Wednesday, February 29, 2012

When should you ask your gynecologist to refer you to an IVF specialist ?

Gynecologists are primary health care physicians for women. This is why when a woman has infertility issues , the first doctor she will contact will usually be her gynecologist. Since gynecologists are specialists in dealing with women's health , they are very capable of handling basic infertility problems and will do so efficiently and effectively.

However, sometimes there are gynecologists who refuse to accept their limitations and are reluctant to refer their patient to an IVF specialist . They will do their best to hang onto the patient because they do not want to "lose" their patient , as this would represent a financial loss to them ! Sometimes , it's an ego issue , because they feel they should be able to offer all the treatment themselves , rather than have to refer the patient to a specialist.

You cannot afford to let a doctor to make all your decisions for you ! You need to become an expert patient, so you know when to ask your gynecologist to refer you to an IVF specialist !
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Tuesday, February 28, 2012

Take a tour of Malpani Infertility Clinic online !



We treat patients from all over the world ! Many of them want to see what the clinic looks like before travelling all the way to India - which is why we have published a series of videos on youtube, so you can see what our clinic looks like !

Has your IUI ( intrauterine insemination) treatment failed ?

IUI or intrauterine insemination is a fairly low cost inexpensive treatment , and because it does not require much technical expertise to offer, most gynecologists will offer IUI as the first treatment option for their infertile patients, after doing a laparoscopy for them.

However, IUI has a high failure rate. What should you do if you have failed multiple IUI cycles ?

Talking big - lots of hot air from the Indian government

The union government will provide free generic drugs at all public health facilities from April 2012 in an effort to reduce the financial burden on patients, health minister Ghulam Nabi Azad said here on Monday.

Read more at http://www.aalatimes.com/2012/02/27/free-generic-drugs-at-all-public-health-facilities-azad

What a joke . Making these kind of tall claims makes for lots of applause after the speech; and gives the Hon'ble Minister his 5 minutes of fame in a newspaper article - but the ability of his department to implement these promises is zero.
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Monday, February 27, 2012

What can you do if all your sperm are dead ?

Most infertile men do not have any sexual problems. When they go to a medical lab to get their sperm tested, they expect their sperm count report to be completely normal .

However, when the semen analysis report comes back as showing that all their sperm are dead, they get a rude shock !

Fortunately,necrozoospermia is an uncommon diagnosis. This is the rare condition in which all of the sperm in a man's semen are dead. Because this is so uncommon, there's still a lot of confusion about the right way to manage this. This article has more information on how to deal with this distressing problem.
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Saturday, February 25, 2012

The medical conspiracy of silence

One of the commonest complaints patients have about their doctors is that they will refuse to criticize a colleague even when they know that he has been grossly negligent in his actions.
Whenever a complication occurs in the course of medical treatment, one of the worries every patient has is - Was this complication preventable ? Could it have been avoided ? Or did it occur because my doctor was careless and didn't do a good job ?

These are difficult questions to answer, because the body heals unpredictably and every illness has its own natural history and runs a different course , which varies from patient to patient. This is why patients will often ask for a second opinion when things are not going well ; and they expect and want and need a truthful answer from the doctor. However, they find that even though they have a very high index of suspicion that their doctor was negligent or careless, it’s very difficult to find another doctor who will agree to criticize another doctor’s actions.
When they encounter this barrier , patients are naturally led to believe that the medical profession engages in a conspiracy of silence against patients. They find this very frustrating., and this adds to their anger.

When things go wrong , patients deserve an honest and truthful answer. If the complication has arisen as a result of medical negligence , in all fairness the treating doctor should be willing to share this information with patients and say sorry. However , the reality is that patients are likely to be vengeful and angry , and because doctors are understandably scared and want to protect themselves , they will refuse to be frank and forthright. However, patients are smart and they can smell that something is amiss. But since they do not have the expertise to be able to figure out what went wrong and why and when , they need another doctor to provide them with assistance.

Unfortunately , doctors out of a misplaced sense of camaraderie and the misplaced belief that they need to protect each other , will often refuse to criticize another doctor. This reluctance is understandable. After all , doctors are often friends. They refer patients to each other and have common interests. They'd much rather close ranks and stand up for each other, rather than be critical. Also, doctors know that medicine is unpredictable; and that it’s very easy to be wise after the event ! They also know that it could be their turn to be on the firing line the next time , and if that they are willing to protect their colleagues now, that their colleagues will be much more likely to protect them , in case something goes wrong with one of their patients. Also, because doctors belong to the medical community , they don't want to be ostracized by being treated as a whistleblower or a critic of the medical profession , so they'd rather keep quiet, rather than stand up and voice their opinion publicly.

Some doctors refuse to criticize others because they feel that it is unethical on the part of one professional to badmouth and other. While it's true that not every complication arises as a result of the doctor’s negligence, I don't think it's fair on patients if doctors clam up and refuse criticize other doctors just because they want to protect each other. This kind of silence only serves to protect the guilty and actually ends up making a bad situation worse because patients start losing faith and confidence in the entire medical profession.

While I'm not suggesting that doctors should start bad mouthing each other, I feel an intelligent doctor can take a balanced approach and share information factually with the patient , emphasizing the fact that even when things go wrong, this is not because the doctor intended the patient any harm . The truth is that the human body is a complex system and it's not always possible to predict how it will respond, no matter how good the doctor's intentions.

If patients can be confident that doctors will tell them the truth, they are much less likely to be suspicious and adversarial. It's only when they feel that doctors are trying to protect each other that they are forced to go to court in order to seek redressal. While we cannot prevent errors from happening, at least being honest with patients about these errors can help to prevent them from happening in the future. Even more importantly, all of us are aware that there are some bad apples within the medical profession and by keeping quiet , we are actually encouraging them to continue with their bad behavior. If we refuse to police ourselves, then judges and lawyers will do this for us - and this is not a very happy situation. Doctors need to step up and take responsibility for the fact that they are a profession ; and that all of us are responsible for making sure that other medical professionals act in the manner in which they supposed to.

