Saturday, July 30, 2016

Any IVF clinic which doesn't routinely transfer blastocysts is a bad IVF clinic


I know this is a provocative statement and is going to raise a lot of hackles, because most IVF clinics in India don't do day 5 transfers. While quite a few do day 3 transfers, many still continue doing day 2 transfers.

We used to do day 2 and day 3 transfers in the past as well, but the technology has become so good that we can routinely do day 5 transfers for everyone who comes to us. I think any clinic which doesn't do, this is actually being irresponsible. Not only are they depriving their patient of the best chance of getting pregnant, they're also signaling that they're not very confident about their ability or expertise or of their embryologist or IVF lab to be able to go grow embryos to blastocyst stage.

You can see what  blastocysts look like at http://www.drmalpani.com/blastocystimages


Now, there's no doubt that the blastocyst transfer has a much higher implantation rate than day 2 or day 3 transfers. This has been proven multiple times in many research studies all over the world. I am quite happy for someone to challenge this statement by providing me with figures to the contrary. Now, I'm not saying that day 2 and day 3 embryos don't achieve pregnancies. Of course, they do, but they would have achieved the pregnancy, even if you've grown these embryos to day 5, so I don't see any advantage to transferring at day 2 or day 3.

In fact, there are multiple disadvantages. For one thing, you often have to transfer more embryos to achieve the same pregnancy rates, so you have end up with a higher risk of having multiple pregnancies which can actually cause more long term problems in the form of premature births or low birth weight babies. This is hardly a desirable outcome.

The trouble is that sometimes IVF doctors are very shortsighted, and all they want to do is achieve a transfer and get a pregnancy, if at all. They are not very invested in the long term outcome for the patient, which means they don't think about what they will do in case the first cycle fails, because lot of them just want to earn the money on the first cycle and never mind about what happens to the patient, because there will be a new bakra to catch tomorrow. They don't really worry about their live birth rates, because once the patient gets pregnant, they wash their hands of all responsibility.

I think smart patients need to understand that the standard of care for IVF today is a blastocyst. It allows us to pick the best embryos, it allows us to transfer fewer embryos, and it allows us to achieve a high pregnancy rate. All of which are major advantages for the patient, so why should a patient be willing to accept suboptimal, poor quality care just because the IVF clinic is not confident or competent? In fact, patient should be proactive, and unless patients demand that doctors improve the quality and standard of services they provide, they will continue being taken for a ride by unscrupulous doctors.

It is true that for the poor ovarian responder with few eggs, there is a risk that none of them may develop to the blastocyst stage. All of them may "arrest", so that there are no embryos available for transfer. While this may cause short-term pain, it does provide useful information for planning the next treatment cycle.

So why doesn't every clinic routinely do blastocyst transfers only ? Why do some still transfer embryos on Day 2 and Day 3 ? This is because they are not competent, and do not have enough confidence in the ability of their IVF lab to be able to grow embryos to the blastocyst stage. You do need a full-time experienced and expert embryologist to be able to consistently grow embryos to the blastocyst stage, and sadly lots of IVF clinics still are not adequately equipped or staffed to be able to offer this option to their patients, which is why they end up cutting corners.



Not sue what the difference between a Day 3 embryo and a blastocyst is ? You need to become better informed ! You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos



Why poorly informed patients get poor quality IVF treatment



I received this email from a patient.

Hope this mail finds you in best of your health , as you may tell from trail mails , we have consulted you earlier also . My wife has failed 2 IVF cycles in Delhi.

Total embryos developed : 7
transferred in first cycle : 3 , 4 were frozen

Transferred in second cycle : 3 , 1 was declared unfit while thawing

They were all grade A embryos , transferred on day 2. We do not have any pictures of embryos.

Hers is a case of unexplained infertility

Sir, we have been going through these treatments since last two years and as many of the patients , now running out of patience.Please help me by giving clarity on areas below :

How many cycles should we attempt for IVF ?
How many cycles before we move to donor eggs?
We are also planning to attempt surrogacy simultaneously through donor egg

One of the reasons I provide  a free second opinion service is because it breaks my heart when I see patients get poor quality IVF treatment. IVF clinics seem to have sprung up at every street corner in India, and many gynecologists style themselves IVF specialists after attending a one-week "diploma" course in an IVF center. The tragedy is that patients are not sophisticated enough to be able to differentiate between a good clinic and a bad clinic, which means it's very for an unscrupulous doctor to take them for a ride. The reason I care is because all IVF clinics then get tarred with the same brush, and patients will no longer have any confidence in even the good IVF specialists. They will end up remaining childless, because they will refuse to attempt IVF, and thus deprive themselves of their best chance of getting pregnant. If good IVF specialists keep quiet  and allow the bad ones to continue cheating their patients, we are inviting a regulatory backlash from the government, which in its typically ham-handed way will pass rules which will make life miserable for all infertile couples.

