Tuesday, April 30, 2013

Waiting for the patient


Patients love complaining about doctors who make them wait ! It’s common to see patients waiting patiently while the doctor is taking his own sweet time , talking to a medical representative ; or seeing a VIP patient out of turn , causing his scheduled to go out of whack . Often the doctor gives an appointment when he knows he is not going to be in the clinic at that time ( because he is scheduled to be in another clinic at the other end of town !) ; and many doctors overbook , by giving many patients an appointment at exactly the same time , as a result of which patients have to be patient.
 
They also tend to get irritated and angry - and sometimes this resentment boils over ! I think this phenomenon is a reflection of poor time management - and means that the doctor doesn't respect his patient's time.

However, just like there is a problem with doctors who make patients wait , there is also a problem with patients who make doctors wait. This may be surprising , but is not uncommon - and this vexing problem is called " no-shows " in medical practise management jargon.

These are patients who treat doctor's  appointments a bit like restaurant bookings - and just like they book a table at a restaurant and then decide at the last minute not to turn up at all, they do this for clinical visits too. This can be extremely disruptive for the doctor . If he is a conscientious doctor who values his patient's time; and gives appointments and sticks to them, then if the patient doesn't turn up , this just ends up wasting 15 minutes of his life, which he could have used more productively seeing other patients.

Unfortunately , patients don't realize the damage they cause by not showing up for appointments , in spite of taking a confirmed appointment . If this starts happening , the doctor retaliates by overbooking, to make sure that even if some patients don't show , up his schedule and productivity don't get adversely affected. He then ends up penalising all his patients - and this is how a few bad apples cause harm to everyone !

This is a big problem in India, where we often don't have a very good sense of time and are not very respectful of punctuality . This creates a negative vicious cycle , because if the patient makes the doctor waits, the doctor in turn makes his patients wait. The patient then feels - what's the point of going on time, because my doctor will be running late and will be make wait anyways. He ends up not bothering to come on time, so the situation gets progressively worse .

The real tragedy is that it is careless patients who end up penalizing the punctual and careful doctors and patients. I wish there was an easy solution to this problem !

Monday, April 29, 2013

Websites for hospitals

Why should I bother to know all this stuff ?


 
A lot of times when I'm explaining IVF treatment options to patients, I find that their eyes glaze over while I am explaining the intricacies and nuances of IVF treatment. They often seem to wonder - Why you telling me all this ? Why do I have to know all this ? Aren’t you the expert ? Isn't this your job ? I know that you're a good doctor and have faith that you will do the right thing for me, so why are you telling me all this ?

I  can understand why many patients are not very keen on learning all the intricacies about medical treatment - after all, biology was not everyone's favorite subject in school. Some of these concepts can be difficult to understand , and it takes time and energy to figure out what’s happening – and busy patients have other things to do in their life !

I explain to patients that I am not trying to make them IVF specialists, but there are many reasons it is extremely important to know all the ins and outs of your treatment.

For one thing , the success rates with any treatment are never going to be hundred percent. And because the outcome is uncertain , unless patients invest time and energy in understanding the process , they will never have peace of mind that they've given it their best shot .

Equally importantly , not every doctor is necessarily good and competent, which is why you need to do your homework. How do you know whether what your doctor is proposing makes sense or not ? Yes, it's s important to trust your doctor , but you cannot blindly give this away, just because of his reputation or because it's convenient for you to do so .

Also, do remember that even if the doctor is well-meaning, he cannot possibly read your mind . The very fact that there are so many treatment options available in IVF - ranging from basic IVF to donor eggs to embryo adoption to surrogacy , that you must know exactly what your priorities are . If you don't , it's quite likely the doctor may end up overtesting and overtreating you - and this is likely to hurt !

One of the unacknowledged reasons patients would rather remain clueless and not

know all this stuff is because it's very comforting to leave everything in the doctor's hands and let him do what he thinks is best ! If this were a perfect world, where you had the best possible doctor in the world , who would know exactly what was right for you , and if IVF had a 100% success rate, this would be perfectly reasonable . Unfortunately , the real world is far messier. Doctors are not always perfect - and many may have a hidden agenda . This is why it's so important to do your homework for yourself !

Saturday, April 27, 2013

Why doctors don't respect patients

Then there are doctors who see a packed waiting room as a badge of honour. Some doctors “routinely make patients wait for two to three hours and then boast that patients are willing to put up with so much trouble in order to see them,” says Mumbai-based IVF specialist Dr Aniruddha Malpani.

How long you end up waiting is also a function of how popular a doctor is. Most patients find doctors by asking around -- who’s the best doctor for delivering a baby? Fixing a broken hip? The bigger the reputation, the longer the wait. But what to do? When you’re sick or desperate, you want the ‘best’. And so, patients will plead for just two minutes with the Big Guy. Waiting? No problem.

“Doctors don’t respect patients because patients don’t demand respect,” says Dr Malpani. Is there a way out? Here’s what patients can do. They can come prepared, study the web, make a list of symptoms and questions. Doctors on their part could leverage technology. Put up information on a website, for instance, so that patients have basic questions answered before they come in.

http://www.hindustantimes.com/editorial-views-on/NamitaBhandare/Our-blood-pressure-s-rising/Article1-1050961.aspx                                          

Why do some embryos stop growing in the IVF lab ?


If you have gone through IVF, you may have heard your IVF doctor or embryologist say - “Some of your embryos stopped developing (got arrested), and we had to discard them .” There are some unlucky women who end up with no embryos to transfer,  because all their embryos stopped developing at some time point during their preimplantation growth ! Why does this “developmental arrest “of embryos happen ? Are there any ways to prevent it ?

About 15% of IVF embryos arrest during mitosis (during cell division) at the 2-4 cell cleavage stage. Some arrest immediately following fertilization and will not divide past the one-celled stage. Over half of all arrested human embryos display chromosomal abnormalities (genetic defect). This means the commonest reason of in vitro developmental arrest is a genetic problem, which prevents the growth of abnormal embryos. However, this is not the only reason for the arrest.

