Thursday, July 31, 2014

Expert patients versus doctors


Most patients hope that their doctor will provide them with both medical expertise and empathy. We want a blend of scientific skill and emotional support – a sharp mind , as well as a shoulder to cry on.

While we cannot critically judge a doctor’s scientific expertise, we trust that he knows a lot about medical science because he has been certified as being competent after going through medical college , lots of examinations, and many years of training. We use his medical degree certificate as a marker for his technical competence, and believe that this stamp of approval means he is qualified and up-to-date . We use additional surrogate markers to confirm our beliefs ( for example, has he published medical journal articles ? authored a text book ? is he interviewed as an expert by the media ?)

Sadly, just the fact that the doctor has a medical degree certificate means very little today. Many of these doctors have passed out from private capitation colleges, where the only language which the faculty speaks is that of money. What matters is not your IQ or your hard work – it’s just the size of your ( father's) bank balance. Degrees are available for sale, and are no longer a trusted badge of competence ( and if you don’t believe me, ask a family member who is a doctor what their frank opinion is about the quality of the medical graduates who are passing out these days).

However, old is not always gold either. Many of the old timers continue to practice inspite of the fact that their medical knowledgebase is outdated and obsolete. They can be equally dangerous because their clinical skills have atrophied over time , and they have failed to keep upto date with recent advances.

This is why patients are often forced to blindly trust the scientific competence of their doctor. However, it’s hard to do so , especially because the medical profession seems to have frittered away the trust which people used to have in it.

Doctors are often treated with suspicion . At the back of the mind, the patient is always worried – is the doctor advising these tests in my best interest , or in the interest of his bank balance ? This is why we spend so much time and energy in finding the right doctor.

While some of us get lucky, we don’t need to feel helpless. Just like the passage of time has created new problems , it has also thrown up new solutions as well. Today there is a  whole group of people who can provide us with exactly the same level of medical expertise which doctors can. The only difference is that they don't have the paper degrees which doctors have .

These are what I call the Expert Patients, and their community is increasing daily. Often, they will do a much better job than a doctor can, for many reasons.

Depth of knowledge about your particular illness.
While the world-renowned specialist in Mayo Clinic maybe the final medical authority on your disease, how do you know how much your personal doctor knows about your illness ? Doctors cannot be experts on everything – and many specialists are also clueless about rare problems ( even though they may not be willing to be forthright and share their ignorance with you.) However, the expert patient who has your particular illness will know a lot about it, because he has chosen to master the intricacies of the topic.

No medical gobbledygook .
Expert patients will talk to you in terms you can understand. They will not use jargon – and neither will they dumb stuff down or talk down to you. They respect your ability to understand, and will help you to become an expert as well.

Empathy.
Expert patients are likely to be far more empathetic , because they've been through what you are going through.

Honest advise.
Because they have no vested financial interest , they will provide you with the right advise.

Even better, because you know you are now talking to a peer rather than a doctor, you are much more willing to ask questions , and work with the expert patient  to drill down to find the answers which are right  for you. The expert patient respects your intelligence and autonomy and will help you in your quest to find what is right for you. He will act as a coach – not just as a fountain of wisdom.

This is why you can trust these expert patients. While they have always been around, today, thanks to the internet, it’s much easier to find them, no matter how rare your illness is. Many expert patients have their own blogs and websites ; and many are very active on forums and bulletin boards.

Since they are willing to express their opinion online, it’s fairly easy to make out whether the expert patient knows what they're talking about , or is completely clueless .

Many of these patients can be extremely knowledgeable about a particular illness . Many times their knowledge would put a doctor to shame , because they spend so much time in researching their problem. They are generous , and are willing to share the fruits of their knowledge with others.

Many have a biological background , and because of their single-minded focus, can actually spend much more time on your particular problem than your doctor – even if they live half way across the world.

They can help you to:

  • make sense of your test reports ; 
  • do research about your treatment options ;
  • get a second opinion; 
  • find the right specialist.


Smart patients will make use of all possible resources which are available today ; and while this includes doctors and the medical system , it should also include the network of expert patients who are now available online in practically every disease you can name.


Obviously not all expert patients are reliable. Some have a hidden commercial agenda ( because they are sponsored by a pharmaceutical company); others don't understand the big picture , and cannot interpret your information in the right context . Because they don't have professional training, some are very biased and try to extrapolate from their personal experience , to everyone who asks them for advise. They naively believe that what worked for them will also work for everyone else as well !

However, the incompetent expert patient is far less dangerous than the incompetent doctor. Doctors have an aura associated with them , because of their professional status, and we are very scared to challenge our doctor or to push back against his advise, even when we don’t agree with it

On the other hand, we are likely to be much more skeptical about what an expert patient says, and we do our own research to verify his statements. By the quality of their answers, we are in a better position to judge exactly how reliable they are. Even better, because the expert patient cannot actually prescribe medicines or treat us, the harm he can do is very limited. His primary role is to act as a patient advocate, and speak up for the patient.

What happens if the doctor's advise and the expert patient's advise differ ? This is actually a healthy situation, because it emphasises the fact that the patient has more than one option, and he needs to apply his mind and choose what is right for himself.  In fact, an expert patient's advise is often more valuable than another specialist's second opinion (  most specialists tends to provide similar advise, as their perspective is coloured because they are professionals who tend to think along the same lines ).

We need to remember that this is not a confrontation ! In fact, smart doctors often refer their patients to expert patients !  Expert patients and doctors have complementary skills, and clever patients learn to make the best of both. We are all on the same side - the patient ’s !


Wednesday, July 30, 2014

What can I do to make my embryos stick ?

English: 8-cell human embryo, day 3
Patients who have failed an IVF cycle are often understandably desperate . It can be hard to come to terms with this failure, because most were very sure they would get pregnant in their very first attempt ( few patients would have the courage to start an IVF cycle if they did not secretly believe in their heart of hearts that it would work for them !) They start hunting for solutions to increase their chances of success in their next IVF cycle.

Most will have had good embryos and an easy embryo transfer . When the cycle fails, it’s obvious that the reason for the failure is that the embryos did not implant – what is grandly called – “ failed implantation”. The logical solution is then to do something to get them to stick – perhaps some kind of embryo glue which will make sure the embryos don’t fall out after they are transferred ?

Sophisticated patients and doctors might find it amusing when the patients expresses her desires in these simple terms. This is because many people  still have lots of misconceptions and myths about the entire process of what happens to the embryo once it is transferred into the uterus.

The truth is that most good looking embryos do not implant, and we know that the commonest reason for failed implantation is that there is a genetic problem in the embryo . This is often not something which we can diagnose, even with today's advanced genetic technology , which uses whole genome testing, array CGH and next generation sequencing ( NGS) .  This is because embryos which appear are normal on genetic testing may still have lethal genetic anomalies which we cannot pick up. Our genetic tests are still fairly crude, and only allow us to count the number of chromosomes. We still cannot analyse individual genes.

Embryo implantation is a complex process which depends on many variables. Along with the embryo, the uterine lining plays a key role as well , and this is affect by multiple complex variables, including: the blood supply to the endometrium ; the hormone receptors on the endometrium ; and the complex crosstalk between the embryo and the endometrium.

The problem is that most patients don't understand a lot of this , and doctors don't bother to explain this to the patient . This is why many patients jump to the conclusion  that the reason their cycle failed  even though  the doctor carefully deposited their beautiful embryos inside the uterus with the help of ultrasound guidance , was  that they must have done something wrong which caused embryo to get dislodged . Perhaps they put too much pressure on the uterus by lifting a bucket ? or did going through that big pothole cause the embryos to fall out ?  was their diet too hot ? or did they not rest enough ? Hundreds of doubts plague them, and it’s hard to find straight answers. They are very reluctant to ask their doctor their questions, because they feel these are “stupid”. Also, bulletin boards are full of misinformation and myths.

We need to keep on reminding women that medical science has its own limitations , and we don’t know why embryos do not implant.  , some doctors try to distort the truth by saying – “ I made perfect embryos for you. The failure suggests there is something wrong with your body . Perhaps it is rejecting the embryo , because you have some kind of immune dysfunction “. This “explanation” makes sense to the patient, even thought it is completely false !

They will then spend lots of money and time and energy on testing for these immune dysfunction problems , and even " treating " them . All of this might seem extremely medically sophisticated , but these tests are just as useless as thinking that the embryo got dislodged because the patient coughed or sneezed after the embryo transfer.

