Thursday, March 19, 2015

“’I don’t know’ are three of the most underused words in IVF


" What’s really interesting about IVF – and I think this is true for a lot of fields whether you’re in physics, math, chemistry, history, or whatever it is – the more you learn, the you more you realize how little you know.”

IVF doctors need to learn humility and accept the fact that there's a lot about human reproduction which we do not understand. We should stop pretending to be wiser than we are. We need to be transparent with our patients and tell them truthfully when we are not able to answer their questions. The questions are often very simple ( Doctor, why did my embryos fail to implant ?) but the answers are mind-bogglingly complex. However, rather than level with the patient, most doctors prefer to take an intellectually dishonest shortcut. They order pointless untested tests ( which are expensive and of unproven clinical value), and when the results come back as abnormal, they triumphantly tell the patient - We now know the reason for the IVF
failure ! The reality is that the so-called abnormality may be of no importance, and is often just a red herring.



This leads to avoidable care , which is a result of  “magical thinking - convictions that both doctors and patients tend to hold , despite evidence that should lead to more nuanced beliefs.”(  Institute of Medicine president Harvey V. Fineberg ) . " Some examples of such thinking are the beliefs that technology is always good, that new technology is always better than older technology, and that uncertainty is intolerable."

This attitude causes arrogance , overtesting and overtreatment. We cloak our ignorance with technology and pseudoscience.   The truth, as any good IVF researcher will tell you, is that  the more you know, the more you know that there is even more that you do not know. 

Sadly, there is so much pressure to commercialise the research, that these tests are marketed with a lot of hoopla and hype, through press releases , medical journal articles, and keynote speeches at medical conferences . It's surprisingly easy to take doctors for a ride, because most of them have never been taught to be sceptical and critical. Many naively believe that every journal article contains the unalloyed truth, because they have failed to read the essay,  Why Most Published Research Findings Are False. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124 

In her blog Less is More, Dr. Otte suggests a “just right” or “Goldilocks” approach, and this ‘not too much and not too little’ approach aims to strike a healthy balance. Doctors need to use the right amount of medicine, focusing on patient-centred, evidence-informed practice. That way, we can just focus on doing more of the things that are known to have positive outcomes with patients, and not end up causing unnecessary harm.

IVF doctors who do not get more humble as they 1) get older, 2) grow as a person, or 3) learn, are not paying attention.  No matter how hard IVF specialists work,  because IVF is so complex and there are so many known and unknown variables which affect embryo implantation, that there will always be much that we do not know.  The best IVF specialists have been able to develop systems that deal effectively with the fact that IVF is a probabilistic process, and will help the patient to navigate the journey with realistic expectations. It actually requires a mature physician who is confident about his own competence, to be able to tell the patient - I don't know !

I find that patients prefer doctors who are honest and who level with them.  While some patients crave certainty and want a doctor who has all the answers, the truth is that patients also know that doctors are not omniscient ! Patients are smart, and while you can fool some of the patients some of the time with fancy medical gobbledygook , you can't fool all of them all the time.

A more mature approach is being frank and saying - We don't know exactly what the problem is, but we can work together to craft a solution to bypass the problem. Patients and doctors can then forge a partnership , to help them reach their goal of having a baby .

Need help is making sense of your IVF treatment options ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

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