. An embryo might undergo developmental arrest because of :

1)    Sub-optimal culture conditions
2)    Chromosomal abnormalities
3)    Failure to activate its embryonic genome
4)    Mitochondrial defects

When embryos are exposed to sub-optimal culture conditions in the IVF lab ( for example, when the lab incubators malfunction; or if there is an infection in the culture medium) , they might stop dividing further because of the insult they have suffered. If you learn that the greater proportion of your embryos have stopped growing, please ask the the embryologist about the possibility of lab error, and ask them to show you how embryos from other patients are faring under the same culture conditions. This will help you to understand whether lab conditions have played a role in the growth arrest of your embryos . Some labs maybe understandably reluctant to share this information with you, and this should serve as a red flag.

Oocytes from women of advanced maternal age have a higher chance of carrying genetic defects such as aneuploidy (wrong number of chromosomes). Such oocytes , when fertilized , can give rise to embryos; but depending on the chromosomal abnormality they are carrying, they stop growing at different time period. Some do not get past the single-celled stage (zygote stage); some stop developing before they are transferred to the uterus (in the IVF lab petri dish); some after being transferred to the uterus; and some even after implantation (remember that 60% of miscarriages happen because of a genetic abnormality in the embryo !). Genetic lesions in embryos are one of the commonest factors for developmental arrest, which is why embryos from older women are more prone to growth arrest when compared to embryos of younger women !

When the egg and the sperm fuse together , fertilization happens and an embryo is formed. The embryo thus formed carries the genetic material from both the mother and the father. On the first day of its formation , an embryo is just a single-celled entity. This single-celled embryo develops into a full-fledged baby provided it carries all the necessary genetic information .  The initial few cell divisions of a single celled embryo are carried out by the information provided by the oocyte (egg) and not by the sperm . The cytoplasm of the egg contains key information which will help the embryo to divide upto the 4-8 cell stage. It is only after the the 4-8 cell stage that the embryos’ own genome gets activated , and it produces the information necessary for further development. In some embryos this genomic activation fail to happen and they stop developing past the 4-8 cell stage, causing developmental arrest.


An embryo needs energy for its development.  The energy requirement of the dividing embryo is met by specialized organelles called mitochondria, which are called “cellular power plants”. They carry their own genetic material. They synthesize energy molecules called ATP (Adenosine triphosphate). ATP is the “energy currency” of a cell and the cells utilize ATP to carry out several functions, including cell division. Because the mitochondria are found in the cytoplasm, the embryo gets all its mitochondria from the mother - from the oocyte cytoplasm The mitochondria from the sperm are immediately degraded after fertilization. When eggs from a woman of advanced maternal age are used to form embryos, there is a higher possibility that these mitochondria are genetically or functionally defective (as a result of aging !) Such defects compromise their function, including ATP production, as a result of which the embryo might not get enough energy to carry out its cell division , and will eventually stop dividing. This kind of mitochondrial dysfunction of oocyte has been proposed as one of the causes of developmental arrest. It has been shown that when the cytoplasm ( which contains the mitochondria ) from the oocyte of young women is transferred to the oocyte of older women (cytoplasmic transfer) , the developmental capability of the embryos was restored. Such kind of cytoplasmic transfer is being used to treat certain forms of infertility, leading to live births; but their efficacy and safety is yet to be appropriately investigated !

Once you find out your embryos have arrested in vitro, can anything be done to revive them  ? Sadly, the answer is no.  The arrest is irreversible and these embryos cannot be rescued. The important thing is to document this; and learn from it, so you can improve your chances of success in your next cycle.

If you are an older woman who has experienced developmental arrest of your embryos, donor oocytes can be a very good alternate option to have a baby. If you are young, and if you were informed that all your embryos have arrested, you should consider changing the IVF clinic. If this situation repeats itself, cytoplasmic transfer is one treatment option which you could explore; but this treatment is still in its infancy, and is not practised widely. If you are undergoing IVF, you should be aware that a very small percentage of your embryos can arrest during their development in IVF lab, and this is quite normal.

You should always ask your IVF clinic to provide you with photos of your embryos ! You can see what embryos should look like at www.drmalpani.com/embryos.htm

The bitter truth is that during IVF, not all the eggs can be fertilized; not all the embryos which are formed will be good enough to be transferred to the uterus; and not all the embryos which are transferred to the uterus will develop into a baby. Which embryo will become a healthy baby is a million dollar question, and hopefully in the near future, with the help of scientific advances, we will be able to pin point that single “good embryo” which will grow into the much desired baby. Until then it is wise to remember this – “all babies come from embryos but not all embryos can become babies” !


This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.


You can email Manju at manjupadmasekar@yahoo.com


Her blog is at www.myselfishgenes.blogspot.com

Friday, April 26, 2013

Why are Indian hospital websites so bad ?

Even though Indian hospitals claim they are world class, their websites are of poor quality because they only provide information about the hospital and their doctors and their services . They are not patient centric - they provide very little information which patients want and need - for example, information about symptoms or accurate , easy to read information about diseases. This is a wasted opportunity ! Online marketing is a great way to attract patients - but providing patient-friendly content which patients can trust is the first step in this journey - Content is King !

Thursday, April 25, 2013

Why do doctors get irritated by patient's questions ?


Most patients believe that doctors don't like to be questioned . Many get irritated when the patient asks too many questions and this is very obvious - both from their conversation as well as their body language . The doctor wants to move on with the consultation , and feels that having to answer what he feels are irrelevant questions from the patient is a waste of time for him .

Why are doctors reluctant to answer questions ? One reason is that it takes time to answer queries, and doctors are busy people . The more the time he spends on answering questions, the less the time he has to see other patients . Doctors have mastered techniques to maximize their efficiency and will do their best so they can move on to the next patient !

You, on the other hand, want your doctor to answer all your queries. You know how precious his time is - after all, it's taken you for weeks to get an appointment to finally see him ! You don't know which queries are relevant and which of your concerns are medically important, which is why you have a long list of questions - after all, it may take months before you may get a chance to see your doctor again.

Doctors are reasonable people, and understand your concerns . They'd be quite happy to answer your important queries and field the others for some other day , especially when he is running late !  However, what really irritates doctors is that lots of patients will think nothing of asking questions about their uncle's blood pressure - questions which just end up causing the doctor's blood pressure to rise, because he's busy.