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Thursday, February 23, 2012

How to make love to a plastic cup

Every once in a while you come across a book title which makes you laugh out loud. This is so rare, that when I saw this book featured online, I just had to buy it from Amazon.com . I have just received my copy and would like to review this great book, which is called– How to make Love to a Plastic Cup - The guys guide to the world of infertility by Greg Wolfe.

In general , it's true that women are the neglected sex and are often treated as second-class citizens. However in the world of infertility, it’s exactly the other way round. It's the men who are neglected because most of the attention is centered on the woman. While this is not always an unmixed blessing, it's true that men feel left out during the entire infertility process

In most IVF clinics, men ( also know an DH) are usually considered to just be appendages to their wives. Their only role seems to be that of being a sperm donor ( and a banker !) Of course, if they have no sperm , then they do become the focus of attention, because we need to extract their sperm from their testes – but really that's just about it.

There's not much discussion about what the poor man feels - or what goes on in his head and his heart when he sees his wife crying because she can't have a baby. Most of the books on infertility are written for women - there is very little written for the man. Also, most infertility bulletin boards online are populated by women ; and while there lots of shoulders for infertile women to cry on, there’s very little support available for the man.

The great thing about this book is that it fills this need extremely efficiently . It’s written by a man – and is a short, quick read which means that most men will be quite happy to at least pick it up and browse through it, even if they don't read it from cover to cover . Its written in a very breezy style – and while it’s full of accurate medical information, this is presented in an entertaining format, so it never gets overwhelming or boring.

With chapter headings such as " Begin by Putting Tab A into slot B “ and “ What a prick” ( no, this does not refer to what you think it does !) , this book is tailor-made for men with short attention spans , who just want to know enough so that they can fix the problem. With such a great title, how can you not give it at least one shot ?

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Wednesday, February 22, 2012

The Medical Report Jargon Buster at www.medexplain.in























Please check out our new Medical Jargon Buster at www.medexplain.in ! This free application has been designed to help patients make sense of their medical reports !

Feedback and suggestions are very welcome.

Thursday, February 16, 2012

When doctors make their patients cry

I was just talking to a patient who was in tears. She had had diabetes for many years and was having a hard time controlling it , but was very sure that she did want to have a baby desperately. Since she was already 38 , we did an IVF cycle for her and she conceived in her very first attempt . We referred her to an obstetrician , who could provide her with the antenatal care she required , since she was a high risk pregnancy . She promptly went to a senior obstetrician, but came back to me in tears. She was extremely agitated, angry and upset and when I asked her what happened, this was her story.

Doctor I'm a grown-up woman and run my own company. I have lived with my diabetes for many years , and I know that I haven't done a very good job controlling it , but that's the reality because I am so busy working . I have spent many years trying to lose weight; control my diet; and get my blood sugar to normal. If you remember , I had come to you 5 years earlier, because I wanted to get pregnant, and you had advised me to control my diabetes, and then get back to you. I did not manage to do so, and finally requested you to do IVF for me, because I am already 38, and my biological clock is ticking away.

I'm pregnant after so many years and I'm extremely excited. I'm looking forward to the fact that I will finally become a mother. I went to the senior doctor you referred me to, so that he would help me manage my diabetes , so that I could have a healthy baby. However, instead of explaining to me what he would do and how we could work together to make sure everything would go well, he started berating me for doing such a bad job at controlling my diabetes - and even went so far as to say that it was irresponsible on my part to do IVF in order to try to get pregnant when I had such uncontrolled diabetes. Not only was he rude, a lot of what he had to say was extremely hurtful and I was very shaken up and upset.

My mother had come with me to the consultation ; and now I'm sure the next eight months of my pregnancy are going to be living hell. Rather than looking forward to an enjoyable pregnancy and a healthy baby in my hands at the end of it , I will be worrying about the possibility of this baby having birth defects. I had much higher hopes from such a senior doctor. I know that he told me off for my own good , but there are better ways of criticizing a patient.

I had to spend about 15 minutes consoling her , explaining to her that the doctor didn't really intend any harm, and perhaps he was saying things in order to motivate her to be more careful about managing her diabetes. I also told her that sometimes patients tend to over interpret the doctor’s expressions or his statements , when he really doesn't mean to be critical.

She refused to be consoled, and insisted on going to a second doctor . I did refer her to a second one , with whom she was happy, but I think this story has important lessons for all of us.
Doctors sometimes forget the power of their words and expressions when talking to patients. Patients are extremely vulnerable , and hang onto every facial expression or word. I know doctors can’t be on their guard all the time , but they need to understand that how they frame a particular sentence makes a world of difference to the patient. They need to learn to be positive and to understand the patient's anxieties. After all , managing the patient doesn't just consist of controlling her blood sugars. It also consists of managing the patient's peace of mind and building confidence in the patient - both in her own abilities to manage her problem , as well as the doctor’s ability to be able to care for. Unfortunately, this doctor , even though he was very senior , failed on all counts.

I think part of the problem is that when patients are upset with doctors , they just walk away and go to another doctor. Because they never provide any feedback to doctors about these negative encounters , doctors don't even understand that they're making mistakes ; and they merrily continue making them all the time. I'm sure I'm guilty of the same error, even though I do try my best to be as responsive and alert to my patient’s signals.

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Wednesday, February 15, 2012

Should doctors tell patients what to do ?

There are many doctors who don't like patients who ask questions and argue with them. They basically want their patients to agree with their advice and to just do what they are told by the medical expert. The get irritated when patients want to discuss alternative option they have found on the internet. These the doctors have a paternalistic approach and sincerely believe that patients do best when they follow the doctor's orders, rather than try to apply their own mind and make decisions for themselves. There doctors don't like patients who have made up their own mind. This is often the case of an irresistible force meeting an immovable object ; and because the chemistry between the doctor and patient is never right, they never managed to hit it off ; and may end up hitting each other ( figuratively !)

There are also doctors who want patients to provide inputs and to make their own decisions for themselves. These are the doctors who will make a list of options , and ask patients to select the option which they prefer. They get irritated when patients refuse to do their homework; and they dislike patients who want to just passively follow the doctor’s advise, because they feel that their doctor is God !