The honest doctor will tell the patient that once we have transferred the embryos into the uterus, this is now a “ black box “ area  - a non-man's land.  While we do our best to facilitate implantation ( for example, by providing luteal phase support with estrogen and progesterone), we still cannot control biological processes . This is often a matter of luck , but  patients don't want doctors to use terms like fate or chance or destiny. They crave certainty and  when a doctor tells them the unvarnished truth , they get upset and go hunting for another doctor , who will pacify them by providing them with a pseudoscientific explanation for the failure by invoking scientific garbage such as the presence of a .”pregnancy destroying factor” in their body which needs to be “ treated “ !

Not sure why your IVF cycle failed ? Want an honest second opinion ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Tuesday, July 29, 2014

Meet The Doctor Who Is Empowering Patients And Bridging The Doctor-Patient Gap


A doctor’s duty doesn’t end with just treating the patient’s symptoms. The anxiety, fear and vulnerability of the patient and his family need to be addressed too. As the blame game between patients and hospitals continues, Dr. Malpani has come up with an idea to empower patients and make every one’s task simpler. Read more to know how he is bringing both of them together on the same page.

http://www.thebetterindia.com/12671/meet-doctor-empowering-patients/

Monday, July 28, 2014

Doctors polish soft skills to deliver tough news

The Times of India has a great article on how physicians and surgeons in India are attending creative and communication workshops to help increase their patience towards patients. 
http://timesofindia.indiatimes.com/india/Doctors-polish-soft-skills-to-deliver-tough-news/articleshow/39085240.cms
Doctors can learn how to be patient from their patients ! 

Why do infertile women spend so much time on the net ?


Lots of infertile women spend hours on the Internet , hunting for information and looking for treatment options and the best possible doctor. This is especially true when they have failed an IVF cycle and are trying to find what they can do differently the next time , in order to improve their chances of success.

Infertile women need lots of emotional support , which is why they often glued to the PC, reading posts on bulletin boards ; searching for nuggets of information on blogs  ; and posting information about their problem and looking for solutions from other infertile women .

This is because husbands are quite poor at providing emotional support – and doctors are even worse. An online community , which can provide support ; and which is anonymous and instantly available can be so comforting for them . It gives them a chance to network with other women , who have been there,  done . These expert patients can provide wise counsel, which is not contaminated by commercial influences, which means that it’s trustworthy.

A lot of husbands get irritated by the amount of time which their wife spends on the Internet . They feel that the Internet has become an obsession with them , and believe that it adds to their stress levels. Because they spend so much time and energy trying to find out stuff , they feel this time is wasted. Their belief is that the doctor is the expert, and they should trust him. They are worried that a little knowledge can be dangerous , and that their wife has become an infertility net junkie.

Many women also get frustrated , because so much of the online information is untrustworthy . Viewpoints and opinions on many websites are exactly the diametrical opposite of what other sites claim – and women get confused because they don't know which sites to trust . They are not sure what their next action step should be, and often get paralysed into inaction.

When they ask their doctor for help, he often gets irritated by “internet-positive” patients who bring pages and pages of Internet printouts to them. They will often be dismissive of these website, and will say – “ Don’t waste your time hunting for information on the Internet . I am your doctor and I will  provide you with the right solutions . You just need to trust me !

I don't think this is a very constructive approach . We need to acknowledge that infertile women are hungry for reliable information, and the Internet is a great source of potentially valuable information. However, patients need to be taught how to use the net intelligently , so that they can then access reliable sites , rather than waste time on dodgy commercial sites, which are out to peddle their wares and cheat patients of their hard earned money by making false promises and ridiculous claims ( for example, the Clear Passage Therapy website).

Banning infertile women from going online will just result in throwing out the baby with the bath water ! Doctors need to help their patients identify reliable websites , so that they can use Information Therapy to maximize their chances of getting pregnant .

Confused by all the information you are finding online ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?





Friday, July 25, 2014

More patient complaints and compliments for Malpani Infertility Clinic


Patient Compliments for Malpani Infertility Clinic 2013  

We understand it's hard for patients to judge how good or bad an IVF clinic is based on just their website. After all, most websites looks very similar ! 
This is why we have included excerpts from our Complaints and Compliments book at our clinic, so you can read the unvarnished truth, as to what our patients think about the care we provide them.

Wednesday, July 23, 2014

Patient Compliments and Complaints for Malpani Clinic

Why IVF patients are treated as guinea pigs


I am very critical about the overtesting which is so rampant in IVF today. This leads to overtreatment , and ends up wasting a lot of time and money , because no one really knows how clinically useful a lot of these test results are. Just because tests make logical sense on paper doesn't mean that this logic always translates into clinical benefits.

The sad fact is that real life can be quite messy , and what sounds very sensible in theory often does not work out well in practice .

I recently saw a patient who had failed multiple ICSI cycles. His doctor had told him that this was because of his high sperm DNA fragmentation, and that we would need to use donor sperm.

I have a very low opinion of these sperm DNA fragmentation tests . They are of very limited utility , and have not been validated in clinic practice, because of the huge problem with false positives they suffer from.

He challenged me. Doctor, if you are so skeptical about these latest and newest cutting-edge tests, then how will medicine possibly advance ? Don’t we need to run tests to find the “root cause” of the problem ? Don’t we need to know the answer to the question – Why did the cycle fail, so we can improve our chances with the next attempt ?

I have nothing against new tests. Our IVF clinic is state of the art and we offer all the latest technology, including blastocyst transfer, vitrification, laser hatching,  and PGD using CGH. However, we don’t offer tests simply because of their novelty value ! I'm not a Luddite and I'm not old-fashioned . My point is that while some of these tests may be extremely useful in a research setting , they cannot be blindly applied in a clinical setting . Just because a test works in a mouse lab doesn’t mean it will work in real life for human patients . We cannot afford to get carried away by marketing pressures and technological jargon.

We need to understand the limitations of these tests before incorporating them into clinical practice . A lot of pressure to overtest comes from the marketing departments of the companies who invent and discover these tests. Also, some of the itch to order tests comes from doctors themselves . Doctors will often indulge in a game of one upmanship ! They all want to be one better than someone else , and one way of doing this is by ordering the latest or the newest test .

This way the doctor. can position himself as being state-of-the-art , because he's better informed than the other “old fogeys” whom the patient saw earlier , and who did not have the sense to order the test. This goes to “ prove “ that he's much smarter and has much more expertise than the rest of them , because he read about this test in the latest issue of a medical journal; or saw a presentation at the recent global medical IVF conference.

Patients need to be extremely wary about this kind of cowboy approach if they do not want to be treated as unwilling guinea pigs. Sadly, many patients pressurize doctors to order some of these new-fangled tests, because they have read about them on a website or a bulletin board. New is not always better , and it requires a mature and experienced specialist to say - No further testing is needed ! It’s very profitable for the doctor to order these tests, but good doctors know that if the test has not been proven to improve IVF clinic outcomes, then they should desist from ordering them.

We take pride in the fact that we refuse to treat our patients as  guinea pigs !

Tuesday, July 22, 2014

To be or not to be ( pregnant !)


Why some doctors are scared of Information Therapy


I recently had an interesting conversation with a senior doctor who was quite skeptical about the
value of empowering patients with information. He felt this was a fad, and would just create
more problems. He believed medicine was a complex subject – after all, it takes years of full-time training to become a surgeon, so how can one expect patients to understand the nuances of their medical problems in a few minutes? Isn’t it far better for them to trust their doctor, who is the true
expert, and who can help them heal quickly?

The doctor was very critical of patients who came with pages and pages of Internet printouts about
their medical illnesses. He felt they were often very confused and ended wasting a lot of their own time and his by wanting to discuss options and alternatives that did not make any sense. He also felt
that second-guessing just caused patients to doubt their doctor, and this loss of faith and trust would end up harming patients and doctors as well.

In general, he was quite dismissive about “well-informed patients” who felt they had become “half-doctors” by reading and researching their medical problem online. He believed a little knowledge can be dangerous, and patients who think they know a lot about their disease often created more problems than they solved by challenging their doctor’s decisions.

He also highlighted the fact that doctors, not used to having patients disagree with them, can often end up getting upset and angry with “well-informed” patients, which makes doctor-patient relationships confrontational rather than cooperative.

While everything he pointed out was true, this doesn’t mean there is anything wrong with the idea of information therapy. Like anything else, information can either be used properly or misused and abused.

