Wednesday, March 30, 2011
Management seems to have become the panacea to all ills - and it's a very tempting idea ! After all, isn't it obvious that managing something can just help to make it more efficient and effective ?
Sadly, in real life, this is not true. In order to manage healthcare, we need managers who have special training and expertise in management; and then inject them into hospitals to manage doctors . All this ends up creating is an additional layer of people between doctors and patients - a layer which has no medical expertise - and which just adds to costs and paperwork !
Interestingly, this is as true in education as it is in medicine. A great book by Philip Howard called Life Without Lawyers has a thought-provoking chapter titled - Bureaucracy Cannot Teach ( from which I've lifted the title of my post).
He writes - " All these reforms have been based on an unspoken assumption: that better organisation is the key to fixing whatever ails schools. The theory is that by imposing more organisational requirements - better teacher credentials, more legal rights, detailed curricula, the pressure of tests - schools will get better. That's the theory. The effect, however, is to remove the freedom needed to succeed at any aspect of teachers' responsibilities - how they teach, how they relate to students, and how they coordinate their goals with administrators."
Applied to healthcare, this would read, He writes - " All these reforms have been based on an unspoken assumption: that better organisation is the key to fixing whatever ails hospitals. The theory is that by imposing more organisational requirements - better doctor credentials, more guidelines, more legal rights for patients, detailed medical curricula, testing for performance - hospitals will get better. That's the theory. The effect, however, is to remove the freedom needed to succeed at any aspect of doctors' responsibilities - how they treat , how they relate to patients , and how they coordinate their goals with administrators."
Bureaucracy often ends up smothering teachers - and doctors as well ! When we try to manage something, we often end up mismanaging it !
Most management principles are simple applied common sense - and rather than try to have more managers, it would make much more sense to teach doctors basic managerial skills, so they can do a better job managing their patients - and themselves !
Tuesday, March 29, 2011
However, most of these apps have been developed in the West and they are designed for "smartphones". They are cool and fun to play with but we desperately need clever developers to produce apps for dumb phones - the kind of phones the billion who are at the "bottom of the pyramid" have to use daily. This is a much bigger challenge - but the results can be earth-shaking !
Monday, March 28, 2011
An interesting "recent" innovation in economics is the introduction of "controlled trials" to determine the true impact of interventions to help alleviate poverty. Common sense would suggest that giving the poor loans will them help to turn around their lives - but in reality, this is not what usually happens. The road to hell is paved with good intentions, and "aid" can often end up killing initiative ; fueling waste and corruption; and breeding dependence ! Handouts don't always work well - and it's easy to waste a lot of money very quickly ! The only way to find out what works and what does not work is to perform experiments in the field - something which doctors are very good at ! Innovations are a part and parcel of medicine - but which ones are really useful ? And which ones aren't ? Doctors are very good at figuring this out because they've been doing this for so many years - and the staple technique we use to do so is called a controlled clinical trial. Economists are now adding these to their armamentarium to judge how valuable field interventions are , so they have data to analyse impacts, rather than just having to depend upon their intuition !
Interestingly, marketeers do this all the time as well. They need to figure out which ads work; which don't; and which provide the most bang for their buck. In marketing, a randomised trial is called split A/B testing !
Sunday, March 27, 2011
I hope we can agree that there’s a moral obligation to be honest, to treat people with dignity and respect, and to help those in need.
I wonder if there’s also a moral obligation to start.
I believe there is. I believe that if you’ve got the platform and the ability to make a difference, then this goes beyond “should” and reaches the level of “must.” You must make a difference or you squander the opportunity. Wasting the opportunity both degrades your own ability to contribute and, more urgently, takes something away from the rest of us."
Some old-fashioned doctors still think it's unethical for doctors to have a website. They fell this is like advertising - and not something which medical professionals should do !
It's interesting to see Dr Vartabedian's viewpoint, which I agree with completely ! The word doctor is derived from the word "docere" = to teach; and I feel doctors have an ethical obligation to do so. They need to teach not just the next generation of doctors, but their patients as well. The internet is a very powerful means of teaching and doctors who do not use it to educate their patients are doing a disservice - to themselves, the medical profession; and their patients !