Sometimes doctors get irritated because the questions are completely irrelevant and just show that the patient is completely misinformed. This can be quite frustrating, because doctors would rather deal with intelligent patients , who have taken the time and trouble to do their homework before coming to see them .

At the other end of the spectrum are patients who irritate doctors because they come with a long generic laundry list of questions which they have printed from the Internet . While it's good to have a checklist of questions , before you subject your doctor to an inquisition, the least you can do is try to figure out the answers for some of them for yourself.

Asking the right questions is an important part of medical treatment. Your doctor is there to answer your questions and encourage you to ask them, but in order to get the most out of your time with a physician, you should focus on asking the right questions rather than as many questions as you can think of.

The answers to a lot of questions are available online - and if you take the time and trouble to research these before your consultation. you will be able to ensure that your doctor can deal specifically with the particulars of your case, thus allowing you to make more efficient use of his time , without getting bogged down asking generic questions.

Finally , there are some doctors who may feel threatened by their patient's questions . They may feel that patient knows too much - more than even they do . This creates a feeling of insecurity, especially when then they know that they are not as well-informed as they are supposed to be . It's not humanly possible for a doctor to be a specialist in everything - and this is specially true if you are a family physician . Rather than being honest and upfront with the patient , some doctors will try to brush off these questions. They will often do this in a disparaging manner , and some will put the patient in his place by saying things like - A little knowledge is dangerous; or - Don't try to become a half-baked doctor !; or - You don't need to bother your head about all these trifles - I will take care of you !

Good doctors encourage questions . They understand that medicine is not a perfect science ; that outcomes are always uncertain ; and that the more the patient is engaged in his care , the better the outcome is going to be - both for the patient and the doctor. However, if the quality of the questions is poor, any doctor , no matter how good he may be , is likely to get irritated and put off . Therefore , if you feel that your doctor is getting irritated by your questions , you need to ask yourself - Is there a problem with the doctor ? or - Is there a problem with me ? Am I asking poor questions ?

The solution may be to work on improving the quality of your questions , and presenting these to your doctor in  the manner he prefers. While it's true that some doctors may feel threatened , because this is not their style of practicing medicine . They are used to unquestioning obedience - from nurses , assistants and patients ! They are not accustomed to the patient asking them questions , because of the paternalistic style of medicine which they have been taught - and which they have practiced successfully for many years. They they may feel that the patient is challenging their authority , and may get agitated and upset when the patient asks too many questions. Fortunately, this older generation of doctors is gradually passing away, and most young doctors take a much more enlightened approach towards answering the patient's questions.

Th smarter ones are using technology ( such as online FAQs and youtube videos) to answer their patient's common questions, so that they don't have to repeat the answers for each patient !


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Wednesday, April 24, 2013

The most important question your doctor can ask you !


One of the most useful questions to ask a patient is – What do you think is wrong with you ? The second most useful is – What did your earlier doctor tell you ? This gives me a lot of insight as to how well informed the patient is ; how much she understands about her problem; how realistic her expectations are of the medical treatment ; and insight into her emotional state of mind , as to what her fears and anxieties are.

When the patient tells you what she thinks is wrong with her, it tells you more about how well she understands human anatomy and physiology ; and this is useful to know , because this becomes the starting point for your explanation . Good doctors start from where the patient is , and then educate the patient starting from that point .

The patient’s description of that their earlier doctor told them tells you how much the patient understands from their earlier medical encounters. Often , when the patient says the doctor didn't tell me anything ( a very common answer !), it either means that the earlier doctor was not very good at communicating; or often that the patient is not a very good patient and did not bother to ask his doctor any questions or do her homework in order to verify her doctor’s advise. This is potentially a red flag , and means that this patient will require a lot more handholding as compared to patients who are willing to invest in information therapy.

Sometimes patients don't understand why I ask these questions . They wonder why I want to know what their earlier doctor said ! They are worried that this means I may not know enough to draw my own conclusions. After all, they have come to be because they want an independent second opinion. They are worried that sharing the earlier doctor’s opinion may skew my opinion and cause me to be biased . This is not true. A good doctor will always factor in what someone else has said – and then make up his own mind. However, this is a useful starting point – why not take advantage of what the earlier doctor has done ? After all, there’s little point in repeating the same tests and treatments !

Unfortunately , there are still patients who like playing games with their doctor. So they start by telling the doctor they do not have any medical records – and then half way through the consultation ( perhaps when they feel the doctor is competent !), they start pulling out their earlier test results and prescriptions ! This is not something I would advise, because it irritates the doctor – and wastes his time as well as the
patient’s.


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Tuesday, April 23, 2013

Non-profit ? Or Beyond Profit !


I had the good fortune to meet Harold Rosen , the CEO of Grass Roots Business Fund in Mumbai, at a meeting they held for the Mumbai Angels, of which I am a member.  GRBF has have been doing some great work with helping social entrepreneurs create businesses which are sustainable, scalable and have a social impact . He talks about converting Social enterprise ( with a capital S ) to a social Enterprise with a capital E. The logical extension would be to create a Social Enterprise with both a capital S and a capital E !

Is it possible to achieve that balance between doing both social good and being profitable ? This is very similar to the question of achieving work-life balance which all of us face in our daily lives - how do we manage to balance both personal satisfaction with professional achievement ? We manage to learn over time  as we mature - and I think companies can learn this as well, as they mature - they need to learn to balance profitability with impact !

The problem is that because it‘s so easy to measure profitability , this is what economists have spent most of our time and energy doing. It’s easy to work with numbers ! However, it’s much harder to measure impact, because it’s often intangible  . However, businesses do this all the time – for example, when they put a value on their brand name or goodwill. The Grass Roots Business Fund is now creating social metrics , to allow us to do this for impact as well.

I do not think these companies should be called nonprofits. This is a very negative word, which suggests  that they make losses – and that it’s acceptable for them to do so ! A far better word for them would be Beyond Profit Companies - BPC or BPO ( Beyond Profit Organisations)  . As you grow older , you realize that the measure of your life should no longer be just how many dollars you earned , but far more importantly - what legacy you have left behind and what impact you have had on the world .  As we mature , we understand the importance of going beyond just counting the amount of money we have in our bank balance ! As capitalism matures, companies will realize that just being profitable is not enough !