The key is that the information we provide needs to be reliable, updated, evidence-based and tailored to each patient’s needs. If every doctor prescribed information rather than forcing patients to
seek it out for themselves, this would create a win-win situation. The patient would trust this information since it was coming from his doctor and would not have to waste his time wading through pages of potential misinformation. The doctor would also be more confident that the patient was well informed and had realistic expectations of his medical treatment.

WHAT IS INFORMATION THERAPY ?

Information therapy can be defined as the prescription of the right information to the right person at the right time to help them make better health decisions.

The ‘right’ information is accurate because it is evidence-based, approved by experts, up to date, easy to read and understand, available in many different formats (including local languages and audiovisual formats) and referenced.

The ‘right’ person means this information needs to be delivered directly to the patient (and their
caregivers). This information is best dispensed to a patient by his or her own doctor – the person they trust the most when it comes to their health.

The ‘right’ time means the information should be provided when the patient needs it – that is, in time
to help them make the best possible medical decisions.

So, what is the ‘right’ information, and who decides what is right?

ON THE RIGHT PATH

There are several ways of delivering this powerful tool – it can be clinician prescribed, system-prescribed, or consumer-prescribed. At present, most patients get information through their own research, often online where plenty of unreliable and misleading information exists.
Unfortunately, patients are often not knowledgeable enough to conduct searches that yield valuable results. In an ideal world, all relevant information would be routinely handed over to patients by doctors.

It’s a fact that hospitals and medical centres that systematically implement information-therapy
applications will be in a better position to gain market share, profitability and prestige over those
that don’t. It actually makes good business sense in a world where healthcare is rapidly evolving
around the world. We now have empowered consumers (who demand time, information, control, and service), a new focus on quality (which promotes safer medical care and a move towards
pay for performance), and a new way of validating what does and does not work in medicine (the science of evidence-based medicine).

Thanks to the Internet, we are also equipped with the technology needed to reach out to consumers
– it connects anyone, anywhere, any time to quality information.

These drivers create a compelling case for information therapy, which revolves around an expanded patient role. As healthcare evolves, the following should occur:
• Every clinic visit, medical test and surgery is preceded or followed by information-therapy prescriptions.
• Information prescriptions sent between in-person visits will extend the continuity of care.
• Patients will play an active role in shaping how they want information to be delivered to them.

Information therapy is a very cost-effective solution that allows a doctor to put each patient at the heart of the care he or she provides. As the renowned poet and writer Kahlil Gibran once said, ‘Progress lies not in enhancing what is, but in advancing toward what will be’.

In the delivery of excellent patient care, you and every one of the doctors in your practice should be prescribing information to each and every patient.


BACK TO BASICS

It’s important to remember here that the word doctor is derived from the Latin word docere, which means to teach or instruct. When doctors don’t do so, we are abdicating our responsibility and forsaking our patients, who feel lost and are then forced to fend for themselves.

The solution is simple – doctors need to guide their patients, and prescribing information therapy is a simple way of doing so. This must be curated, reliable information that both doctors and patients trust, thus ensuring they are on the same page and are active partners in a healing relationship.


This article first appeared in the Autumn issue of the Private Practice Magazine, which is published in Australia.


Monday, July 21, 2014

The difference between follicles and ovarian cysts

  Cyst ? Or follicle ?

A patient just sent me this query

I am 29 and trying to conceive for past 4 years.I have irregular cycles. My doctor prescribed me Injection recagon 100units for 6 days from 12-May-2014. On 11th day of cycle during follicle study I got dominant follicles on both ovaries and doctor prescribed to take orgamed capsules for 14 days This month I didn’t get my periods and HPT is negative and even checked with doctor , it is negative again and she prescribed me regestrone tablets for 10 days I have a clarification . If I got dominant follicles on both ovaries, where the follicles would have gone? As per my assumption it should be either fertilized or I should have started periods . I'm so confused. Please guide me

It’s very common for infertile women to be confused about reproductive basics. They often do not understand the relationship between menstrual cycle and ovulation; or the difference between follicles and eggs; or how follicles are different from cysts.

We need to go back to basics, to make sure there is clarity going forward. Otherwise this poor patient will keep on going round and round in circles, cycle after cycle !

This was my answer.

The reason your periods are irregular is because you Do not ovulate. This is called anovulation. Read more at www.drmalpani.com/articles/anovulation.htm.

 This maybe because you have PCOD ( polycystic ovarian disease). You can read more about this at www.drmalpani.com/articles/pcod.htm.

 You need the following medical tests.
1.    Blood tests for you for the following reproductive hormones – FSH ( follicle-stimulating hormone),LH ( luteinizing hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone)
( to check the quality of your eggs). Do this from a reliable lab such as SRL ( www.srl.in);
2.     A vaginal ultrasound scan which should check for the following.
a.    Ovarian volume
b.    B. antral follicle count
c.    C. uterus morphology
d.    D. endometrial thickness and texture

Please send me the detailed test results and medical reports . You can scan them in as a single Word file and email them to me. Patients with PCOD will typically have a high AMH level; a high LH:FSH ratio; increased ovarian stroma; and many small cysts arranged around the periphery of the ovary.

 So what’s the difference between a follicle and cyst ?  A cyst is basically a follicle which does not contain an egg.  They both appear as hollow dark spherical objects in the ovary on ultrasound scans.  Since we cannot make out if the structure we see on scanning contains an egg, this creates a lot of confusion in the patient’s minds .

To make matters worse, doctors often loosely refer to the follicles seen on ultrasound scanning as eggs. In reality, eggs are microscopic, and can only be seen in the IVF lab when the follicular fluid is examined under the microscope by the embryologist. While there are many kinds of cysts, the commonest kind we see is called a functional cyst, which looks exactly like a follicle , except that it’s larger.

Thus, when a mature follicle ( which contains an egg) fails to rupture at the time of ovulation, it collects fluid and becomes larger. This is called LUF syndrome. Read more at http://www.drmalpani.com/articles/luteinized-unruptured-follicle-syndrome-LUF-infertility.htm

A functional cyst ( so called because it is functioning and produces hormones) will often result in the period being delayed, as a result of the hormones it produces. This is why it may cause the period to be delayed. It’s possible to make this diagnosis by doing an ultrasound scan. The period can be induced with medications . These cysts will usually resolve on their own.


Have a query you are scared to ask your doctor because he is too busy ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!







Sunday, July 20, 2014

Great video on why human reproduction is so inefficient

Many infertile couples who do IVF are frustrated by the fact that the success rate is not 100%. After all, if the doctor is actually making embryos in the lab, then why shouldn't they get pregnant in the first cycle itself ? After all, isn't every embryo a potential baby ?

Sadly, human reproduction is not very efficient, and even fertile couples take time to make a baby. To see why, check out this brilliant BBC video , Inside the Human Body: Creation

Inside the Human Body: Creation [1/4] by silichip

Saturday, July 19, 2014

Hospitals can be dangerous to your health


Hospitals were originally designed to be places of sanctuary , where patients who are sick could be taken care off in a facility which was comprehensive because it brought lots of doctors and specialists and nurses and medical equipment together under one roof . It was much easier for the doctor. to provide care to ill patients in a hospital, as patients did not need to run around and all the medical facilities were available in one facility.

Both patients and their family members and doctors felt safe when the patient was admitted to hospital because they knew that the latest medical technology and medical expertise were available to take care of any complications.

Sadly , things have changed considerably . Hospitals used to be considered as the last resort , and if the problem could be managed at home , patients would prefer this option.

However today it seems that any time a person falls ill, no matter how trivial, the knee jerk response of the doctor is to advise hospitalization. Hospitals are a great place for doctors to be, because they spend most of their time here. It’s much more convenient for them to see lots of patients at one time during their hospital rounds, rather than make home visits. It’s also logistically easier for them to do all the tests and get the second opinions they need.

However, hospitals are not good places for patients to be in ! In fact, they can actually be dangerous,  because of problems such as hospital acquired infections . Patients need to be aware of the fact that even if the doctor. advises hospitalization , this may not always be in their best interests .

While hospitalization makes sense for an emergency situation or for someone who's acutely ill, for most
cases , there are usually much simpler ( and much less expensive ) alternatives . Sadly, health insurers also contribute to the problem of unnecessary hospitalization, by refusing to reimburse for ambulatory medical care.