Let's look at the above email.

It's obvious is that this patient has selected a poor quality clinic.

For one, they transferred embryos on Day 2. No good clinic does this anymore. The standard is a  Day 5 ( blastocyst) transfer, which has a much higher implantation rate; and also reduces the risk of a multiple pregnancy. Any clinic which does not have the confidence to grow embryos to Day 5 is a poor quality clinic. I know these are strong words, but there is enough research to back up this statement, and I would be happy for someone to disprove this !

Secondly, they failed to provide embryo photos. This is diagnostic of a bad IVF clinic, because this means they are trying to hide information from the patient.

Thirdly, they lost an embryo after thawing it. In a good clinic, survival rates after thawing vitrified embryos should be closed to 100 % !

While I am disappointed with the poor quality of care this patient received, I am even more disappointed with the poor quality of his questions.   This shows that he is not thinking clearly and has become no wiser even after spending so much money ! There is no need for him to use donor eggs; and to combine both donor eggs and surrogacy is the worst possible option, because it is both the wrong medical choice, and also extremely costly. You may think I am being excessively harsh by criticising a patient - after all, he isn't a medical expert, so why blame him ?

However, I do believe that patients should take responsibility for making their own medical decisions - they simply cannot afford to leave everything upto God, or their doctor anymore ! And it's irresponsible of educated patients to take such a passive uninformed approach in this day and age, where so much high quality medical information is easily available free of cost from reliable websites.

You can download the  IVF comic book free at www.slideshare.net/malpani/ivf-comic-book





The importance of educating illiterate patients


I was talking to a friend who had come back from Mayo Clinic , and he was raving about how helpful the doctors there were. They shared tons of information, so he could make a well-informed decision ; and they spent a lot of time counselling him and helping him to decide for himself. He was very impressed with how much time and trouble they  had taken in creating and disseminating patient education material. And then he said - But of course , this will never work in a country like India , where people are illiterate and poor , and cannot understand what's happening.

I had to respectfully disagree with him. Yes , we can't copy and paste the American model for patient education , but the truth is that just because people are illiterate doesn't mean that they are not able to make their decisions for themselves. In fact the poor have to be much street-smarter than us, simply in order to be able to survive .

The truth is that the opportunity to educate patients is far greater in India, because we are starting with a clean slate. While Americans suffer from an information glut, Indians are starving for health information which is designed for their needs.

As doctors , the onus is on us to think of clever way of reaching out to them and educating them . We need to start with where they are , and then hold their hand to bring them to where we want them to be. Now just because they can't read and write doesn't mean  that we can't teach them . In this day and age, it's possible to use video on a smartphone in order to make sure that patients understand what their options are , so they can make thoughtful decisions in partnership with their doctor.

The big problem is that doctors don't respect patients who are poor or illiterate. They look down upon them because they believe they won't be able to understand anything. This is actually a shortcoming on the part of the doctor - that he cannot explain in terms which are simple enough for them to
follow ! 

Because the doctor cannot explain their problem and options to them in a medium which they can understand , he then resorts to calling them stupid. Doctors need to learn new techniques in order to teach illiterate patients. An investment in these educational initiatives would provide a far better ROI because there are so many poor illiterate patients in India. If we can reach out to them, we would have a much greater impact on the health of Indians as compared to educating the urban rich.


Thursday, July 28, 2016

Useful practical tips for students headed to the USA


My elder daughter is headed off to Stanford Business School to do her MBA, and this is the advice my younger daughter ( who is at Yale) had to give her.

Things to do when you get to  USA (in order of importance)

1) Set up a bank account . I don't know about the West Coast but pick one that has the max number of ATMs and branches close to you and Stanford. I've heard BoA is always good (that's who I bank with). Get a credit card to start building credit history - they'll give one to you without an SSN ONLY IF YOU GET IT AT THE STUDENT BANK OUTLET AT STANFORD. Otherwise getting a credit card without a job and credit history is hard.