Rebranding these companies as being Beyond Profit companies, rather than calling them nonprofit companies is important, because the term nonprofit really doesn't express anything. We need a better meme !

A Beyond Profit company is one which not only makes a profit, but also does extraordinary things which ordinary companies don't do – they help to make lives better , while making money ! This also fits in well with the aspirations of the younger generation , who understand it's important to strive both for making money and for creating an impact. Otherwise you end up becoming a very rich 50-year-old senior bank executive,  who have a humongous bank balance , but who now suffer form mid life angst, because they wonder what good they’ve accomplished with their lives !

They then start thinking about what they can do to help other people who are less fortunate than them – which is why you have people like Bill Gates who set up philanthropic foundations ! Now this is a good thing to do – but a better model would be to start when you're younger , and start doing both things – making money and doing good  simultaneously,  so that you then create a positive virtuous cycle !

Names are important, and the problem with the label non-profit is that these nonprofits are considered to be a second class asset class. Investors are reluctant to invest in them because they feel that the returns on investment are not going to be good enough. The only reason these companies design themselves as being nonprofit is that they have the insight to understand that the only goal in life is not to maximize their profits ! Trying to do so means that you often end up ripping customers and charging them an arm and leg. This is not always the best way of doing business – either for the customer, the company, ,or its employees ! In the long run, it may be more enlightened to reduce the amount of money you make , to ensure that everyone benefits in the long run . These companies are driven by vision , and if they need to remain honest to their mission, it's important that they think about goals which are more important that on maximizing profits.

Take the example of Healthwise , whose mission is to help people make better healthcare decisions . This is one of the reasons why they will not accept any funding from any pharmaceutical company or medical device manufacturer, even though these companies would be very happy to buy out Healthwise ! If Healthwise were a for profit company, it'd be extremely logical for them to sell out and make big bucks ! After all , if your first responsibility is to your shareholders, and you run a company for making money, then this is the “ right “ thing to do. However, if you take that route , the trouble is that the information you provide gets corrupted and contaminated as a result of corporate influences , and then you are no longer an influence for good - you actually end up being and influence for creating harm ! 

Rather than think of them as being as second-class companies , which don't offer as good a return on investment as for-profit companies , we need to realize that they actually offer a better return on investment , because not only are they capable of making money, they are also capable of doing something which is far more important - doing good in this world. The world has more than enough money - what it really needs is more people and more companies whose focus is on doing good , and not just one getting rich.

As an analogy, compare the life of a CEO and a doctor . While the financial income of doctors is a small fraction of a corporate honcho, their emotional income is a hundred times better ! The satisfaction we get when we see our patients smiling because they are getting better; the satisfaction we get when patients say thank you because you saved my life; the satisfaction we get when patients say Thank you , Doctor , for doing such a good job of taking care of my father – how can the happiness a CEO gets by doubling his bottom line possibly compare with this kind of joy ? One of the reasons people become doctors is because they want to help others. Being of service to others is very fulfilling - and after a particular point, the amount of money you have in your bank balance makes very little difference to the amount of happiness you have in your life. The best way of being happy yourself is to create happiness for others,  and doctors have the good fortune to experience this delight daily, by being of service to others.

Beyond profit companies also have the same ethic ,  and this is why these are the kind of companies which attract mature and motivated  employees , who are extremely faithful and committed , and who will remain with the company for long periods of time , because they understand that there is more to life than just earning money . They are grateful that their company gives them a chance to interact with people whose lives they can improve – and this helps them to feel good about themselves. This gives them far more job satisfaction than just earning a little more money !

Does the fact that not-for-profit companies are less profitable than for-profit companies mean that the grapes are sour, and that I am concocting arguments to justify their poorer financial performance ? Not at all ! It actually requires a lot of maturity for a person to say - I have enough for myself, and I do not need anymore ! My focus should no longer be on just trying to earn more money , but on trying to create a better and happier life both for myself , my employees , and my customers ! It's when you reach that stage of enlightenment that not only are you personally satisfied , you are also professionally contented that you will leave behind a legacy which you can be proud of. This is what our focus should be on. Many of us take a long time to reach thus maturity – and some of us never get it. Often by the time they're 45 of 50 , many of us have an epiphany, by which time it’s often too late to reinvent yourself. The good news is that the younger generation seems to be much smarter , and realizes that there is far more to life than just earning a higher paycheck .

Beyond Profit Companies have the wisdom to be able to say – Enough ! Others are forced to resort to gimmicks and window dressing in the garb of Corporate Social Responsibility, in order to salve their conscience.
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Monday, April 22, 2013

Why are there so many "treatments" for failed embryo implantation ?


As an IVF specialist , one of the commonest questions patients ask me is - Why did my IVF cycle fail ? This is a perfectly valid question , and I can understand why patients want an answer. After all, once we knew what the problem was , it's quite logical that we would be able to find a solution for it ! However, the sad truth is that our technology has limitations and it's not possible for us to answer the question as to why an individual IVF cycle fails. After all , when you transfer a microscopic ball of cells inside the uterine cavity , it’s impossible to determine its fate and to find out exactly why the embryo did not become a baby ! Did the embryo arrest (stop dividing ) ? Or did it fail to implant because there was not enough endometrial blood flow ? Unfortunately, when we can't answer these questions , patients get frustrated and upset .

The right answer is - We don't know ! However , when you tell patients the truth, they get upset, because they feel that if you don't know what the problem is, how will you ever find a solution for this ? They start getting extremely pessimistic – and even worse , they start doubting the doctor’s competence ! They
feel ( but rarely express loudly !) – If this doctor cannot even provide answers to these basic questions, how will he ever be able to get me pregnant ? They therefore start looking for second opinions and start doubting the doctor’s ability ! ( This is truly ironic, because only a very confident competent doctor has the courage to say – I do not know . However, few patients have the maturity to appreciate this forthrightness !) This is often why many doctors ( because they are under pressure to come up with answers), rather than being upfront with their patients and telling  them the truth , will start doing exotic and expensive tests , and coming up with fanciful answers such as “ immunological rejection of the embryo “ to keep their patients happy.