Once you get admitted in a hospital and put on a hospital gown which leaves you half-naked and vulnerable, you to lose a lot of your autonomy . Things can easily spin out of control. Your doctor is never available, and the standard answer for most questions is – This is “ standard hospital policy , and this is the way we do things here. Often one thing leads to another , and patients often fall prey to the domino effect. Thus, even if you are admitted for abdominal pain, if  a “ routine “ chest x-ray shows a suspicious shadow , your doctor will ask for a specialist opinion; and will then order additional tests such as a CT or MRI . This means the focus of attention is no longer on the original problem for  which the patient got admitted . Incidental findings which are commonly picked up during routine tests ( especially for older people) often have no clinical importance , but once the patient is in a hospital , the doctor. cannot afford to ignore these findings.

Doctors operate under certain compulsions , and are so worried about being sued these days, that they will do extensive tests to chase up red herrings. Ironically, the problem is exacerbated for very rich patients, for whom finances are not a limiting factor, and who get overtested and overtreated.

Hospitalization can be extremely disruptive , and it's important to discuss and explore what alternative options you have with your doctor.  A good doctor will try to keep you out of hospital as far as possible !



Friday, July 18, 2014

Low cost IVF treatment in developing countries

" The unmet need in developing countries is higher still. That is partly because people have less money, but also because infertility is more common. Genital mutilation, unsafe abortion and poorly attended births cause infections that leave women with blocked Fallopian tubes, making normal conception impossible. Sexually transmitted diseases scar both men’s and women’s reproductive systems. The World Health Organisation estimates that around 50m couples worldwide have been trying to conceive for at least five years without success. Almost none of those in developing countries can hope to get treatment.

The grief of infertility is sharper in poor countries, too. In Africa and much of Asia it carries a stigma, nearly all borne by women. Male-factor infertility is rarely acknowledged except when a man has failed to father children with several women. A “barren” wife is often ostracised, beaten or abandoned, or infected with HIV/AIDS as a result of her husband straying in the hope of a child. She is at higher risk of being murdered or committing suicide."

http://www.economist.com/news/international/21607881-vitro-fertilisation-once-seen-miraculous-now-mainstream-rich-countries-soon

India has a great opportunity to become a market leader in the low cost IVF  field. Unfortunately, IVF is still not provided in teaching hospitals and medical colleges ( who can afford to provide it at a fraction of the cost which private IVF clinics charge).  Not only is this unfair on poor patients, it's also means that the new generation of gynecologists has no hands-on experience in providing IVF treatment. This means that when they start practise, if they want to start doing IVF ( as so many want to these days), they are forced to attend a 7-day workshop. While this gives them a "certificate", it also means that their skills in doing IVF leave a lot to be desired, as a result of which patients suffer needlessly.

Expert advise about IVF from an expert patient

This was a question a reader posed to Manju, our expert patient.

Question:
Need your advice - IVF . I have been on menopur 75 iu and gonal f multi dose 450 iu from 3/7/14 to date taking 225/0 in the morning and at night. I am 42 years old. Yesterday my scan and blood test showed estrogen level of 69 with 4 follicles. I have one ovary and the size of the follicles are 7.6, 6.4, 6.1 and 6.0 the nurse said they are not growing fast enough and we should cancel on Saturday I.e tomorrow if the estrogen level does not increase and if the follicles don't grow.  I need your advice.. I decided to give it my all and continue to take the meds ...I am also taking royal jelly,  maca powder, flax seed in order to improve my levels by tomorrow.  Any other suggestion.  I want to have a baby. I hope you will reply before my visit tomorrow.  I am off from work,  I am unable to focus had to leave work as I was crying too much. I don't want to loose hope this is my only chance.

Answer:

I understand your pain. Please calm down ! Getting tensed and crying will not help a bit. I understand it hurts, but you have to have realistic expectations about your situation. You are 42 years old. You want a baby badly and decided to try IVF. When they stimulated your ovaries they found that your ovaries are not growing any follicles even after giving lots of gonal F ( this is the highest dose anyone would use ). Now you are heartbroken that your dream is slipping out of your hand and you are desperate to find out whether you can do something to grow your follicles, isolate few eggs, get some embryos so that you can become pregnant. Your wish is very much justified BUT your body is not cooperating. Your heart yearns for something but the reality is different. You adamantly hoped that everything will go on well but now it is not so. Why not accept the reality A ? Then the pain gets lesser and you can think clearly of your next move.

A woman's ovary runs out of eggs as they age and that is what has happened in your case.Since your ovaries are not growing follicles even after using maximum dosage of gonal F, it is clear that your ovaries have no more eggs in them. A, I am really sorry to say this - there is nothing you can do to grow the follicles or to coax your ovaries to produce eggs; the present scientific development is not intelligent enough to help your ovaries to produce eggs. Just because you can't produce eggs it doesn't mean you can't enjoy a pregnancy or have a baby. You just have to embrace other treatment options that are available. Using eggs of a young woman will give you a very good opportunity to conceive and enjoy a pregnancy. If you ask me whether you would be able to love a baby which doesn't carry your genes - yes you will  ! Actually our genes are not that important as we might think. Just close your eyes and imagine what will happen 100 years from now -  none of us will be alive, NONE. Is it then worth worrying about your genes ? :) Any baby you love will be yours. So please do not lose heart. Do not get afraid and upset tomorrow if the doctor says that your estrogen did not rise as it should. Ask him what else you can do to have a baby?

I am sure you will not like my answer but this is the bitter truth. I wish you lots of good luck in your endeavor! May all your wish come true!

Be strong and happy!

Reply:

I appreciate your reply. I will ask about donor eggs.  I am trying to stop crying but it's hard.

Reply:

Thank you for setting me straight.  I just left the doctors office... the result was that we cancelled.  But I came to my senses and accepted it all and decided to continue with donor egg. I guess even though I don't know you....your email helped me a lot. Thanks again!





Need IVF advise from an expert patient ?


 You can email Manju at manjupadmasekar@yahoo.com


Her blog is at www.myselfishgenes.blogspot.com

Wednesday, July 16, 2014

Infertile Patient query - IUI versus laparoscopy ?


Physicians perform laparoscopic stomach surger...

Hi, Dr Malpani.

I have been reading your blog and have found it to be very helpful. My husband and I have started infertility treatments and options. Briefly, this is what has happened: -We have been trying for a year naturally (both 29 years old) -Did blood work to check all hormonal levels and everything is normal -Husband did semen analysis and that is better than normal -PCT was done twice (wish I had known this is kind of outdated and most doctors don't do this but oh well, what is done is done!) and both showed that sperm were not swimming like they should at all -Doctor/OBGYN had recommended using mucinex but cervical mucus seemed "perfect" for each PCT

After we Visited Infertility Clinic: -Vaginal Ultrasound completed: Showed that my uterus was slightly tilted; Right ovary looked great and easy to find; Left ovary difficult and painful to find -Completed HSG and one tube the "spill" was great, the other seemed tangled - due to scarring? endometriosis? something else? -Tried 1 unsuccessful IUI (follicles on the "open" tube seemed good, so IUI seemed like a good option) Now the doctor has two options, and after reading some of what you have written and what he has suggested it seems like Option 1 would be the best choice:

Option 1: Use drugs such as Clomid to increase egg development and use IUI as an intervention to see if that helps. Option 2: Laparoscopy My Dr. things it might be best to do Option 1 which is less invasive and easier. I guess I just worry, will my issues - whatever they may be - make it hard to get pregnant again later? Will they keep me from getting pregnant right now? I'd hate to do a bunch of IUIs and then find out surgery would have helped the whole thing. Three of my friends who have infertility issues all got laparoscopy, and two got pregnant after, one did not and did IVF. Both my husband and I are healthy - it's just such tough decisions. I think we will go with Option 1 but I would love to hear your opinion and other information you could give me that would help me to be better informed going through this difficult process.
Thanks, A

A is a well-informed patient – my model of an expert patient. She has done her homework, and is now on the horns of a dilemma.

 Her question is simple – Should I have a laparoscopy or not ?

This is a deceptively simple question, but there is no easy answer.
Actually, there is no one right answer, because both the answers are correct.
Each has pros and cons, and she needs to think through these rationally, to make the right decision.  However, it’s important she does not  use the experience of her friends  as a guide – every infertile woman, is different, and their case is not the same as hers

Many doctors will advise doing a laparoscopy routinely for all infertile women. They position it as being a simple diagnostic test, with the added advantage that the doctor can “fix” problems if there are any at the same time of the laparoscopy.  They tell the patient that a laparoscopy is the only way of making the diagnosis of subtle diseases such as peritubal adhesions and endometriosis, which is why it’s compulsory to perform this.