Saturday, March 26, 2011
http://www.scribd.com/doc/51531491 - Hodgkins Lymphoma
http://www.scribd.com/doc/51532544/Testicular-Cancer- Testicular Cancer
Many IVF patients get very confused about how the doctor calculates the age of their pregnancy
( = gestational age, in medical jargon). Logically, shouldn't it be from the day of the embryo transfer ? After all, it's only after the embryos are transferred that a woman can be considered to be pregnant !
However, doctors are not always logical, and we usually use the menstrual age when talking about the length of the pregnancy. This is because obstetricians usually see women who have got pregnant after having sex in their bedroom. Very few of them will know the exact date they ovulated , which is why we use the menstrual age in clinical practise. This does not change just because you have had an IVF pregnancy - the clinical rules remain the same !
This creates a lot of confusion in patient's minds - especially when they are trying to make sense of their ultrasound scan results or their HCG levels.
Remember that your OB is always talking about the menstrual age - not the age of the
embryo ! This is purely for clinical convenience and is a well-accepted universal convention.
So how do you convert the date of embryo transfer to menstrual age. This is very simple ! The key reproductive event you need to focus on is ovulation ! It makes much more sense to talk about the pregnancy in terms of DPO ( days post ovulation), rather than the menstrual age or the day of the embryo transfer. This is because we can use this landmark for all situations
( including IUI pregnancies; and for Day 3 embryo transfers and Day 5 embryo transfers as
Since every IVF patient knows the date they ovulated ( = the day of egg collection), it's easy to calculate your menstrual age. Just subtract 14 from your date of ovulation. This is your
" corrected LMP" ( last menstrual period) .
( Corrected) LMP = Date of egg collection minus 14
The reason we do this is simple - it's because text books assume the follicular phase is exactly 14 days ! Once you know your corrected LMP, it's then easy to use this as the anchor, based on which your OB can calculate your gestational age.
This means that the menstrual age will always be 14 days more than the actual age of the embryo.
Confused ? Let's look at an example.
Let's suppose your LMP was 5 Jan; and your egg collection was done on 24 Jan ( let's assume you took a long time to grow eggs); and your embryo transfer was done on 29 Jan ( Day 5 transfer). The HCG pregnancy test will be usually done about 14 days post ovulation ( DPO), which is 7 Feb. If it's positive - say 120 mIU/ml, the doctor will confirm you are pregnant ! This means that even though you are only 14 DPO ( and your embryo's age is only 14 days ) , he will calculate your corrected LMP as 10 Jan ( date of ovulation , 24 Jan, minus 14 days) - which means your clinical gestational age ( or menstrual age) will become 4 weeks ( 28 days) ! Once you understand this " 2 week gap" and the rationale behind it , you'll find it much easier to date your pregnancy !
Friday, March 25, 2011
The only difference between black money and white money seems to be whether or not taxes have been paid on this . I used to be very proud of the fact that I am an honest citizen and that we pay our taxes, but given how the Indian government misuses the revenue it collects, I am not sure any more that paying taxes is such a big deal.
I feel the difference between good money and bad money is whether the money is being used or not. Good money is circulated - and bad money is locked up in safes !
I think this is flawed. The only kind of people who become billionaires are the ones who have a very strong acquisitive streak - and these are not usually the kind of people who are willing to part with their money.
I know Gates and Buffett get a lot of good press about donating money - but when you consider their net worth, the amount they give away is a pittance. Thus, if Gates' net worth is 50 billion dollars, and he wants to keep the corpus of his trust fund intact so that it continues to function even after his death, he should be giving away at least 5 billion dollars a year !