We all know that a lot of these patients will get pregnant in their second IVF cycle, even if they repeat exactly the same treatment protocol which they did for their first cycle ( and we will never know why the second cycle worked or why the first cycle failed !) Of course, if the doctor does make a change ( for example, he adds “ new treatments” such as intravenous immunoglobulins ( IVIg) or low molecular weight heparin ( LMWH), the patient is happy to give credit to this intervention for the success !

This is one of the reasons why there are so many myths and misconceptions about what can be done to increase the chances of embryo implantation. This flawed reasoning causes a lot of confusion. For example, if the patient has done one IVF cycle which failed, and then the doctor does a second cycle after giving IVIg, and she then gets pregnant in the second cycle , the doctor logically jumps to the incorrect conclusion that it was the IVIg which converted the failure to a success . He starts swearing by IVIg; starts presenting his results at medical conferences; and starts putting all his patients on IVIg, without ever scientifically analyzing whether the IVIg actually had anything to do with the success !

This is why the field of failed embryo implantation is full of myths, misconceptions and half truths , and lots of doctors and patients are confused. The trouble is that unless patients have the maturity to understand that doctors don't have all the answers, this vicious cycle will continue. Of course, the “answer” will change from decade to decade, depending upon what seems to be the molecule in fashion at that particular time .

The bottom line is that the quality of the doctors answers depend upon the quality of the patient's questions . Unsophisticated , poorly informed patients ask poor quality questions , which end up compromising their medical care . Conversely, patients who invest in information therapy ask intelligent questions , thus ensuring they are satisfied and happy with the quality of medical care they receive.

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Saturday, April 20, 2013

Healthwise, Aravind, healthcare, spirituality, nonprofits and missions


In the last two weeks , I have come across two remarkable organizations in the healthcare space . They are located at diametrically opposite ends of the world, but they are uncannily similar !

One is Aravind , the world’s largest eyecare organization, located in Madurai in south India ; and the other is Healthwise , the world’s largest producer of health educational materials, in Boise in north USA.  Both are world leaders, but what’s amazing is that even though they are located on opposite parts of the globe, they are uncannily similar, because both are nonprofit organizations , which are mission driven.

Both have been started by individuals who had a vision for making healthcare better. One was a retired ophthalmologist , who wanted to cure needless blindness ; and the other is a founder who believes that patients are the largest untapped healthcare resource - and that information therapy can help them to get better healthcare . They are manned by people who subscribe to that sense of mission - who have imbibed the company culture , so that the people who work at both Aravind and Healthwise believe in what they're doing. Not only does this affect the company’s DNA , it also makes sure that everyone is on the same page . Their ability to retain employees is remarkable , and both have many talented people who been working with them for over 10- 15 years – even though they could be earning much higher salaries elsewhere. This helps is ensuring continuity and longevity , so that they will outlive the founders and will remain sustainable.

The other remarkable thing is that even though both are doing such great work , they are very down to earth and humble . You actually have to go out of your way to find out how great some of their accomplishments have been ! It’s been such a pleasure to find organizations who accomplish so much without talking too much – this is such a refreshing contrast to the big boys in the healthcare space who are quite happy to hog all the limelight and tom-tom their capabilities, even though they may not actually accomplish a whole lot !

Another common denominator seems to the sense of spirituality which imbues their work. This is not a term they use in their daily work, but they both agree that they are “mission gifted” !
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Friday, April 19, 2013

What makes Healthwise so special ?



When you see a successful organization like Healthwise, the first question you ask is - What makes this organization so different and so special ? Why does it work so well ? How is it possible to replicate them ?

A lot of what makes them so special is intangible.

The Healthwise mission statement is simple – We help people make better healthcare decisions. Most companies have equally memorable mission statements, but what makes Healthwise remarkable is the fact that this actually does drive the entire organization . This is something that each individual employee believes in – it’s not just something which is published on a website or plastered on the Annual Report.

There are three principles which guide the work done at Healthwise. The first is respect. The second is teamwork . The third, and perhaps the most important of all is - do the right thing. This is an organization which doesn't just pay lip service to these statements , unlike most other organizations . The employees actually live and breathe these principles in every act they perform . I think this is what differentiates a good organization from a great one.

This is one of the key criteria which Healthwise uses in selecting new employees – is this the kind of person who believes in our values ? Will she be able to live by them ?

The other remarkable feature is how humble everyone here is . They have great self-esteem, and are proud of what they are doing , because they know they are doing some great stuff - but they are not being self-congratulatory about it at all . They just get on with doing their job, to help improve the world and make it a better place for all of us !

The founder and leader plays a great role in shaping the DNA of an organization , and Don Kemper is a great role model. He truly inspires his employees , all of whom hope to follow in his footsteps !

( In case you are wondering why I selected this image, please note the gorgeous dog in the lobby of the Healthwise office building. Staff are welcome to bring their dogs into their office - and most take their dogs out for a walk daily. Not only does Healthwise talk about improving health - they actually practise what they preach !)

Thursday, April 18, 2013

The 3 Ps for producing high quality patient educational content

One of the interesting things I learned at Healthwise is that while it is easy it is to write content , it’s extremely difficult to write high-quality content . Writing generic health content is extremely easy – the challenge is to design content which is engaging to the user , so that the user will take action , thus helping them to change their behaviour and make better healthcare decisions.

We all know from personal experience that changing our own behavior is very difficult ( remember the last time you tried to stick to a diet ?) Changing someone else's behavior is even harder , and unless you provide the right information to the right person at the right time , this information is of no use at all, even though it may be crafted well. This means that just creating high quality reliable content is no longer enough.  Even if you have high-quality messages which are written in plain English , the important thing is that they need to be personalized.

How can you tailor the message to a particular individual ? You need to understand what the needs of an individual are at that particular point in his life . If you target the right person with the right information , his chances of taking action are far more as compared to just giving him over 100 pages of print and telling him - read this and try making sense of it.