It’s fairly easy to convince patients, because the laparoscopy is described as being a “ minimally invasive” surgery . “ No cut or scar – just a bandaid”. It seems temptingly easy to do, and since patients are hungry to find out what the problem is,  many will sign up without even realizing that this is not always a good idea.

While laparoscopy may be “minor” surgery for the doctor , the truth is that for the patient, every surgery is  major ! Also, the focus should never be on finding problems – it should be on finding solutions. While it’s true the doctor may find a few minor lesions , this does not mean that these were the cause of the infertility; or that “treating” them will improve her chances of having a baby ! In fact, sometimes overenthusiastic laparoscopy can end up actually reducing the patient’s fertility. Thus, the doctor may find a small chocolate cyst which is of no clinical importance. However, now that the doctor has a laparoscope in his hand ( and can also charge more for doing an operative intervention, as compared to doing only a diagnostic procedure), he  goes ahead and removes the cyst. The patient  is  also very happy. She feels the doctor was smart, because he has diagnosed the problem, and treated it.

However, 6 months after the laparoscopy, when she fails to get pregnant , she realizes her hopes were misplaced and she is back to square one ! In fact, this surgery may end up reducing her fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing her ovarian reserve.
Most good doctors prefer being conservative. After all, the first rule of medicine is – “ Do No Harm”.  They prefer using non-invasive tests to make a diagnosis, rather than doing a laparoscopy.

The question should NOT be “Why am I not getting pregnant ? “
Rather, it should be – What can I do in order to get pregnant ?”
After all, no one cares about problems – we only care about results – about having a baby !

This is my advise.

The fact that you are not getting pregnant means that the eggs and sperm are not meeting in your fallopian tubes when you are trying naturally.
The next step would be IUI. We prefer HMG/IUI, as this has a higher pregnancy rate than clomid/IUI. If 3 cycles of IUI don’t work, then we suggest IVF.

This “stepped-care” treatment plan does not need a laparoscopy, as the laparoscopy does not affect the treatment options at all.

Finally, patients should remember that while the process is in their control, the outcome is not. The should follow their personal path of least regret, so they have peace of mind they did their best.


Need your query solved ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






Tuesday, July 15, 2014

IVF overtesting in the futile quest for certainty


When I review the medical records of patients who have done IVF in other clinics , I'm quite amazed by the amount of testing which they've undergone . A lot of these tests are extremely expensive  -and many are exotic ; of unproven value; and provide information which is of no clinical use. It’s a long list – and includes: NK cell testing; pregnancy destroying factor; TB PCR testing of the endometrium; and TORCH tests.

Why do doctors do so many unnecessary tests ?

There are multiple reasons.

One is financial. It’s much more profitable to order the test , and it's often easier to do this. One of the reasons doctors order tests is that this is an easy way of terminating the consultation, so they can move on with seeing the next patient. This is much easier than spending 10 minutes explaining why the test is not needed. Not only does this eat into the doctor’s time, they can’t charge for this either. This is because the system doesn’t reimburse doctors for talking to the patient – even though this is often far more useful ( and much less harmful) than ordering tests and doing procedures !

On the other hand, the doctor can order the test, charge the patient, and say –  Please come back and we will discuss treatment options once we get the results !


Lots of doctors crave certainty , and when we come across problems for which we don’t have clear answers ( for example, why a perfect looking embryo did not implant),  the standard knee jerk reflex is – We need more data in order to find out what’s going on, so it's quite logical to order tests to get to the root of the problem. ( Some doctors like to think of themselves as being scientists who are running experiments on their patients).

Unfortunately , more information doesn't always help. Many studies ( across multiple fields ) have shown that more information often just increases the expert’s confidence levels , but does not improve accuracy. Many of these test results don’t actually help to improve clinical outcomes – and these results often just add to the noise, without improving the quality of the signal.

Doctors love doing tests. These are modern, cutting-edge tests ( many use complex genetic analysis,  which is Greek and Latin to most patients, and their doctors as well) , and this is a clever way of signaling to the patient – I am well-informed, which is why I am ordering the latest, newest, state of the art tests for you.  Sadly, your earlier doctor was clueless, and didn’t even know about these tests, and this is why I am better than he was.

Doctors can then present these results at conferences; and dazzle other doctors with their brilliance, by showcasing their findings in order to demonstrate how avant-garde they are. The trouble is that the focus on the outliers – the zebras. This impresses the other doctors, who are then happy to refer even more patients to this specialist, who orders so many tests and discusses their science and results so intelligently

.
Patients also contribute to the problem, because they expect the doctor to order tests when they see him. Few patients have the maturity to understand that when a doctor says he doesn’t know (rather than trying to fob you off by ordering more tests in order to cover up how little medical science understands about many complex areas) . this actually means he’s a good doctor because he is sharing the limits of medical knowledge with you . There are still huge areas of ignorance in IVF , and we  need to learn to live with these. While research labs will continue trying to push the frontiers of our knowledge, this is not the right approach in a clinical setting – especially where the patient has to pay out of her pocket to do tests which do not help her to have a baby. Doing more testing is not the right solution .

Sadly, most patients don’t even understand that these tests on experimental and unproven ! Because they are new and expensive and are aggressively promoted with the help of colourful brochures ( and incentives paid to the doctor as well), it’s easy to convince patients that more is better !

Infertile patients are often so desperate , that they are willing to be used as guinea pigs . Patients will often put pressure on the doctor by saying – Doctor, is there anything else you can do for me ? Any other tests you can order ? It’s very tempting for the doctor to buckle down under pressure and order the latest test – often once he has heard about in a medical conference , or read about in a medical journal article – especially if this has been published abroad).

Ordering the test is the easy bit - interpreting the result is extremely hard ! The major issue is the problem of false positives – when the results are abnormal, but are not related to the patient’s clinical problem . These are a major hazard of all tests , and will often lead to more testing , because the doctor then starts chasing red herrings . A lot of time and money is wasted on unnecessary treatments as well , in order to “treat” these abnormal results. The damage done in barking up the wrong tree is often concealed, until the patient gets a second opinion.

A common justification for overtesting is – Lets run the test just to make sure that we aren’t “missing” anything; or we need to rule out a treatable cause, so let’s just order the entire panel of tests. After all, how can it hurt ?

This is one of the reasons good IVF programs have well-defined protocols , which clearly demarcate what tests are acceptable , and which are experimental and unproven . This is especially true when the government pays for IVF treatment in countries such as Scandinavia .

Good doctors  understand that patients are often desperate for answers, but it’s often much kinder to explain that it’s not always possible for us to provide these.

Remember the aphorism - Good surgeons know how to operate, better ones when to operate, and the best when not to operate. This is true for IVF specialists as well. Good doctors know which tests to order, better ones know how to interpret them, and the best know when not to test !

Worried that your doctor is wasting your time and money on doing too may tests ?
Please send me your medical details by filling in the form at
http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






Monday, July 14, 2014

Fee for service results in overdoctoring

" The financial incentives for doctors are wrong. Sometimes a doctor should be rewarded for not
intervening !"
http://www.ehfg.org/839.html

If we pay surgeons for doing surgery, then why are we surprised that they respond rationally to these economic incentives by doing more surgery ?  It's not the surgeons who are unethical - it's the incentives which are irrational !

If back surgeons were paid for not doing back surgery, I am sure many more of them would advise conservative non-surgical therapy ( just like so many orthopedic surgeons do , once they retire from active surgical practise)

IVF process versus outcome


The outcome of an IVF cycle is always uncertain . When a cycle fails, the patient is never sure whether the failure was because the right process was not followed, or because of plain bad luck or an intrinsic  biological problem ( for example, women with poor quality eggs have a low chances of success, no matter how good the quality of medical care they receive)

How does the patient judge the quality of care provided – whether or not the doctor did a good job technically and followed all the right medical processes ?

Sadly, most patients are never certain whether she should change the doctor for her next cycle; or if sticking with the same clinic is her best choice.

This is the key difference between the expert patient and the uninformed patient .

The uniformed patient is clueless about the treatment details – they do not know what the right treatment involves, and they are not even aware of what was actually done. Bad clinics exacerbate this problem by keeping patients in the dark.  On the other hand, expert patients are sophisticated enough to demand openness and transparency and will refuse to go to a clinic which does not routinely provide photos of embryos.