Thursday, March 24, 2011
This is typically what happens when these big buck projects are implemented with a Top-Down approach. A bureaucrat with a lot of money to burn decides this is a clever idea and tries to put it into practise. ( Because there's lots of money involved, it's easy to grease palms) . The results are very predictable - the project flops because there's no buy in from doctors . The project is then scrapped - and the technology gets a bad name ! It's not the technology or the idea which is flawed - it's just the way it was implemented. However, this will set EMR projects back by at least a decade, as everyone will now believe that the failure of this project " proves that EMRs do not work in India "
After a couple of months & a million clicks on the net, we decided to go to a specialist. The research on the net had classified us suffering from “unexplained infertility”. We landed up at Dr Malpani’s in search of explanation. Few new tests were prescribed for my wife and same old ones for me. Everything looked normal to the doc, which was a source of confidence that it would happen sooner or later. We were suggested to try IUI at our local gynec for 3 cycles. There was a hint of sadness creeping up after every unsuccessful IUI. Doubts started cropping up… Did we leave it for too late to start the family? We were back to the drawing board. Dr Malpani assured that everything was ok and he suggested IVF and we decided to go ahead. It’s to the clinic’s credit that the entire process is handled so systematically & in such an organized way that it gives you the confidence that every thing possible will be done, without going overboard,
to make it a success. The entire IVF process went as planned by the doctors and bingo…now we have graduated from being TTC couple to 12 weeks pregnant!
A BIG thanks to both Dr Aniruddha & Dr Anjali and their team!
Wednesday, March 23, 2011
We had nothing to lose, and decided to give it a shot. My work had anyway brought me to Mumbai from Bangalore and we decided to make the most of this opportunity.
Our first consultation with doctor boosted my confidence tremendously and I felt that finally I had reached the right place. The doctor put me to ease instantly. After perusing all my earlier reports, he advised me to get a couple of blood tests done. We were glad that we were not asked to repeat any of the tests done earlier. He explained the details of the entire treatment and assured us to remain positive.
One the first day of my next cycle, I visited the doctor's clinic again. Then started the routine of injections and scans. On day 9, the day of my first scan, I had gone to the clinic with a lot of hope, only to be devastated. The doctor was completely disappointed with the results as the follicular growth was well below expectations. After increased dosages of injections and regular scans the results were still not satisfactory by Day 14. It seemed to be the end of the world!
Dr. Anjali recommended that I need not lose hope and advised that we continue the round of injections for another few days. We are extremely grateful to her for instilling hope and believing that the results will improve and that there was a chance… somehow! Finally on Day 21 (exactly a week later) the doctor recommended that the follicles were now ready and we could go for egg collection.
I had thought that this cycle would be futile and we would have to wait for another cycle to try our luck, but thanks to the experience and reassurance of Dr. Anjali, we were able to utilize the current cycle as well.
After the IVF procedure, started another difficult phase of waiting for the results. Since I had 3 failed IUIs and a delayed ET in the current cycle, I was quite prepared for the worst. Finally 14 days after ET, it was time to get the blood test (BHCG) done. And lo and behold... the result was positive. My husband and me could not believe the results. I did not want to celebrate as yet. As recommended by the doctor, the tests had to be done twice again and we waited patiently. Each time the results were positive and finally, reality had sunk into me. It was unbelievable. I had finally conceived... It was something which I thought could never happen to us and we cannot thank Dr. Malpani and Dr. Anjali enough for making this dream come true for us. Now I am 4 months pregnant and hoping all goes well till the end...
We would like to emphasize the personal attention, constant assurance and the positivity that we experienced at Dr. Malpani's clinic. The staff too is very cordial, well-trained and caring. I can certainly compare my experience here with the others that I had consulted and taken treatment, and frankly there is no comparison. The Malpanis are extremely passionate in what they do, they treat every patient with equal care and patience and make each one feel important. I only wonder how they manage to do this even after so many years of practice and doing the same things over and over again. Hats off to the doctors!! I am also amazed at the responsiveness of the doctor to emails. Rest assured that you will get a reply to your email within 24 hrs, no matter how busy he is!
I would certainly recommend Dr. Malpani to everyone seeking infertility treatment anywhere in India. Please make the first visit and you will never regret!!
It's amazing how smart medical applications for smartphones have become !
Tuesday, March 22, 2011
I am very pleased and proud that my blog was selected ! It's the only blog from an Indian physician on this list - why aren't more Indian doctors blogging ?
Monday, March 21, 2011
Seeing your baby's heart beat for the first time on the scan can be a very emotionally charged moment ! This photo essay by Dr Hemant Morparia shows you how a normal pregnancy evolves, as seen by ultrasound scanning, so you know what to expect !