This is where the Healthwise concept of the 3 Ps ( Plain, Personal and Possible) comes in . The information should be in Plain language; it should be Personal ( which means you tailor the message by understanding how the user thinks and makes decisions , using the science of user experience, persona and mental
models ); and it should be Possible – which means the information should encourage the reader to think that it's possible for him to make the recommended changes . These need to be small changes , one at a time , which focus on what he can do , rather than what he cannot.

If you put all this together , it's possible to produce messages which can be extremely effective, but as you can imagine, this is not a simple exercise and most people aren't willing to take the time and trouble to craft persuasive messages which are going to impact the user in a way which makes a difference to them and causes them to take action. This is what makes Healthwise content so special !

Wednesday, April 17, 2013

Less is more


One of the important things I learned by visiting Healthwise is that sometimes less is more please . I used to think that if you had lots and lots of content , this proved you were better. Because medicine is such a vast field, and because patients want information , it’s important to be comprehensive and encyclopedic and make sure you cover everything.

Unfortunately, people are not very keen to read a lot about their health problems. Reading educational content not the same as reading a novel. When people are sick or ill , they are confused , and they basically want concise bits of information which are relevant to their needs. Rather than drowning users by providing them with too much information, which leaves them more confused than ever, Healthwise is repackaging its content .

By chunking up its content into small paragraphs, each of which is extremely well and tagged with keywords and metadata , it's possible for the user to retrieve exactly what information is relevant to her needs . This means that the information which is provided is very specific. This can be done because you know a lot about the user ; and because the information has been properly tagged , so that it's possible to match the needs of the user very specifically. This is a smart approach and works very well. This is especially true today , when people have short attention spans , and access information on their smartphones. The last thing they want to do it to scroll to read to tons of content.

Healthwise is also reinventing itself. Because users find video far more engaging and memorable than the written word, they are creating an extensive library of 2 minutes video modules ! By adapting its contents to the needs of users, and staying uptodate with the latest technology platforms, Healthwise shows that its respects its users.

Tuesday, April 16, 2013

How to earn your doctor’s respect


The commonest complaint patients have about doctors is that they do not take the time or the trouble to explain to them what's happening . Doctors are notorious for cutting off patients right in the middle of a sentence. They also use a lot of jargon, thus obfuscating matters and confusing patients. This causes patients to become frustrated and unhappy , because they feel doctors are not being transparent ; and are not willing to share information.

It's not that doctors are trying to hide information from their patients . Doctors are busy people , who obviously want to increase their throughput , and see as many patients as quickly as possible. This is why when the patient asks a question , the doctor tries answering it as quickly and efficiently as possible. This often means that he uses a lot of jargon , which the patient often doesn't comprehend . The doctor doesn't take the time or the trouble to figure out whether the patient has understood what he's saying, thus creating a vicious cycle. Patients are intimidated, and will often sit in front of the doctor, nodding their head, even though they are completely clueless about what the doctor is saying. This is increases the gap in doctor-patient communication.

While it's true that the amount of time which the doctor will have to spend with patients will always be at a premium , there is a simple trick which patients can use in order to make sure that doctors answer their questions properly . The trick is to craft  their questions intelligently . This will ensure that the doctor will pay attention to your questions and answer them properly . If you use the right medical terms, the doctor is much more likely to respect you, because he will understand that you know what you are talking about !
You need to earn your doctor’s respect , and the best way of earning the respect is by doing your homework before the visit , so that you are well informed about what your problems and possible treatment options. If you well-organized and you ask  intelligent questions which show the doctor that you've done your homework , the doctor will respect you as being a smart patient , and will make sure that he answers your questions properly and carefully.

The rule is simple – the squeaky wheel gets the grease , and the more the time and trouble you take in educating your self , the more your doctor will be willing to respect you and educate you even more. Since you can't possibly change the doctors behavior , the key is to learn to change your own behavior , so that both you and your doctor are likely to be much more satisfied with each other !

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Monday, April 15, 2013

Healthwise in India


Even though I have been working with Healthwise for over eight years, I am ashamed to say I didn't know much about how they actually went about creating their patient educational content until I visited them in Boise.

We've been having a hard time promoting patient education in India , even though there is such a great need for it. Patients are all online , and are looking for information which they can trust - but they often get lost and confused , because there is much garbage online. Doctors often get irritated by patients who carry pages and pages of Internet information , because so much of it is unreliable.

Healthwise provides a win-win solution, because they have done a great job of producing high-quality patient educational content , which is distributed through hundreds of sources in the US - hospitals ; health insurance companies ; web portals ; and even the government . They all use the content regularly and routinely .

I needed to learn how we can replicate what they've done so successfully in the US in India as well. The common denominator between HELP and Healthwise is that we both put patients first – and that patients are the same all over the world ! However, hospitals , health insurance companies and governments in India are stuck in a world which is at least 20 years away from where the USA is today.

However, my learning will help us to figure out where we are likely to be a few years down the road , as India catches up with the rest of the world, so that we will be well positioned to take advantage of these seismic changes in the Indian healthcare system.

While I have always been very impressed by the high quality of the content which Healthwise produces , it's only when I actually visited their office did I realize the amount of effort , time and money which they invest in order to create such as high quality product. Healthwise has over 250 employees – of which more than 30 are IT engineers ! They continue to spend energy in modifying and creating and delivering their information , according to the patient's needs , which evolve as the world progresses.

Because they put patients first, they place a lot of emphasis on  user experience. It’s not just a question of saying – Okay , here's this information – read it and do what it tells you ! It’s far more complex than this, because you need to engage the patient to make sure that he acts based on the information which you provide .

We are finding it hard to get Indian companies to license this health information , so they can provide it free to their customers and patients, even though it is of such high quality. Even though Healthwise has been very successful in doing this in the USA, most Indian companies are not willing to learn from the market leaders in the USA. There is still a lot of resistance in actually investing in these patient educational resources ! Hospitals don't seem to see any value – and they come up with the same excuse - No one else seems to be doing it , so why should we bother ? Health insurance companies in India are still not profitable enough as yet , to be able to invest resources which will help them to differentiate themselves from the competition .

I think it's a matter of time till India catches up with the US , because Indian patients are as demanding as patients in the US  - it’s just as important for them to make the right decisions , as it is for patients in the US ! In fact, the need in India is far more, because there is such an acute scarcity of reliable information which patients can trust. We hope that by learning from Healthwise , we will be able to leapfrog and catch up with the US far more quickly than we would otherwise !