One would think that this is a very enlightened approach , because it treats the patient as an empowered adult; and that patients would appreciate doctors who treated them as intelligent partners. However, there are some patients who don't like this kind of doctor, because they believe that these doctors are wishy-washy and confused and can't make up their own mind ! These are the kind of patients who want authoritative doctors who will just tell them just what to do. They’d rather not than discuss the pros and cons with their doctor, because they feel that all this discussion just leads to paralysis by analysis and creates more confusion, rather than solving problems.

These patients want a doctor who will guide them and make the decisions for them - someone who's a father figure , who will tell them what the best treatment option is for them. These are patients who can't be bothered to apply their own mind , because they don't think it's worth the effort. Why not leave everything to the expert ? They believe that half knowledge is dangerous ; and that it's better to leave such critical decisions up to the professionals , who are trained to make them , and presumably will make better decisions as compared to an untrained layperson.
I don't think one type of doctor is any better than the other type . In fact , a really good doctor will be able to tailor his approach to what the patient needs. However, if there is a mismatch between the worldviews and personalities of the doctor and the patient, both are likely to be unhappy . On the other hand, when the patient who is seeking an authoritative doctor finds a doctor who has a paternalistic mindset, both are likely to be happy. Similarly, if a patient who believes in making decisions for themselves finds a doctor who believes in offering patients choices , so that they can choose their path for themselves, they are both likely to do well with each other.

As the patient, sometimes you may not have much of a choice ; and you may be forced to live with a doctor who has a philosophy which is diametrically opposite to yours. You should be aware of this , and realize this is likely to create a lot of angst and unhappiness for both of you. However , if you do have a choice , it's well worth spending some time searching for a doctor who shares your worldview - you’ll both be a lot happier !

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Tuesday, February 14, 2012

Teaching patients how to ask good questions

I encourage patients to ask questions. This is important, because it allows them to understand exactly what their problem is ; and what their treatment options are , so they have realistic expectations as to what I can do for them.

However, sometimes patients ask such poor quality questions that it's very hard to provide intelligent answers. This is why doctors sometimes get so frustrated by patients who carry lists of over 100 questions , and expect the doctor to answer all of them. The truth is that the quality of the doctor’s answers depend on the quality of the patient's questions. The problem is that patients are not sophisticated enough to be able to differentiate between good-quality questions and bad quality questions.

How can doctors help patients to ask good quality questions ?

This needs to be a two-step process. Firstly , patients should compile a list of generic questions and then try to answer these questions by doing their homework online. If they do this properly about 80 percent of their questions will already be answered before they go and see their doctor . This way, the doctor can focus on the really important stuff , which applies to their individual problem . Doctors can encourage this by providing information to patients on their own website , so that most of the generic questions have been answered before the actual consultation starts. This will save the doctor a lot of time and also ensure that the answers to the generic questions are retained by the patient, because they've been clearly documented. Many studies have shown that patients forget about 50 percent of what their doctor tells them during the consultation , so that this kind of blended approach helps to ensure retention of information by the patient.

Patients need to learn what questions to ask ; and how to ask them. This is an important skill, which is worth acquiring , and doctors can play an important role in teaching patients the difference between good quality questions and poor quality questions. Broadly, if the question can be answered by doing a google search, it’s not a good idea to ask this question to your Doctor . Good-quality questions are those which relate to your specific problem ; and which require the doctor to tailor the information specifically to your condition .

This approach will create a win-win situation , where patients get satisfactory answers to all their questions ; and doctors are happy because they've been asked intelligent questions , and their time has not been wasted on generic stuff.

Yes, I agree we also need to teach doctors how to provide good quality answers to good quality questions – and this will be the subject of another post!
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Monday, February 13, 2012

Using Felopio and herbs to unblock your fallopian tubes naturally

Every once in a while I come across a website which make my blood boil, because it takes advantage of an infertile women's ignorance; and exploits her hopes and desires to make a quick buck.

A good example is www.felopio.com, which promises a " natural herbal remedy " which will allow women to open their blocked tubes.

This is a very tall claim to make - but they can make it and get away with it, because it's a herbal remedy, so it does not need to be tested or approved ! Also, this is the internet, so people can make any claim they want !

Felopio is a tampon which contains herbs , which are supposed to work their magic on the fallopian tubes, after being placed in the vagina. This is a very clever marketing ploy, and even though it's all hocus-pocus, it's not hard to understand why it's so successful.

Women would rather try natural stuff at home rather than go to a doctor - and if they can order a simple remedy sitting at home, they are very tempted to do so ! Using felopio is easy to do - and because they can do it for themselves, they feel they are taking control of their problem and tackling it proactively.

Husbands also like the idea that this is a DIY remedy , which is safe and non-invasive. After all, what's the harm of trying it out ? It's local - and putting the herbs so close to the tubes makes a lot of intuitive sense ! So what if doctors don't recommend this ? Doctors don't know everything, do they ? Aren't there lots of other herbal remedies which have been shown to be effective
( which doctors don't learn anything about ?) Even if doesn't work, at least it won't do any harm ?

It's true that it's tempting to buy this product. The site is very attractively laid out - and is full of glowing testimonials and (unauthenticated) success stories.

Yes, it's true that some women may get pregnant after using Felopio - but this does not mean that the Felopio opened their tubes ! Often, the diagnosis of "blocked tubes" itself was wrong in the first place. It's common for doctors to report the tube is blocked, when actually it's just a cornual spasm which prevents the dye from entering the ( open) tubes.

The tragedy is that it is still very easy to fool infertile patients, who are deperately seeking a quick fix solution. It's easy to prey on their ignorance - and this results in their wasting valuable time and money .

Don't get taken for a ride - your best protection is Information Therapy !

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Saturday, February 11, 2012

i am 9 days late and and 3 pregnancy tests have come out negative. What could be wrong ?

As we all know, the commonest reason for missing a period is pregnancy. This is why, when you miss your period, your first thought is - Am I pregnant ? If you are infertile and have been trying to conceive for some time, there's a lot of hope and suspense when your period does not come on time.