Poorly informed patients have unrealistic expectations of IVF treatment . When the cycle fails, they will often blame the doctor for the failure . Their doctor, on the other hand, will blame them for the failure, by saying they did not follow instructions  properly !  This is why they lose confidence in themselves - and in their doctor as well. 

The expert patient has done her homework before the IVF cycle starts. She knows exactly what steps are involved in an IVF cycle, and takes an active interest in ensuring that the steps are being followed properly . When things go according to plan , she knows the process was performed properly , so even if the outcome is bad , they do not end up blaming the doctor – or themselves. They have peace  of mind that they received good-quality medical care ; and know that for them it's just a matter of time till they get pregnant . Doctors also find it much easier to manage these patients, because they have realistic expectations, and don’t go to pieces if the cycle fails.

Expert patients can proactively identify deviations and deficiencies in the treatment process . They are able to understand what can be done differently the next cycle , in case things don’t go according to plan. They can discuss with the doctor what changes can be made to the next treatment protocol , to increase the chances of achieving a pregnancy ; or they may decide to change the doctor.

A good analogy is investing in the share market. Both IVF and the share market have risks and uncertainties. No matter how expert your financial advisor is, the market can go up or down, for reasons which are beyond his ( or anyone’s) control. A sophisticated investor doesn't lose his cool just because his portfolio goes down . He takes things in his stride and is mature enough to take a long-term perspective, because he knows that historically the odds are in his favour.

The uninformed investor , on the other hand, panics when share prices drop . He doesn’t have enough confidence in himself , or in his financial advisor, to be able to manage the ups and downs of the share market ride, which can be very bumpy. He often ends up buying high and selling low, and consistently losing money in the process.

The average patient also ends up burning her fingers , partly because she is capable of identifying the right doctor; or making sure that the right medical treatment process was followed.

Some patients refuse to invest the time and energy which is required to allow them to become expert patients – and this can prove to be very expensive in the long run, both in the form of wasted opportunities and wasted money.

The good news is that it's no longer difficult to become an expert patients. There are tons of online resources available , including free e-learning courses and games, and you can check them out free at www.ivfindia.com.


So what are the possible combinations ?

Good process plus good outcome = happy patient - and happy doctor
Good process plus bad outcome = bad luck. Try again !
Bad process plus good outcome = dumb luck. Count your blessings !
Bad process plus bad outcome = every patient's nightmare. Information Therapy will help to prevent this toxic combination

A good doctor, just like a good financial investor, will spend time educating you about the risks and uncertainties involved in IVF, so that you have realistic expectations of the treatment, and can manage the IVF emotional roller coaster ride without losing your cool. Remember that we cannot control the outcome - but we can ensure the process followed was impeccable !

Want to make sure you are getting good quality medical care ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !


Saturday, July 12, 2014

The 2014 budget and the Indian healthcare industry


The healthcare industry was very hopeful that the 2014 budget would provide lots of incentives for health care service providers. There was a lot of buzz that the government would place a lot of stress on education and healthcare; and that they would make universal healthcare a reality for all Indians.

Unfortunately , none of that has come to pass, and hospitals, doctors and patients are quite disappointed. The only sweetener is the fact that healthcare checkups ( upto a cost of Rs 5000 ) have been made tax exempt. This is actually a regressive step ! It will only encourage people to get health checkups done. However, a lot of scientific medical research has shown that routine healthcare checkups for asymptomatic, well people are of no value at all . They only end up converting healthy people into the worried well, who sit and worry about every minor test abnormality, and go running to a doctor for reassurance – and often even more testing.

However, the fact that foreign direct investment ( FDI ) in insurance is being encouraged is actually a very promising step in the right direction for patients. So far, the most important people in the healthcare ecosystem have been the healthcare providers, because most medical care provided has been on a fee for service basis, where the patient pays from his pocket. 

However, payers ( healthcare insurers) will have an increasingly important role to play, as medical care becomes increasingly expensive . Most people will find hospitalization unaffordable , and will be forced to take out health insurance policies to protect themselves.

While hospitals and doctors make money when people fall ill, it makes business sense for health insurers to keep people healthy  and stop them from falling ill.  The health insurance sector in India is now very attractive, and as new players start coming in from all over the world and competition increases, they will understand the importance of putting patients first !



Friday, July 11, 2014

SCOPED helps patients make better decisions

Making decisions when you are ill is hard. Patients are often confused - and the overload of poor quality information on the internet just makes a bad situation worse.

Doctors are often not very helpful, because they can be quite directive, and are likely to push patients into doing what they think is right for them, rather then allow patients to make up their own mind.

Jeff Belkora developed SCOPED as a checklist for making decisions.

SCOPED stands for:
Situation, Choices, Objectives, People, Evaluation, and Decisions.
People use SCOPED to think, talk, read and write about decisions. 
Situation: clarifying known facts about my condition
Choices: clarifying which options are available
Objectives: clarifying my goals and priorities
People: clarifying roles and responsibilities
Evaluation: clarifying how my choices affect my objectives
Decisions: clarifying which choice is best and next steps

http://www.scoped.org

This is a very valuable tool for non-directive counselling, as it helps patients to find the right answer for themselves. All doctors and patient advocates should use this - especially for elective medical procedures 

Thursday, July 10, 2014

For patients considering surgery, knowledge is power

 
English: U.S. Air Force surgeons Dr. Patrick M...

Clear, specific patient education helps patients - and surgeons ! 
 
Decision and communication aids used in orthopaedic practice had benefits for both patients and surgeons. These findings could be important in facilitating adoption of shared decision-making tools into routine orthopaedic practice.
 
Some surgeons are worried that if they tell the patient all the possible risks and complications of surgery, they will  be scared and refuse the surgery.

As this study shows, this is not true ! Surgeons need to respect their patient's intelligence, and help them to make the right decision for themselves by sharing information. Patients trust doctors who are open and transparent.

http://www.ncbi.nlm.nih.gov/pubmed/24048550

Answering IVF patient's questions


I enjoy answering questions from IVF patients. It keeps me on my toes; I am happy to share my knowledge; and I learn a lot from them !

Here's a question I got recently

Dear Dr. Malpani,

Let me start off by saying that I have lived by the information you provide on your website. I have never seen better information in one place.

I have a question that I would really only value your opinion at this point. I just had a failed FET. It was a « perfect » blastocyst. Had a HSG at 35 at 10 days past transfer, which came down to 8 yesterday,and they told me to stop all my medications.

Fine-that’s not the problem.

Why would a clinic only test my beta? What if my progesterone level was low (I was taking suppositories as opposed to injections, which now I feel really guilty about). They only tested my progesterone once, and it was at 2 days past transfer, and it was 8.6 Well, that sounds low to me, but they said it’s fine for Endometrin.

Is it possible for a reputable clinic not to test everything at once when I go in for my beta check? Including Progesterone, Estrogen, as well as my thyroid level given that I am on levothyroxine.  I just feel failed by my clinic. I understand the embryo might have been abnormal, but how will i ever know it wasn’t me? What if the suppositories didn’t produce enough progesterone for me?  I don’t know, it seems common sense to me that a clinic would test me for everything once I’m in for a beta test.

As a side note,  I do have a healthy 2 year old from my fresh cycle on a first try, so I don’t think I have some autoimmunie issue, etc…
This is a very well-informed patient, who is looking for additional answers.

Here are my thoughts.

 1. I'd like to see a photo of the blastocyst; as well as medical details of the IVF cycle ( including endometrial thickness and texture) so I can review the medical details

 2. I don't think measuring progesterone levels helps at all. These measure the levels in the blood - and there is  little correlation between progesterone levels in the endometrium
( which is what we are really interested in ) and the blood levels

3. There's no need to feel guilty for not taking progesterone injections. They are very painful - and less effective than the suppositories, which deliver the progesterone directly to the uterine lining through the vagina

4. It's easy for a clinic to do lots of tests, but the fact is that more tests do not always help. In fact, they can create more problems ( because of false positives ,which lead doctors and patients astray because they start chasing red herrings of no clinical importance)

5. You need to be kinder to your clinic. I understand you are upset, but why would the clinic want your cycle to fail ?  Their interests are aligned with yours - every good doctor wants their patients to do well !

6. You should be more assertive proactively, rather than have regrets afterwards ( which does not help, and just adds to your burden of guilt). You could always ask the clinic to do more tests, if you wanted them . No good clinic would refuse, if you made a request which was reasonable.