Saturday, April 13, 2013

What can husbands do for their wives during their IVF cycle ?


This is a guest post from an expert patient !

If your wife is going through IVF, there are many ways you can support her.  Most couples find it difficult to talk about their infertility problems and experiences with family and close friends.  This leaves them isolated without much emotional and moral support from the outside.  Women need to talk about their problems and feelings in order to feel better and to gain a realistic perspective on things.  Going through infertility treatment is difficult enough, but going through it alone, with no one to share your feelings with is much worse.  Unfortunately, I think most women end up in this predicament because they feel they have no one to talk to who understands what they are going through.   Husbands know everything that is going on and so they are the perfect person to step in and act as the support system.  This means talking with her about how she feels and about how you feel, and listening to her no matter how much she wants to talk about it.  Make sure she knows that it is not her fault and that no matter what the outcome is you love her and your life will be fine even if you don't succeed in having a baby.  Try to be her cheerleader.  Infertility slowly takes a huge toll on a woman's self-esteem, so do whatever you can to remind her that nothing is wrong with her and she is not any less of a woman. 

A good way to get some insight as to what your wife might be thinking and feeling is to read the hundreds of infertility forums on the Internet, which are full of women talking about their feelings.  Reading about it might make it easier for you to talk to your wife and offer support.  Also, it will probably make your wife feel pretty good if she knows that you are reading the forums and trying your best to understand.  Speaking of the Internet, your wife probably spends countless hours researching everything there is to know about infertility and treatment options.  I think most wives would appreciate it if their husbands spent a little bit of time doing some research too, and being active about making plans.  Often it is the wife who takes care of everything, but I'm sure she would appreciate if she felt your commitment in a more pro-active way. 

If you and your wife are going through an IVF cycle, there are also little things you can do to make your wife feel that you are more involved.  For example, you can remind her when to take her medication and even offer to give her the shots.   Ask her everyday how she feels and if there are any side effects from the medications (she is pumping a lot of hormones into her body)?  Any little thing you can do to let her know that you are going through this with her and are there for her will help.  Even if it is just outwardly showing her that you are as anxious to know how many embryos have and if any implanted.  The two-week wait is more bearable if you are both counting down the days together.


julien102011@gmail.com

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Friday, April 12, 2013

Why we all need Health Guardians in a hospital


It’s always a pleasure meeting Don Kemper, the CEO and Founder of Healthwise. He is one of the world’s thought leaders as to what the healthcare system can do to put patients first ! He has coined a great new term for what I call patient advocates – he calls them Health Guardians . This is a great description ! He believes that there are two constants when a patient is admitted in the hospital: one is his medical record , which everyone refers to ; and the second is the person who's looking after him . We would traditionally call this person a patient advocate , but health guardian is a much better term because it conveys precisely what patient advocates do. The word patient advocate has the negative connotation of being associated with lawyers and disputes and courts and confrontations - but guardian is much more positive . Words carry a lot of weight – and using the right term ensures everyone's interests are aligned ! When a doctor says - I need to talk to your health guardian, the patient feels a lot more confident - and so does the doctor and the guardian.

Health guardians guard your health: they keep a close eye to make sure you are getting the medications and treatments you are supposed to; they ensure things do not fall between the cracks; they prevent medical errors; the make sure that your preferences are respected and that the medical team taking care of you understands your needs; and that the medical staff washes their hands before examining you !

Health guardians act as guardian angels – and we all need one when we enter a hospital !
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Why patients come back for their second IVF baby !


Many patients who do IVF feel their life will be complete once they have one baby.

If you have such a gorgeous kid, how can you not want to have more ?

Thursday, April 11, 2013

How Healthwise creates trustworthy health educational content

I just spent a week in Boise, learning how Healthwise creates health educational materials .

If you haven’t heard of either Healthwise or Boise, this is quite understandable ! It’s a little known secret that Healthwise is the world leader in creating high quality health educational materials – content which is curated, updated , reliable, trustworthy and simple to understand . Now one would think that creating patient education material cannot be such a big challenge - all you need to do is to find the facts ; get a medical writer; simplify the facts ; and then present them ! How hard can that be ? Can’t you just Google for information and find everything you wanted to ? Doesn’t wikipedia provide tons of free patient education information for everyone ?

It’s only  when I visited Healthwise did I realize what a complex task creating high quality engaging patient educational content can be ! It's true that creating basic patient educational materials is not hard - but crafting content which actually helps patients make better healthcare decisions is extremely
challenging ! Writing and delivering content which leads to a change in behavior is one of the hardest thing in the world to do – and this is the standard which Healthwise uses when judging the quality of their content.

Healthwise has a large team of medical content writers who specialize in writing content - but this is not enough. After writing the content , you need to make sure that you can deliver it ! In the old days, you just needed to publish a book – but the print book format is something which is no longer very valuable in this day and age , where most people access information digitally . Healthwise has an entire engineering team, which creates products, which allow them to deliver their content in chunks , which people can use,  when they want it - either on the smart phone or on the PC . Learning how to be able to use technology to deliver content in a fashion that is relevant to the user and is tailored to the user's needs is not a trivial exercise. It involves a lot of additional technology such as meta-tagging and responsive design, so that it's possible for the user to get exactly the right information which she needs at that particular time!

Even after creating an engine to deliver the content , you then need to continue making sure that the content is updated ; is trustworthy ; and doesn't get outdated. This is an ongoing exercise ! Unfortunately, Indians still don't understand the value of good-quality health content , and are very reluctant to pay for it. But as Mark Twain once famously said - Be careful when you read a health book – you may die of a misprint. This is especially true today, when there’s so much unreliable and untrustworthy information on the net - information which comes from quacks ; and from commercial sources such as medical device manufacturers and pharmaceutical companies , whose information is often contaminated and untrustworthy because it's biased – they are just trying to sell their products !

The great thing about the Healthwise information is that because it is produced by a nonprofit organization , whose sole mission is to help people make better healthcare decisions, this is high-quality information which can be trusted. In fact , it can be trusted perhaps even more than you can trust your doctor , because they have no biases or prejudices.