Please remember that the weeks refer to clinical age ( as calculated from the last menstrual period, LMP) and not the actual age of the embryo !
While it's true that the idea of using donor eggs can be very difficult to accept, it's a treatment option which has a very high success rate ! It also offers many advantages. You get to experience pregnancy; bond with your baby; and your child will have your name on its birth certificate, so that the fact that you have used donor eggs is something which no one else needs to know. It's thanks to donor egg technology that we are now seeing a spurt of celebs who are 40+ who are giving birth to twins and triplets !
We will be happy to help you find an egg donor . We have many healthy young fertile Indian women ( all of whom are less than 30 years of age , have been medically tested for their fertility ; and screened for infectious diseases such as hepatitis and AIDS ) on our egg donor panel, who have been fully evaluated .
Saturday, March 19, 2011
Read more at http://www.drmalpani.com/women-with-vaginismus-who-come-for-infertility-treatment.htm
Friday, March 18, 2011
It's very easy to blame the doctor, but this is hardly helpful ! Patients need to understand that getting good medical care requires they they establish a healthy doctor-patient partnership - and in order to do this, they need to become expert patients !
This has become surprisingly easy to do, thanks to the net. All you need to do is invest some time and energy - and if you do get lost, there are lots of people who can help, including online bulleing boards and forums; and librarians.
The rewards are well worth it - after all, if you are not part of the solution, you are part of the problem ! You cannot change your doctor's behaviour - but you can change yours ! Do not underestimate your intelligence and common sense - you have a lot at stake ! A big plus to doing so is that armed with the information, you'll be able to find a better doctor !
Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !
Thursday, March 17, 2011
• Bettering the information in health records by using PCHRs could lead to more accurate diagnosis and treatment.
• Rather than completely depending on the doctor for explanations of technical issues, patients could use the Internet to further their understanding.
• Giving patients more power over their own health could make them more committed to bettering their health.
• The greater exchange of information could lead to a stronger relationship between doctor and patient. Instead of spending clinical visits exchanging basic information (which would have already been conveyed by PCHR and email) the two could discuss more detailed information about the patient’s situation.
The fact that the WHO has kept on changing the definition of what a normal sperm count just testifies to the fact that experts are as confused as patients are. This is especially true when we consider 3 contentious areas. While it's true that the sperm provides 50% of the child's DNA, can it be responsible for:
failed fertilisation after ICSI ?
poor qualty embryos ?
Read more at http://www.drmalpani.com/sperm-dna-fragmentation-assessment.htm
A clever startup will use technology to marry PHRs with Information Therapy with social media, so patients can have intelligent conversations online with doctors , loved ones and other patients !
1. Push marketing: targeting physicians. Urging them to “push” certain drugs to their patients.
2. Pull marketing: targeting patients. Urging them to “pull” or request certain drugs from their physicians.
The most important approach to marketing taken by many pharmaceutical companies has been push-oriented. All those busy pharma reps swirling around hospital hallways are trying to persuade you to prescribe their drugs to your patients.
Nevertheless, the pull-approach has become more and more prevalent these days. Pharma companies are increasingly targeting the patients themselves.
These brochures encourage patients and care recipients to become active, involved, and informed participants on the health care team. The message of the Speak Up program urges patients to
Speak up if you have questions or concerns, and if you don’t understand, ask again. It’s your body and you a have a right to know.
Pay attention to the care you are receiving. Make sure you’re getting the right treatments and medications by the right health care professionals. Don’t assume anything.
Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan.
Ask a trusted family member or friend to be your advocate.
Know what medications you take and why you take them. Medication errors are the most common health care errors.
Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission.
Participate in all decisions about your treatment. You are the center of the health care team.