7. Why good looking embryos do not implant is still one of those things we do not understand - it is
one of medicine's unsolved mysteries . Human reproduction is not very efficient . Don’t forget that even fertile couples take time to make a baby in their bedroom ! Please don't get disheartened - your chances remain good. Sometimes you just need to be patient until you get lucky !

Got questions ?
Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?



Wednesday, July 09, 2014

Diagnosing Indian Doctors

A friend forwarded this email to me. I think it's worth sharing and hope it will nudge you into treating your doctor with a little more kindness.

I am grateful to my patients. Helping them get better adds meaning to my life. But the way in which doctors are being maligned today makes we wonder if it's worth continuing practising medicine anymore.

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


Recently read a flash news about Eminent Doctors taking cuts / referral fees. There cannot be any justification. But if a whole system based upon corruption, a whole society facing inflation expects only one of its components to be sane, it’s insanity.

Hence these thoughts.

I apologise in advance if this hurts some feelings. This isn’t a placebo though.

For the “Nautanki” people who appear so shocked to hear about corruption in the Medical field, here’s the naked truth: There is corruption in every aspect of every field including religion, law and judiciary, government, politics, police, press, military, film industry, YOUR FIELD, and also medicine, as the doctor is a part of this very same society, not from Mars. There is corruption in every aspect of medical field: referring a patient, lab tests, CT/MRI, Surgeries, Cross referrals, almost everything.

But as in every field, there are people who do it by choice, there are some who have to be a part of the system to survive in India, and some who refuse to be a part of it all, facing many other problems including a perpetually low income.

Think Simple: why would a person with highest of merit, hardest of hard work, tendency for helping others want to become corrupt? Not by choice. No one becomes a doctor for greed (Someone might attempt, but these people drop out in the first six months or a year: Those not dedicated to a hard life cannot endure medical education in India).

Every doctor wants to do good to his patient and also live a decent life. After a lifelong meritorious career, why should he be expected to toil in villages / rural areas without any rewards for it? Why should he not want his kids to go to the best schools? Why should he not want a decent lifestyle? Why should one give up a lucrative career in the west and return to the homeland feeling patriotic, to just be told that in your own country you are doomed to a life of sacrifices just because the society expects so?

“Someone who wants money should not become a doctor” said a dropout actor who is seen doing all immoral things (from peeing openly in a garden for press in real life to cruel crimes and revengeful murders on film: while running a show to change India to an ideal country.. I hope he and his family only use Indian things, medicines etc.). Why?

Why should a doctor not want money for a decent life? Why should he endure the humiliation of so many non-meritorious people from his class living in luxury because they chose not to be a doctor, while he chose the noble profession? Listening day-in and day-out to patient’s problems, tears, cries, allegations, threats, and expectations, not ever having a peaceful sleep for a week at a stretch, not eating in time, not having enough time for family, why should a Doctor NOT want to earn well?

We are not supposed to refuse a case in emergency. Do the Judiciary or Police or Politicians do that?

We are fined crores for medical negligence. What if the Judge is wrong? What if the police are wrong? What if the politician is wrong? What do they pay even when proven wrong? Why the presumption that the negligent doctor’s intention was bad? Negligence is possible in all fields (reactors/ bridges/buildings/ food/ trains/ public transport), can cost life in many, how come the doctor alone pays in crores for a life that he was attempting to save, while in all other cases the motive was profit, not saving life…?

How come the judges decide the amount of fine? In a recent case, the fine was in crores. If the patient had survived, would the court have ordered the same payment for the doctors? Doctors save millions of lives. Some through heroic /exceptional efforts, without thinking of rewards. If a young patient is saved, shall we charge according to all the income he can make all his remaining future? Than why this criteria for fines?

World has become a global village. People travel to the developed world often. Highly specialised doctors in India are expected to be at par with their western counterparts. They often are, because half the world travels to India for medical advice.

But the Indian community is yet to awaken to the Doctor’s fees. An average specialist in the developed world charges between 10,000 to 30,000 INR for the first consult. Appointments are very difficult to get. They don’t work out of 8 am -4 pm slots except in emergencies (some honourable exceptions). And yet they get so many benefits from the hospitals they work at, and also from the government. THEY SEE NO FREE PATIENTS. Most doctors live in luxury in the western world. An Indian doctor on an average charges 200-1000 rupees for an OPD patient. Sees many free patients (almost 40-50%) everyday. Continuously has to be occupied with: 1. Patient’s health and benefit 2. Relative’s expectations, their anger (many think that every patient must get well irrespective of his / her health status). Many hold the doctor responsible for their illness / failure to improve/ complications. 3. Continuous suspicion: Many patients think Doctors are out to loot! Every investigation is with an intention to get more profit out of the patient. They want the best, but like “sabji”, they want to bargain. 4. There is also a widespread belief that pharma industry is actually serving the doctors, not patients. 5. Google searchers who think they know better medicine just because of what they recently read about a tiny drop in the ocean of medicine. They eat up a lot of time, but don’t want to pay for that additional time. 6. The very relatives who shout at the doctor seldom know what medicines the patient is taking: it is all supposed to be the doc’s responsibility. 7. So many Toms, Dicks and Harrys coming over and threatening: this is everyday nuisance in ALL casualties in India. There is no sensible Director in Bollywood to have realised a Doctor’s plight while working under threat in casualty. Everyone loves the populist “Doctor-Threatening” hero!

Then the seemingly innocent weapon (The secret bleeding wound in many a Doctor’s heart!!)

“But Doctor, You are like God / Next to God. The whole society respects you”

That respect is divine for us, that respect and the satisfaction of doing something godly by saving lives, helping people live better lives alone keeps us from going on and not quitting the profession for better incomes. Don’t you think we had the options of making more money had we used our talents elsewhere, especially in today’s IT world?

But that respect does not substitute for our children’s fees. Not for our rents, electricity, travel ANY expense. Almost all doctors and their family members end up paying full bills for themselves at the very hospitals that they work in… some minor exceptions. Everywhere a doctor goes, he pays the same money that any other citizen. There isn’t a separate queue for a doctor anywhere in any office just because he / she has patients waiting. There is no pension. There is no security. I can show you some highly successful (in patient care) ethical doctors who can’t pay for their own treatment TODAY!! If a doctor is sick, his / her income is zero as long as he does not work: No one cares if he has treated hundreds for free. The respect does not substitute for the stress a doctor bears: of years of listening to and attending pain and tragedy, years of sleepless life, fasting days, lost precious time with dear ones.. as with anyone else, the DOCTOR ALSO HAS ONLY ONE LIFE… WHICH HE CHOOSES TO SPEND HELPING OTHERS.. is it a crime to be living well for such a person?

And if Doctors are next to God, very respectable, how come their mistakes become villainous immediately when something goes wrong?

As for the other side:

There are corrupt doctors, corrupt practices. But please understand, a single doctor did not create them, nor did a group plan them These developed over time as the system evolved. One had to fall in line or quit the profession in want of better life. Like in every field, there are greedy among doctors. They ruin the reputation. But a single doctor cannot do anything. Those who try to change the system are boycott, thrown away, maligned. There are some continuously fighting this.

Every doctor cannot afford to start a hospital of his own. He has to choose a specialty hospital which has all the facilities to practice his specialty. These come at a price. I appeal the people who feel bad about investigation prices to just enquire the rates of the machines/skills/ licences/ manpower/maintenance required to make these facilities available. The government makes it compulsory to attend many of its employees free / at subsidized rates, and never pays.. who will pay for them?

So hospitals have their systems. A single doctor cannot change them. Also, not all hospitals are corrupt.

The Medical councils do not have any protocol / system to protect a doctor who faces vindictive attitude from hospitals if he / she wants to argue. Many specialists DO NOT RETURN TO INDIA OR HAVE ALREADY LEFT INDIA AFTER RETURNING due to this one reason. Because specialist practice is based upon referrals, and where most of the referral system itself is corrupt, one has little hope of survival especially in a decent city / town.

Doctors who want to run their own hospitals face same bribery, same licencing scams, same corrupt government practices that any other business does. The rates are probably higher, and the regulations stricter.

Doctors are a weak vote bank., hence not on priority of any party. It is more practical for the politicians to openly criticize the doctor / profession in hope of gaining public sympathy / attention. No one wants to attend to their problems, which are many.