This is why spending the week at Healthwise and learning how they actually go through the process of creating this information was very inspiring !

Wednesday, April 10, 2013

Why has Singapore banned social egg freezing ?


I always thought of Singapore as being an advanced country which offered high quality medical care to its citizens ( they offer free IVF treatment cycles to their citizens) . This is why I was dismayed to learn that they have banned social egg freezing.

Egg freezing is an advance which allows young women to postpone childbearing until they've found the right partner ; or decided that they are ready to have a baby . This is a big boon for young professional women who want to pursue a career. It ensures that biology is not destiny - and that these women can have their cake and eat it too ( just like men can !) It's usually only well-informed successful women who use this option. They know their own mind and freeze their eggs because they are responsible and are thinking well into the future.

The  Singapore government has banned social egg freezing because they are worried that the Singapore population is declining ( this is the reason they provide free IVF treatments , to ensure that couples will have more kids ) ! Their worry is that if they allow the option of egg freezing , then women will postpone childbearing even further ; and that their population will keep on dropping .

This is a typical bureaucratic approach . I am sure most of these decision makers are older men ! This step takes away a woman's reproductive autonomy by saying - Sorry , we are not going to allow you to do this , even though you want to and are willing to pay for this, because we are worried about the social consequences of your personal actions. It’s very easy for a bureaucrat to say no – but is this decision in the citizen’s best interests ? These are not irresponsible flighty young women ! They are responsible , well-informed, educated , farsighted professionals who are making decisions to maximize their own personal best interest. And isn't that what democracy should actually allow women to do ?

One of the arguments which Singapore fertility specialists have used to justify banning egg freezing is that older women have more obstetric complications. Yes , that's true – but that doesn't mean that you should not allow them to explore their choices . This is wrong on multiple grounds . For one, it smacks of gender bias. It’s perfectly okay for an older man to have babies, but this is not acceptable for an older woman ! This is very unfair , especially when she has the technology to ensure that she can freeze her eggs , so that her chances of having a healthy baby remain extremely good , no matter what her calendar age is .

The fact of the matter is that women have many more opportunities today than they did in the past - and their life expectancy has also improved dramatically. Why should we use yardsticks which were developed many years ago for this current generation of women ?

Using this kind of logic , we should be telling all these women to have babies at 20 when their fertility is optimal, rather than telling them to do IVF at the age of 35 ! I understand the concern that this offering this option may cause the birth rate to go down, but in real life, the number of women who will actually pursue the egg freezing option ( which is expensive !) is so small, that it’s likely to have a miniscule impact on society as a whole.

And if bureaucrats really want to reverse the dropping fertility rate, they should logically ban birth control for Singapore women , so that they will be forced to have babies – this will ensure that the Singapore population will continue to grow !


Tuesday, April 09, 2013

Managing an IVF patient's expectations


One of the hardest things for an IVF specialist to do is to manage a patient's expectations. It's hard being infertile and infertile patients come to an IVF specialist with a lot of hopes and dreams and desires. They expect the IVF specialist to help them to have a baby - and understand that IVF represents their best chance of actually becoming parents . Empathetic IVF physicians understand how much rides on the outcome of an IVF cycle, and do their best to keep their patients hopeful. Doctors are naturally optimistic by nature - and when a patient comes to you in pain , you want to your best in order to help them achieve their goal.

The problem is that this often leads to overpromising ! When IVF doctors do a consultation for the first time , they are on their best behavior . He is trying to market himself , because he wants the patient to take treatment which him, rather than go to the competing clinic down the road. Doctors also have high self-esteem , and some of them actually do believe that they are the best IVF doctor in town , which is why the best option for the patient would be to come to them ! ( Also, like all human beings, we tend to remember our successes and forget our failures ). When you want to convince the patient that you are the best IVF doctor , you tend to focus on all the positives and gloss over the things which can dishearten the patient. This is why IVF doctors are often overoptimistic during the first consultation .


This creates the problem that patients have excessive expectations from the IVF cycle. Everyone starts an IVF cycle with the hope that it will succeed , and even though they understand with their head that IVF has a failure rate , in their heart of hearts they think that it's going to work for them. ( No one would strat an IVF cycle if they thought it was going to fail !) This is why when the cycle fails , they often go to pieces. It can be very hard to manage the emotional roller coaster ride .

A good doctor will try to provide a realistic picture , but this can be hard to do - and some patients actually get put off when doctors talk about the possibility of failure. They feel the doctor is being excessively pessimistic , and must not be very confident about his own abilities. IVF doctors have learned the hard way that if they are honest and forthright and discuss the possibility of failure on the first visit, patients get put off because they don’t want to hear about problems – they’d rather go to someone who talks sweetly to them and promises them a baby ! Doctors are scared that being too honest will scare their patient off – and they don’t want to lose their patients to another doctor !

One way of addressing this problem is to make sure that patients get independent counseling . I think it’s even more important that patients invest in information therapy , so they're well prepared and understand that the outcome of any cycle is always going to be unpredictable, no matter how good their doctor is.

If patient expectations are not managed properly , patients are likely to be unhappy and dissatisfied when the cycle fails . They are often bitter and resentful , and a lot of them will vent their anger on the doctor. Sometimes doctors do deserve some of this resentment , because a lot of them actually abandon the patient when the cycle fails . They are not interested in talking to the failures, and would rather focus their energy on attracting the next new patient who is waiting to see them in the clinic, rather than spend time counseling and supporting the patient who is distraught because her cycle has failed. Patients start feeling that IVF doctors are greedy and mercenary – and that their primary goal seems to be to make money , rather than care for their patients. Unhappiness equals Expectations minus Reality - and unhappy patients can create unhappiness for their doctors !

Another way of managing expectations is to offer a guaranteed pregnancy treatment option. You can read more about this at http://www.drmalpani.com/guaranteedpregnancy.htm. This helps to align the doctor’s and the patient’s interests . The patient is comforted that the doctor is willing to put his money where his mouth is !  More importantly, it ensures that the patient no longer thinks about IVF treatment on a single cycle basis – they understand that it may take time to achieve  success, and are willing to invest their time and energy in working with their doctor towards success !

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