Wednesday, March 16, 2011
Read more at http://www.drmalpani.com/providing-feedback-to-doctors.htm
Tuesday, March 15, 2011
Read more at http://www.drmalpani.com/value-of-clomiphene-citrate-challenge.htm
Monday, March 14, 2011
Sunday, March 13, 2011
1. They use lubricants while having sex which kill the sperm . Having "baby making sex" on demand is not much fun for either husband or wife - and it's quite common to have to use lubricants in order to be able to achieve intravaginal penetration. However, many couples will use lubricants such as K-Y jelly or saliva - both of which can kill the sperm ! If you do need to use a lubricant, please use a sperm friendly lubricant. The easiest one to buy ( and the cheapest one) is liquid paraffin. It' easy available OTC at a chemist - just look under the laxatives !
2. Timing sex. Most couples know that the wife is fertile for only a few days during the entire month. However, because they are quite clueless about what these fertile days actually are ( and do not whom to ask or how to calculate them), they often end up having sex on Day 14 ( which they remember vaguely from their high school biology class on human reproduction ( when they weren't busy pretending to be blase because they " knew it all" ; or were giggling and blushing) is the day when ovulation occurs and the egg is released). However, for many women, Day 14 can actually be an "infertile day " ( for example, for women whose cycles are 25 days or less) . Using the Free Fertility Calculator at www.myfertiletime.in will help you track your fertility ! Using OPKs can also help !
3. Not having enough sex. Many wives refuse to allow their husbands to have sex until their "peak fertility day". They believe that if they "store up the sperm" and then discharge this with a big bang, their chances of getting pregnant increase. Actually, this is not true. You cannot really store up the sperm - the count does go up when ejaculation is delayed - but it's the immotile sperm which increase - not the motile ones ! It's far more efficient t have frequent sex, as long as the sperm are going in the vagina !
4. Many infertile women still use BBT charting to try to track their fertile day. This is a big, big mistake. While BBT charting does provide useful evidence to the doctor , it's only retrospective evidence - it does not help to identify the fertile days, as the BBT raises only after ovulation has occurred ( at which time the cervical mucus dries up and sperm can no longer enter the uterus and swim up to the egg).
5. Not doing any homework. It still astonishes me as to how poorly informed many infertile couples are about the basics of baby making ! They will often waste time trying herbs and supplements advertised on dodgy websites to "boost their sperm count"; or take "fertility tablets" to increase their fertility. They will allow months to run into years before seeking medical attention - or even doing a basic ( and inexpensive) fertility workup, to confirm that everything this fine.
" I have set aside this morning to commend you and your beautiful wife on the good work you are doing for humanity. You give hope to the hopeless, healing our wounds of years by showing commitment and concern, even when the situation looks gloomy. You are ready to even pray for mercy and help for your patients! I am impressed.
I have discovered that IVF is a journey. The travellers are the patients, but all of us will have to travel by different means of transportation, The luckiest by air, some by sea, others by road. It means there will be travellers by jet, speedboat, canoe, ships, cars, bikes, rail or even trucks and cartwheels! I am happy you guys are the drivers and my prayer is that the Almighty Creator will always grant you the wisdom to choose the right means of transportation, and the patience/perseverance to convey your travellers to their desired destination.
Please keep up the good work. I love you both and appreciate you."
Saturday, March 12, 2011
Think of an IVF cycle as being a series of hurdles - and you need to cross all these to reach the finish line ! While most patients will cross these hurdles with ease in a good IVF clinic, each of these is a " moment of truth ".
- You should grow many follicles
- These follicles should mature
- Your uterine lining should also mature in synch with your follicles
- Ovulation should not occur before the eggs can be collected
- Mature eggs must be retrieved by the doctor during the "pick-up"
- Your sperm must fertilize the eggs ( with IVF or ICSI)
- The embryos must divide and grow healthily in the IVF lab
- Your embryos should be transferred by the doctor smoothly into your uterus
- Your embryos should implant
Think of it as a series of hurdles, all of which have to be cleared , in order to win the race !As you can see, how well you negotiate these hurdles will depend to some extent on your biology ( how good your ovarian reserve is , for example); while others will depend upon the skill of the doctor !
A good clinic will guide you through these moments of truth, and share information with you, so that you can rejoice when things are going well - and be prepared in case things do not go as planned. Unfortunately, as with any biological system, IVF is also full of ups and downs - and the more you know about what is happening - and what is going to happen next, the more easily you'll be able to go through your IVF treatment !