The medical council never protected any doctor against court cases or hospital victimising them for fighting against corruption. The regulations made are ancient, primitive. When a whole medical system is corrupt in almost every step, they have taken the approach of superficial actions against individual cases: typically populist and sensationalist. The medical councils KNOW every aspect of corruption, but have opted to fit in some screws where the whole building needs extensive repairs. One’s degree and education of fifteen years becomes meaningless in the eyes of medical council just because there is delay in renewal of licences. How can rules be applied only partially in a system? While many people practice without degrees or knowledge, the councils choose to target the qualified for not renewing their licences: a process that involves acquiring CME points, the money for most such events, travel etc comes from pharmaceuticals, the patient pays. They do not have the online option of CME / licence renewal like most western countries, even in this advanced age! So a doctor is expected to leave his town and practice, get involved in events sponsored by pharmaceuticals, travel with help from pharma companies, stay in hotels with their money so as to renew his licence. But not online. And there is no compulsion that he has to attend the event for his specialty. So a Neurologist could attend a gynaecology event just for CME points and its ok for the renewal of his Neurology licence!! One can easily get such CME credits without attending the event! There has to be an online option, or a rethinking of this whole business. And an option to do it without involving pharmaceuticals.

The whole Mediclaim business in India is a fraud: they don’t pay for

1. OPD consultation / investigations of a patient: even if serious. 2. Patients with genuine illness, but without injectables or surgery. 3. When they do not understand the diagnosis or the fact that some cases do not have a proper diagnosis. 4. Emergency / Critical care / Specialist charges etc. 5. Even when they pay, it is their choice how much.

This results in many a wrong practices, or the patients can't afford treatment at all.

So in a mediclaim case, no one benefits except the company: Patients, Hospitals, Doctors all lose. Still, the Medical councils do not want to do anything. In fact, they don’t have a say.

Add to these:

Incessant calls / emails/ whatsapp messages for any enquiries that pop up in the patient’s or relatives (usually the cousin in America) mind at any time of the day or night: and bitter words to follow if reply is delayed. (That doctor has advised so so… what is your opinion?... I just read on google about stem cell therapy to improve my anger… what say? Etc. etc.).

Then there are sons and daughters who stay in US / UK etc., but leave their parents back in India. They expect the same care but at a low price, and also a daily update by the treating doctor. NO WESTERN DOCTOR GIVES OUT HIS CELLPHONE or EMAIL ID TO PATIENTS, THEY KNOW THIS, but they talk from there as if from the top of a mountain..They don’t want to come and attend their dying parents, but vent out this guilt in form of anger towards the treating doctor: Do everything doctor, don’t worry about the money.. I am unable to come to attend my MOM because of business meetings/ no tickets / kid’s exams etc. I lose my patience here often.

If a Judge / lawyer is ever reading this article, Your Honours, please consider these when you next fine crores to a doctor (even if insured, he has to pay huge):

A doctor should not be held negligent if

1. The patient does not follow advice as written 2. Patient continues to drink / smoke /eat tobacco/ or does anything that the doctor has prohibited. 3. Does not follow up as directed (most patients miss their follow up dates: doctors are supposed to jump from illness to illness). 4. Does not show the same care towards his own life that the doctor is expected to take. 5. Has not given all correct information about himself / herself / his/ her illness 6. Hidden some information from the treating doctor. 7. Has lost treatment details. 8. Self medication / cross consultation without knowledge of the earlier doctor, resulting in multiple medications. 9. Has had unknown allergies / reactions in the past.

There should be a doctor’s board for each specialty which opines about every particular medicolegal case before the court makes its final decision.

I always wanted to be a good doctor, like most other colleagues I know. I have always heard the courts of justice demand that one speaks the truth. Here it is. Hope I am not punished for speaking the truth. I am not always correct, I am sure some of my friends will correct me. I will keep learning too.

A warning. If the whole medical system becomes non corrupt, patients will end up paying far higher consultation /surgical fees than what is paid now. This is inevitable. Add the legalities to everything, and many specialists will become non-affordable / non available to most. The many many who get free treatment now will be denied that.

Or the next generations will see less and less specialists opting to settle in India.

I love my profession. I Love my country. I love my patients too.

But I also deserve a good life. It is time I stop thinking I am God because the society has presumed so.

May God confer best of health upon all humanity. May God guide me to always do good to my patient.


Tuesday, July 08, 2014

Empathy for infertile couples


I am an IVF specialist, but I am not infertile. This is why I try to learn what infertile patients go through from my expert patients. This helps me to see things from their perspective and understand their feelings.

Here's an email exchange our expert patient, Manju, shared with me.


Hello Manju,

I'm at that stage where a neighbour's or friend's pregnancy or child delivery sends me off, first its pain, anger, then I begin to compare myself to them asking why? Many times Ive cried in secret, sometimes I just don't care.

In the past people said to me, buy baby stuff, go visit new babies, carry them, play with them and tell them to bring yours for you. Well I did that over 5years and nothing happened. Now 7years on, one positive ivf that ended at 33+ weeks, one failed ivf cycle, thin uterine lining, almost 40 and losing myself in thoughts, I don't visit new babies anymore.

Recently I told my hubby that we should move house. Imagine I attended the weddings of nearly all our neighbours and now most of them have at least 2 kids. Others are either pregnant or not ready yet for another one.  Like seriously Manju, how can they control such factors and I cant? They know that once they are ready for a baby, they will get pregnant.

Its a terrible feeling I have when I see these women and there children. I was once at a birthday party for a friend's daughter and everyone else came with their own kids, I was so pained I went into the bathroom and cried.

A neighbour once told me that i was wasting my husband's money wearing good clothes, visiting hospitals, changing hair styles and buying nice things, only because I don't have kids to train in school or feed. Its the worst thing to be childless especially here in Nigeria where no one ever minds their own businesses.  No one should suffer so much.

Now, we are ready for a 3rd ivf which I pray will be successful because hubby says its the last he will pay for, and we are not sure where to go. I've been in touch with Dr Malpani since after my first cycle but travelling to India is difficult, also getting a donor is also hard as the doctor said they only have Indian donors.

Well, God help us. Your post is totally real  and maybe you were speaking to me for a change of attitude,  its just a difficult advice to take.

My mail is quite long, yet I've so much more to pour out lol.

Thanks for letting me share my burden with you.

Dear L,

Very happy to hear from you. You have lightened my burden too with your mail, I must say thanks to you too !

I understand completely when you say how the situation is for a childless woman in Nigeria. Indian society is not very much different than that of yours. I do hear lots of inconsiderate comments. India is the second most populated country in the world, you could see children and hear news of childbirth everywhere.
U, you must remember that, most of our problems are aggravated not by others or by our actual situation itself but by the way we view our problems. I want you to remember certain things which might help you to deal with this struggle a lot more better :

Children are just a source of happiness and not an absolute necessity for a happy life.

No one can hurt us without our permission. Don't allow reckless comments to bother you.

Every journey is different and this is yours. Never compare your life with others. Who knows what others are going through !

Changing place is not a solution to escape your problem, you just need a change of mind.

Being with children and shopping children stuffs might not give us a baby but will definitely give us happiness, we just need to appreciate other's blessings and have an open mind. I know it is easier said than done but not impossible. I find great solace when I am with my friend's child. I do attend all functions without fail. All the children who were born in front of my eyes have children now :)

I am really sorry for your neighbor, for the kind of person she is. It needs lots of bitterness within her to hurt someone like that, with such unkind words !

If possible, I want you to do something which will give you self-importance. It can be like helping the needy, participating in some charitable activities in your community or helping women who are in a similar situation as you are. Please be kind to yourself, cultivate lots of self-love; respect your soul and body for bearing this suffering so well ! All this will help you to be confident and proud about yourself, then you might not cry thinking that all others have children while you do not have ! Have you thought like this - have you ever wanted to be thankful for being perfect when seeing a physically handicapped person ?

I agree, not having our genes propagated like everyone else is painful. I have that pain too. But I do not want to spend my life in a bitter, unhappy way because I have to struggle for a child. Who knows what future holds !

I am not sure whether my words are of any help. But when I write, it helps me a lot ! :)

Lots of good luck for your upcoming cycle ! I will be praying for you. Losing a baby at 33 weeks is such a horrible pain, you are such a strong woman and please be proud of yourself. ((((Hugs))))

Keep in touch !



 You can email Manju at manjupadmasekar@yahoo.com

Her blog is at www.myselfishgenes.blogspot.com

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