken. Consent and its adequacy has been the most common issue that crops up in medico-legal situation. This is especially true in certain specialties such as obstetrics.

Initially, the concept of Informed consent was developed in order to protect the health of participants in clinical trials and healthcare research. However, in view of the importance of patient autonomy, and the need to protect doctors against medical lawsuits, it is now considered to be an important component of all aspects of health care. Though a very commonly used term, , the fact remains that it is very difficult to prove that the patient did in fact provide true “Informed consent” in a court of law in a medico-legal case.

There are many reasons for this. The limited amount of time available to counsel patients in a busy practice may make this impractical. Also, “How much to reveal” and “How to inform the patient about the risk of complications without scaring the patient away ” is another practical issue , thus making it difficult for doctors to fulfill the legal criterion of informed consent. The inadequate level of education and the language barrier poses another important and genuine problem in our country.

We all know that mere signing on the consent form is not considered to be enough in a court of in law. Similarly , doctors feel very vulnerable when a patient, inspite of being genuinely adequately informed about the risks of the procedure, conveniently claims that no explanation was given to him by the doctor, when he is on the witness stand !

All good doctors want to have a truthful, genuine, transparent doctor- patient relationship where the interests of both the parties are recognised and respected. There is adequate data to prove that giving proper information to patients has improved patient satisfaction and decreased litigation in medical practices.

As a step in streamlining the consent taking process and helping it to make it truly informed consent, to protect both doctors and patients , we are launching P.E.A.S™ Patient Consent software, which has been developed with the help of one of India’s leading medicolegal experts, Dr Nikhil Datar. This software helps manage medicolegal risk with innovative tools which enhance doctor-patient communication at the same time ! The software provides a multilingual, audio visual patient information - cum - consent taking solution for the first time in India . This allows doctors to achieve detailed, provable documentation of the consent process , without wasting his precious time .


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Saturday, July 03, 2010

Medical ethics and double standards


I agree that doctors need to improve their ethical standards, but what really upsets me is the double standards which have now been institutionalised, with the entry of corporate hospitals into the medical field.

While everyone is happy to loudly criticise the specialist who gives kickbacks to the family physician for referring patents to him, why is everyone so mute when it comes to the kickbacks which the hospitals give to doctors for filling their hospital beds ? All corporate hospitals give these cuts and commissions openly and shamelessly. They employ a large number of very presentable executives ( mostly female) in their Dept of Public Relations, and cleverly call it a "patient management fee", when the only management involved is writing the referral note !

It's the same story with the medical tourism companies. All hospitals are happy to give large commissions to these tourism companies for the "facilitation services" they provide, but these are costs which then get passed onto the poor unsuspecting patient !

Why should we allow double standards in medicine ? After all, both doctors in private practise and hospitals are competing for the same patient - let's have a level playing field; and not be hypocritical ! If it's OK for hospitals to give kickbacks ( which they treat as " the cost of doing business") , then let's allow doctors to do this as well ! In fact , doing it openly will help to improve transparency !
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