So you check by doing a urine pregnancy test - and keep your fingers crossed - hopefully, this is the time when you've finally hit the jackpot ! Maybe it's the weekend trip you took which finally did the trick ?

However, when you find the test is negative, your hope go crashing to pieces ! Maybe I did the test too early ? Or perhaps I didn't do it right ? Aren't there lots of stories of women who were pregnant but whose pregnancy tests were negative for many weeks ? Maybe the test is not very reliable ?

The reality is that urine pregnancy tests are quite reliable - and if these are negative, this most probably means that you are not pregnant.

Your next step is to do a blood test for HCG to find out if you are pregnant. This is much more reliable. If this is negative, this establishes the fact that you are not pregnant.

This means the reason you missed your periods is because you did not ovulate. This is called anovulation. You may need to induce a period with medicines.



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Friday, February 10, 2012

Why I no longer want to practise medicine

I recently met a classmate of mine who been practicing as an obstetrician and gynecologist in the city of Bombay. He was a bright student and had his own nursing home ; and had what I thought was quite a flourishing practice in the suburbs. However, when I met him , he told me he was planning to retire from medicine altogether. I was quite surprised , but what he told me opened my eyes . This is what he had to say.

I have been practicing as a doctor for the last 25 years , and I am proud of the fact that I provide good medical care . I enjoy taking care of my patients - and my patients love me . It's been very satisfying , but so many things have changed now , that it's just not worth the hassle to continue practicing medicine as an independent doctor in private practice in my 15-bed nursing home anymore.

For one thing , the rules and regulations have become so onerous and difficult that I seem to be spending half my life just filling up forms and doing paperwork - for renewing my registration for my nursing home ; for the insurance paperwork for the TPAs; and complying with the biomedical waste rules. I'm at the mercy of any bureaucrat or clerk who wants to come and trouble me , and there's very little I can do about it.

I used to do ultrasound scans , but now I have stopped doing them. Every time I do an ultrasound scan , because of the PNDT Act, I have to fill up the form which says I have not disclosed the sex of the fetus. Why can't people just accept the fact that doctors are respectable citizens ; and that it's not good for our self-respect to be treated as crooks and criminals .

I no longer have the autonomy which I used to have . A lot of my patients have insurance ; and filling up their paperwork ; getting pre-authorisation; and following up with the insurance companies for my payments has become such a pain , that I no longer have the energy to do it .

Finally, I don't think my patients respect me as much as they used to. They no longer treat me as a trusted a professional. They think I am mercenary ; and often challenge my recommendations . Medicine is no longer considered to be a very respectable profession , and I'm pretty much fed up , which is why I want to retire. It's because we have not stood up for each other that doctors like us have contributed to this decline - we only have ourselves to blame !

What will you do in that case ? You are only 50 !

That's not a problem at all . I own my own nursing home ; and given the astronomical real estate rates in Bombay today , I will get a huge amount of money by selling it . Even if I just park this in a fixed deposit , the interest I get will actually earn me much more than what I'm getting from my medical fees right now ! I'll be quite happy and contented - and don't forget I'm a Doctor , which means I am smart. I'm sure I'll find something to do without having to deal with all the daily hassles I have to put up with today.

It is a shame and tragedy that things have come to this pass. We don't realize how much harm we do by pushing doctors against the wall . Some of this damage has already happened in the US , where primary care physicians no longer want to take on new patients , because they are fed up of the restrictions which are being placed on them. Sadly , the Indian medical system seems to have imported all the bad bits and bobs of the West; and sooner or later , we're all going to pay the price. Most doctors no longer want their children to become doctors anymore , so that the profession which used to attract the best and the brightest is no longer seen as being desirable . This is one of the reasons why we have all these private medical colleges which charge huge tuition fees - and we are now producing a new generation of doctors, which is more focused on the bottom line rather than being focused on providing good patient care. I dread the day when I become older and fall ill !



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When things go wrong in the IVF lab

The IVF lab is the heart of the IVF clinic . This is where we nurture your eggs and sperms to make your embryos ; and grow these embryos carefully before putting them back in your uterus , to maximize their chances of becoming a baby. In most well-run IVF labs , things go as expected , because we are very scrupulous about making sure that proper procedure is followed ! Biological systems usually behave themselves and do what they're supposed to do, provided the IVF lab has the right equipment and the right expertise.

Read more at http://www.drmalpani.com/when-things-go-wrong-in-ivf-lab.htm

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Thursday, February 09, 2012

Why do patients come to India for IVF treatment ?

This website has an excellent study on " Trans-national Reproduction: An exploratory study of UK residents who travel abroad for fertility treatment".

Read more at http://www.drmalpani.com/why-do-patients-come-to-india-for-ivf-treatment.htm


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Judgment based medicine versus evidence based medicine

Modern medicine is based on scientific principles . This can be very reassuring for patients , because they know that doctors have a body of evidence which they can trust ; and use logical principles in order to treat them correctly. However, medicine is not an exact science. It's an uncertain science , and this is hardly surprising given the fact that we're applying this science to a complex biological system - the human animal.

Doctors are used to dealing with this kind of biological variability because they spend so many years in medical school ,learning that they can be a lot of variation between the way patients respond treatment. However, when it comes to insurance company bureaucrats , policy wonks, and hospital administrators , this kind of complexity makes them extremely uncomfortable . They are much more comfortable handling numbers , which are much more predictable ! This is why they would rather deal with cut and dried systems , which make logical sense on paper. This explains why protocols and flowcharts and algorithms and guidelines have become so popular . Doctors today are being pushed into practicing medicine using published guidelines, rather than their own personal judgment or clinical intuition . This is why the movement towards evidence-based medicine has become so popular.

If you have a rigid yardstick to measure doctors by, it's easy for clerks and pencil-pushers to see whether doctors are performing according to that yardstick ! Those who do can be incentivized to continue doing so; whereas those who don't can be appropriately penalized . Evidence-based medicine has been thrust upon doctors and patients , not because it's better, but because it easier for non-doctors to manage, because it's less messy than real life medicine ! It's has been dressed up as providing patient centered care while it's really system centered care.

The difference between the two is highlighted very well by Doctor Groopman in his book, Your Medical Mind . He criticises the modern fashionable trend towards evidence-based medicine , where all patients are treated like widgets. We cannot afford to continue to pretend that one-size-fits-all ; and that if the guidelines are followed, all patients will behave exactly the same way . Since Doctor Groopman is a practicing physician who deals with the uncertainty and orneriness of real life medicine daily. He feels that doctors should be allowed to apply their judgment , so that they can tailor evidence-based medicine to an individual patient, and practice what he calls judgment-based medicine.

This is what you should ask for the next time you visit your doctor !

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How to Have a Baby - the Comic Book for Infertile Couples

How to Have a Baby - the Comic Book for Infertile Couples

Are you unhappy with your IVF Doctor ?

I often see patients who complain bitterly about their IVF doctors , saying that they just didn't have the time to talk to them ; or that they never explained anything to them . When I go into their history , I find that they've done three cycles with the same Doctor ! This is something which I just can't understand . If you do one cycle and you're not happy with your doctor, then why would anyone in their right mind repeat the second and third cycle with that same doctor ?

When patients are unhappy with their IVF doctor , why do they continue going to him ? Lots of patients are happy with their IVF doctors because most IVF doctors are competent , proficient and empathetic – and they do their best to help their patients to have a baby. However, it's true that some are pretty bad ! They are either incompetent; or not very communicative or open about what they are doing and what's happening during the IVF treatment.

While patients can't do much about how their doctor chooses to behave, it is within their control to decide whether to go back to that doctor when the first cycle fails ; or to change doctors . Why do patients continue going back , even if they not very happy with their
doctor ? Some patients feel trapped - they don't know that they can explore alternative options ! Others feel the known devil is better than the unknown one – after all, what’s the certainty the new doctor will be any better ? The fear is that they may be going from the frying pan to the fire and that the new doctor may be even worse than the old one. At least this one knows my case and my details and has all my records ! Others are scared to leave because they don't have their medical records ; and are worried that if they go to a new doctor , they’ll have to repeat all the tests and spend all that money all over again.

Some of them fall prey to the sunk cost fallacy - we’ve already invested so much money and energy and time with this particular doctor , that it’s better if we continue sticking with him. Others have been taught that they need to be faithful to their doctor. They understand that it takes time to get pregnant after IVF and that it's better to stick to the same doctor even if he's not very good and if they not very happy with him, rather than to switch doctors.

One way of getting out of this hopeless situation is by encouraging patients to get a second opinion . This is something I think every patient should routinely do when the first IVF cycle fails , so they have a clear understanding of whether they are on the right track or whether there are other options they should be exploring . If the second opinion doctor offers a perspective which is different from the first , this means they now have additional options to explore . They can always go back and discuss these options with the first doctor - or maybe even switch to a new doctor , if that's what they prefer .

Getting a second opinion helps you in many ways ! The new doctor is likely to treat you with kid gloves and be on his best behavior , because he knows you're already taking treatment from another IVF doctor and are a potential new patient . He’ll treat you like a VIP and do his best to make sure you come to him. Even better , when your original doctor finds out that you gone to another doctor to get a second opinion will be much more careful when he answers your questions , because he knows that you may walk away and that's not something which he wants !

It is not always easy to get a second opinion, and we try to make this easier for patients by offering a free second opinion online. This is an option which costs you nothing and it's well worth exploring because at least it helps you find out whether you're on the right track or whether you should be looking for alternatives . And because we’ve made this so painless, you don’t even need to switch doctors if you like your present doctor !

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Wednesday, February 08, 2012

Why do patients make the wrong decision sometimes ?

Patients are often forced to choose between various alternatives when they are ill . They sometimes make the wrong decision. Doctor Groopman's book , Your Medical Mind , provides some very interesting insights into this phenomenon. Making a decision involves thinking, as as with any other thought process, we are exposed to the risk of four common cognitive biases when we make medical decisions.

The commonest cognitive bias is called framing. It's very easy to be influenced by the promotional literature which a pharmaceutical company provides ; and by the glowing testimonials on a medical website , when you need to make a decision for yourself . Our decision making process is commonly flawed , because of the way our brain works. This means that we're all prone to certain fallacies when making decisions ! These are the four common fallacies which he highlights. The first is called framing . When exactly the same information is presented to you , how you make a decision will be strongly influenced by the way the information is presented to you. Just like a certain picture can look particularly attractive because it is mounted in an attractive frame ( rather than because it has an intrinsic artistic merit) , advertisers and marketers can subtly influence what you decide, by presenting information in a particular format ( or frame). This can be both positive and negative - and depends upon their playing with words ; or with numbers. Websites which promote "natural treatment options" for treating fertility are masters at this art !

Thus, instead of saying 51 percent of patients responded to treatment , they will say - the majority of patients improved with treatment ! It's easy to fool patients , so they come away with the wrong impression. It's only when you're aware of this framing fallacy that you can be on your guard and look out for it.

The most important numbers you need to find out are :
1. NNT , or number needed to treat . This is the number of people who need to be treated , in order to improve .
2. NNH, or number needed to harm . This is the number of people who need to receive treatment in order to suffer side effects .

It's important to compare apples to apples - and you need to make sure that the people who are being studied are similar to you - they should be age-matched; and have a similar severity of their disease.

You must remain alert to the fact that framing numbers can result in cognitive pitfalls and biases and the best way to overcome this is to be aware of these. You may need to drill down to get to the meat of the information presented to you, so you can focus on the steak and not get carried away by the sizzle !

The second bias is called aversion loss ; and arises because most of us regret potential losses far more than we care about potential gains. You need to be aware of this fallacy when you make decisions about your health. Sometimes we are so scared about losing something ( for example, your ability to have sex, ) that we may go over the top and make a decision which helps to minimize the loss , but may not always be the most rational decision . The third cognitive bias is the fact that our decisions are often skewed by what he calls the focusing illusion . When we try to think about the future , we often focus on just one particular aspect which could be negatively affected. This becomes such a dominant feature in our decision-making , that we forget that we have enormous resilience and can adapt and have a satisfactory life ( even if we can't have sex anymore, for example) . Finally , there is the availability bias. When something is "top of mind" and easily available, this sways your decision making process. This is sometimes why listening to stories from other patients can result in making decisions which are heavily influenced by what happened to that particular patient. This is why infertile couples are more likely to do IVF treatment ( which they may have resisted for many years), when they meed a friend or a relative who has just had an IVF baby. Being aware of your biases will help you identify certain fallacies in your decision-making process so that you're more likely to make the right decision, rather than than do this in a haphazard disorganised fashion !




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Why do patients make the wrong decision sometimes ?

Patients are often forced to choose between various alternatives when they are ill . They sometimes make the wrong decision. Doctor Groopman's book , Your Medical Mind , provides some very interesting insights into this phenomenon. Making a decision involves thinking, as as with any other thought process, we are exposed to the risk of four common cognitive biases when we make medical decisions.

The commonest cognitive bias is called framing. It's very easy to be influenced by the promotional literature which a pharmaceutical company provides ; and by the glowing testimonials on a medical website , when you need to make a decision for yourself . Our decision making process is commonly flawed , because of the way our brain works. This means that we're all prone to certain fallacies when making decisions ! These are the four common fallacies which he highlights. The first is called framing . When exactly the same information is presented to you , how you make a decision will be strongly influenced by the way the information is presented to you. Just like a certain picture can look particularly attractive because it is mounted in an attractive frame ( rather than because it has an intrinsic artistic merit) , advertisers and marketers can subtly influence what you decide, by presenting information in a particular format ( or frame). This can be both positive and negative - and depends upon their playing with words ; or with numbers. Websites which promote "natural treatment options" for treating fertility are masters at this art !

Thus, instead of saying 51 percent of patients responded to treatment , they will say - the majority of patients improved with treatment ! It's easy to fool patients , so they come away with the wrong impression. It's only when you're aware of this framing fallacy that you can be on your guard and look out for it.

The most important numbers you need to find out are :
1. NNT , or number needed to treat . This is the number of people who need to be treated , in order to improve .
2. NNH, or number needed to harm . This is the number of people who need to receive treatment in order to suffer side effects .

It's important to compare apples to apples - and you need to make sure that the people who are being studied are similar to you - they should be age-matched; and have a similar severity of their disease.

You must remain alert to the fact that framing numbers can result in cognitive pitfalls and biases and the best way to overcome this is to be aware of these. You may need to drill down to get to the meat of the information presented to you, so you can focus on the steak and not get carried away by the sizzle !

The second bias is called aversion loss ; and arises because most of us regret potential losses far more than we care about potential gains. You need to be aware of this fallacy when you make decisions about your health. Sometimes we are so scared about losing something ( for example, your ability to have sex, ) that we may go over the top and make a decision which helps to minimize the loss , but may not always be the most rational decision . The third cognitive bias is the fact that our decisions are often skewed by what he calls the focusing illusion . When we try to think about the future , we often focus on just one particular aspect which could be negatively affected. This becomes such a dominant feature in our decision-making , that we forget that we have enormous resilience and can adapt and have a satisfactory life ( even if we can't have sex anymore, for example) . Finally , there is the availability bias. When something is "top of mind" and easily available, this sways your decision making process. This is sometimes why listening to stories from other patients can result in making decisions which are heavily influenced by what happened to that particular patient. This is why infertile couples are more likely to do IVF treatment ( which they may have resisted for many years), when they meed a friend or a relative who has just had an IVF baby. Being aware of your biases will help you identify certain fallacies in your decision-making process so that you're more likely to make the right decision, rather than than do this in a haphazard disorganised fashion !




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Does exercise help to increase IVF success rates ?

It’s common knowledge that exercising and maintaining a healthy diet are key to keeping healthy. However there is little research as to whether exercise can help with In Vitro Fertilization (IVF) or not.

Here are some reasons that maintaining a good, but moderate level of physical fitness may help:

Read more at http://www.drmalpani.com/does-exercise-help-to-increase-ivf-success-rates.htm

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Tuesday, February 07, 2012

How patients think

I have always been fascinated by why different patients make completely different kind of decisions , when faced with exactly the same problem. Thus , there will be patients who will happily resort to IVF when they have a fertility problem ; land on the other hand, there will be those who will spend 10 years taking homeopathic medicines in order to improve their fertility . I just read this great book, called, Your Medical Mind , by Dr Jerome Groopman . He's the author of the book , How Doctors Think - and I think a better title for this book would have been - How Patients Think .

In today's world , there's a lot of emphasis on what is called evidence-based medicine . Administrators are trying to force doctors into straitjackets and want to ensure that doctors blindly follow standard algorithms and protocols . Doctors are being forced to function as assembly line technicians , so that the care which they provide is no longer patient centered care, but system centered care. Unfortunately , bureaucrats don't realize that evidence-based medicine is really not the solution. What we need to practice is judgment-based medicine , where doctors can use their judgment to make the right decision for their patient.

The reason the mindless application of guidelines causes so much angst to doctors ( and distress to patients) is that they do not take into the account the patient's personal preferences and opinions about the various treatment options . The great thing about this book is it provides a lot of clarity as to how we can systematically factor in the patient's worldview , so that we can make individualised decisions which are right for each patient.

Doctor Groopman believes there are three important variables which impact a patient's medical mindset or worldview. All patients need to figure out for themselves where they stand.

First, there are patients who are technologically oriented , as contrasted to those who are naturally oriented . The ones with a naturalism orientation will use natural healing techniques and alternative medicine ; whereas those who have a technology orientation prefer using the procedures with high-tech Western medicine offers.

Secondly, there are maximalists versus minimalists . Maximalists are those who want everything possible done for them - versus minimalists , who believe in the wisdom of the body , and would rather allow the body to heal itself . They prefer letting nature take its own course and are very conservative.

Finally, there are the believers versus the doubters . The believers have faith that there is a solution for their problem - and that it's just a question of finding it. Doubters are typically skeptical and cynical - and are often paralysed when they need to make decisions, because they find it hard to trust anyone or anything.

There is no particular mindset which is better or worse. You simply need to know what your particular mindset is , so that you understand what your biases are , and can make the best use of your worldview. This will also help you understand that there are alternatives , which might actually be better for you , given the particular set of circumstances you find yourself in .

The final variable which patients need to consider is how much control and autonomy they want when they are making their medical decisions. Some patients are fiercely independent ; and want to decide everything for themselves ; while others are quite happy to let the doctor decide for them.

This is a great book for both doctors and patients . It will help patents to understand why there is sometimes so much difference between the opinions they get from different doctors . Don't forget , doctors can be maximalists and minimalists and doubters and believers as well - and this will colour the advise they give you ! It's a great book for doctors as well , because it'll help them to understand how and why they think; and why the patient sitting in front of them may have a different perspective. They can use this framework to help their patients make decisions which are right for them.

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When should I stop trying IVF?

This was the plaintive question posed to me by a patient who had had failed four IVF cycles and had come to me for a second opinion. Should I do a fifth cycle doctor ? Shouldn’t I just forget about it ? Haven't I done enough already ? Haven’t I put myself through enough ? Haven’t I taken enough shots ? Changes enough doctors ? gone to enough clinics ? This is really getting too stressful - and I'm not sure whether it’s even worth trying again. Is it worth putting myself through all this stress and pain just to have a baby ? Is there any hope of IVF working if four cycles have failed ? What can you do differently ?

These are common questions IVF patients ask ; and the reality is we don't have any answers to them. Just because four cycles have failed , does that also mean the fifth cycle will fail? The chances of the fifth cycle working do not increase because of the four earlier failures – but neither do they decrease ! It's effectively a new lottery ticket - and the patient has to go through the decision-making process all over again . It’s a hard process and I don't think that I have the answers .

A lot really depends on the personality of the patient ! Typically , when we were kids , we were taught the importance of tenacity and persistence. We all know the story of King Bruce and the spider - and how we should keep on trying and trying again , until you finally succeed ! That logic is fine when you're studying for an exam or preparing for an interview - but does the same logic apply when you're doing something like IVF ? Unfortunately biological systems don't often follow logic , and it's important that everyone needs to draw their own “ laxman rekha” , their personal limit, so that they don't cross it before going to pieces or breaking down . Each person’s laxman rekha varies and depends upon many factors - emotional resilience ; personality; finances; temperament; social support mechanisms ; and how stable the marriage is .

You need to go through a lot of soul-searching before you make a decision , knowing full well that there is no easy answer no single right decision which applies to everyone - but that whatever decision you come to and find for yourself will be the right decision for you.

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Monday, February 06, 2012

Are patients dumb ?

I had a very interesting conversation recently with a friend of mine. He is a doctor who practices in a government hospital , and it was amazing how different our perceptions about the intelligence levels of our patients was.

I feel that patients are smart and very capable of making their own decisions for themselves. My worldview is that patients have a lot at stake and will do their best to understand what's happening to them and would rather make their own treatment decisions, rather than leave everything up to the doctor. I believe that if patients cannot understand what I'm saying the fault is mine – this means I'm not doing a good job with explaining , and need to try again. I have created a number of audiovisual aids and use these frequently in order to teach my patients about their infertility problems and the treatment options. Not all my patients are CEOs – many are illiterate and uneducated – and we try to teach everyone who comes to us.

My friend , on the other hand , believes that patients are not smart enough to understand about their medical treatment options. He feels that most patients would rather not break their heads trying to make sense of the complexities and nuances of medical decision-making, and are quite happy to let the doctor make these decisions for them

I think both my friend and I are reasonable, intelligent people - and yet we have such markedly different worldviews. The reason for this is that we deal with completely different patient populations. My patients are often articulate, smart CEOs of companies , who are used to deciding for themselves . They routinely exchange e-mails with me. He , on the other hand, has to deal with the masses of the unwashed majority within an outpatient setting in a public hospital where he has to see over 30 patients in the space of two hours.

I can sympathize with the pressures which he needs to work with. But just because his patients come from a lower social economic status does not mean that they are dumb ! In fact his patients are likely to be far more street smart. They live under conditions of poverty and deprivation in which I would not be able to survive for even one week. I think we need to give credit to the ability of our patients to understand for themselves ; and we need to acknowledge that is part of our job description to create educational materials for our patients. I think it's ironic that I spend so much time and money creating educational materials for my patients , who are already quite well informed and capable of accessing the Internet and getting tons more information if they want to . Isn't it tragic that he has not spent any time or energy in creating educational materials for his patients who need these far more, because they don't have any access to these materials at all.

He actually has the resources and the time and the energy to do so because he works in a teaching hospital and has lots of medical residents and medical students who work for him. I just wish doctors would accept that part of the job description involves educating patients and would be willing to spend the energy in order to do so.

Ironically, his creating educational materials would have a far better return on investment as compared to anything I can do , because he sees so many more patients ! However , he feels he's so busy providing clinical care to the patients he has to see on a daily basis, that he cannot find the time to do so. I think this is just a question of setting priorities and deciding that it makes more sense to treat patients as intelligent partners so that they will then be able to do a better job , rather than to complain about a paucity of resources. Let's not forget that patients are the largest untapped healthcare resource and we need to be able to give them the tools so that they can behave intelligently

I think the only reason doctors think that patients are dumb is because we treat them as being dumb; and we don't make any effort in order to try to get them to become smart. ( Or maybe smart doctors have smart patients and dumb doctors have dumb patients ?) This is a tragedy but it's actually an opportunity in disguise ; and I do hope that the next generation of younger doctors and entrepreneurs will take up this challenge !

Why patients need to do their homework !

I saw a patient today who had been taking treatment for the last two years; she had had irregular cycles which is why her doctor had put her on medicines for ovulation induction. However, she had not done any tests to find out whether her tubes were open or not !

When I asked her – “ Why haven’t you done a hysterosalpingogram ( HSG) to check your tubal
status ? “, the answer was one which I’ve heard many times in the past – “I didn't do it because my doctor didn't tell me to do it “. I explained to her how important this basic test is - that you really can't proceed with treatment without establishing whether the tubes are open ; and just because the cycles are irregular does not mean that we can automatically assume that your tubes are fine .

She got very upset and started blaming her doctor . If it's such a basic test, then why didn’t my doctor tell me to do it ? I don't think that's a satisfactory answer anymore in this day & age, where there is so much information available on the Internet for patients , that patients who are interested can easily educate themselves and arm themselves with the right information, rather than leave everything upto their doctor.

Blaming the Doctor doesn't really help anyone - and the damage which has been done to her by wasting her time is something for which she's the one who's paying the price - not the Doctor. It's important for patients to do their homework - not doing your homework can prove to be extremely expensive I think the problem is patients tend to underestimate their intelligence . They think doctors are extremely smart and know everything . Yes, doctors know quite a bit - but you are smart too , and you need to become an expert on your personal problem. You don't need to become a doctor , but you should be finding out about all your options and understanding what your choices are , so you can discuss these intelligently with your doctor .

Doctors are human , and they can make mistakes ; but expert patients , when they partner with their doctor will make sure that the doctor doesn't allow errors to occur , or things to fall in between the cracks .


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Saturday, February 04, 2012

The problem with modern medical imaging

There is no question that medical imaging is one of modern medicine's most dramatic success stories. With today's MRIs scans we can image practically every part of the body with
stunning clarity and make diagnoses which were possible only at the time of doing a postmortem in earlier days. However, being able to probe into the body’s hidden recesses and get extremely clear pictures of the interior has actually created its own set of problems.

Let me explain. Let's look at a patient who has a lower back pain. Now if you have a back pain ( which most of us have had at some point in our life ), we learn to live with it. We take painkillers to deal with it when it becomes acute ; and do exercises and yoga and physical therapy to help us to get better. Lots of these problems are self-limited and will get better on their own , no matter what – sometimes with bed rest, sometimes with cold compresses and sometimes with physical therapy. However, when it becomes acute, or when your wife starts worrying that you’re not improving , you go to a doctor .

Your doctor obviously needs to do something more than what you already tried - something more than the standard home remedies , so he sends you for an MRI scan, to make an “accurate diagnosis” . Now the MRI scan will give you beautiful images of your intervertebral discs and the spinal cord – and will invariably show that you have a prolapsed intervertebral disc. Your doctor will be very pleased with himself – “ See ! I made the right diagnosis . This is the reason for your backpain !” Since his job is make a diagnosis , this gives him a thrill, because he's identified the problem with the help of medical imaging . Not only is the doctor happy with himself , his patients are also extremely impressed ! The doctor made the right diagnosis – and the MRI confirmed it. The patient can see for himself , in clear black and white , exactly what his problem is on his own scan.

However , because doctors are so focused on diagnosing problems , they actually don’t realize the downside of all these imaging results. Once the patient has seen a prolapsed intervertebral disc on his MRI scans he now stops focusing on his back pain and starts worrying about this lesion. He treats himself as a patient, someone who’s “ broken “ his back ; or someone has a weak back , and needs to rest – someone who can't play tennis or do the regular physical work out he used to in the past (when he had back pain , but before he had done the MRI scan. ) Once he's done an MRI scan , he now has a mental image that his body is broken , so that it doesn't work properly . He thinks of himself as being an invalid , and can't function properly anymore.

The tragedy is that these medical imaging procedures cause patients to focus on the problem rather than on getting better - and unfortunately, there's very little doctors do about this. Rather than sit and explain to the patient that a lot of these lesions will regress on their own; that they have a dynamic natural history ; that the body can heal itself and that many will get better on their , they will often advise the patient to repeat the scan every six months , to see how well the lesion is healing. Patients will often comply , just to see how well their disease is doing. The reality is that a lot of these lesions seen on the images have no correlation with either the symptoms or the progression of the disease ; and while they make great pictures for the doctor’s album they often don't help the patient at all !


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Friday, February 03, 2012

Adoption - the old and the new

Adoption is a great way of building families for infertile couples. This is an option which is been available through the ages , and many infertile couples feel that in case their IVF treatment cycles fail , they can always adopt a baby. However, the reality is that adoption has actually become much harder than doing IVF treatment !

This is because there just aren’t that many unwanted babies available for adoption anymore. This is true even in developing countries such as India, where women are becoming more educated and are no longer having unwanted pregnancies because use contraception ; and will terminate unwanted pregnancies . As a result, there are very few babies who are given up at birth or abandoned, which means there just aren't many babies left for adoption anymore.

This is good , because you don't want babies to be abandoned , but what happens to all the infertile couples who want to adopt babies ? Where do they go ? The fact remains that waiting list are now routinely anywhere from 2 to 3 years long - and even after being on the waiting list, there’s no certainty that couples will get the baby which they want.

The good news is that technology has come up with a clever solution , so that instead of doing a post birth adoption of a child, it’s now possible to do an in utero embryo adoption. This actually has a number of advantages as compared to traditional adoption . For one thing, there are no waiting lists because frozen embryos, which have been donated by other infertile couples who have got pregnant and don't want any more babies , are fairly easily available all over the world . Even better , it allows the mother to experience pregnancy and to bond with the baby . From a social point of view it's better because no one else is aware of the fact that your baby was conceived as a result of embryo adoption. This means that the name on the birth certificate is yours, so that there are no long-term issues as regards legal inheritances . Equally importantly, there is no problem with the risk that the baby may have suffered in utero because the mother ( who is going to abandon her baby at birth) did not provide the baby with the right antenatal care. For example she may have smoked should have abused drugs or alcohol because she was an irresponsible mother who didn't want the pregnancy in the first place. After birth , a lot of babies which are handed over for adoption are forced to spend about 3 to 6 months in an institution. Now this can't be very good for them and it does have an adverse impact on their emotional and mental development . The advantage with embryo adoption is that it's possible to bypass all the problems associated with traditional adoption , so that infertile couples can get the baby they want without having to go through the long and convoluted process of traditional adoption.

Times have changed and we need to change with them – and this is all for the best.

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