2) Get a phone number. Don't get a contract - they make no economic sense and they're very tough to get out of. T-mobile has cheap family plans - you can either join someone else's or create your own. They start at 4 lines and have 10 GB of data on each which is INSANE. It works out to about $30 per line per month. Compare this to AT&T who charges upwards of $60 for just 1 GB of data..I've never had issues with T-mobile and my family plan is awesome.Also they have international calling plans - I have one that calls to 80+ countries (including India and the UK) for an additional $10 a month.

3) Get a phone. You can pick whatever you want. I think the phone you have is fine though but get one with 64 GB of data OR MORE. I can't stress this enough - there are SOOOO many apps that take up so much space. Don't compromise on this.
Also get a laptop while you're at it. I'd recommend a 13" mac book air and NOT the new 12" mac cause it doesn't have a traditional USB (it has USB c which hasn't caught with the rest of the world). The Pro was too heavy for me. Get a Mac over PC cause everything here - especially in Stanford - runs better with Macs. Unless you foresee yourself doing a lot of excel modelling.

4) Download these apps :

    Venmo (how everyone transfers money for free - right from $1 to $10,000)
    BoA or your bank' s app. Makes life easy
    Lyft in case you don't already have it
    CamCard in case you don't already use it (to scan business cards and convert it to digital contacts)

Also once you get a house and need to decorate - buy stuff from discount stores like Ross, Marshalls, TJ Maxx and Nordstrom Rack. You find the CUTEST stuff in their home sections for really discounted prices. A lot of it is designer also. Don't waste money at IKEA and stores like Bed, Bath and Beyond without checking these out first. Trust me, I really regretted it. This counts right from lounge chairs to mats and towels to candles and other home knick knacks.

This is her opinion based on her personal experience - your mileage may vary !

Poor quality embryos - was it a sperm problem ? or an egg problem ?


DR. SAIPRASAD GUNDETI, CHIEF EMBRYOLOGIST, MALPANI INFERTILITY CLINIC PVT. LTD.

Embryo quality is the best predictor of IVF outcome. Patients with top quality embryos usually have very high chances of getting pregnant. By contrast, the chances of conception for patients with poor quality embryos are considerably reduced.


POOR QUALITY EMBRYO ON DAY 2
POOR QUALITY EMBRYO ON DAY 3
       

Reason for Poor Quality Embryos :on Day 2 and Day 3

Poor quality embryos on day 2 and day 3 are usually due to an egg factor, and not because of a sperm problem. This is because it is the mitochondria in the egg which serve as the powerhouses which drive cell cleavage. It is poor mitochondrial function ( seen commonly in eggs from older women) is predominantly responsible for slow and poor quality embryos ( fragmentation in early cleavage stage embryos). Sadly, we still do not have a test for checking mitochondrial function in eggs. If we have lots of eggs which end up forming poor quality Day 3 embryos in a good lab , then we can conclude that it was because of a egg mitochondrial problem.

What about the sperm ?  Once the sperm have fertilised the egg, they have no further role to play in embryo development until after Day 3 ( at which time the embryo has about 8-cells).

Reason for poor quality blastocyst formation 

Now , if we have poor quality embryos on Day 3, it is hardly surprising that we will get poor quality blastocysts on Day 5.

However, in some patients, we see a very low blastocyst conversion rate. These patients start  off with a high number of good quality eggs, and we get very good quality embryos on day 2 and day 3 (4-cell grade A on day 2 and 8-cell Grade A on day 3.

The problem starts only after day 3. The embryos stop growing suddenly ( they arrest) , or they start fragmenting, which means we get only 1 or 2 blastocysts on Day 5  - and sometimes we get no blastocysts at all, even though we had lots of great Day 3 embryos.


                                     
TOP QUALITY EMBRYO ON DAY 2   

                        
TOP QUALITY EMBRYO ON DAY 3


POOR QUALITY BLASTOCYST ON DAY 5

When we observe this pattern in a good quality IVF lab, then we can conclude the problem is with the sperm. This is called the Late paternal Effect , and occurs because of failure of paternal genomic activation.  Sadly, we don't have a test for this, and it can be quite heart-breaking to see great-looking  embryos on Day 3 fail to form blastocysts. The problem is that we cannot predict this because there is no sperm function test which provide this information. Sadly, the sperm DNA fragmentation tests available today are very unreliable .
This is the reason why IVF /ICSI can be so useful - because it provide us with so much valuable diagnostic information.

The only way to conclusively prove which gamete ( the wife's egg or the husband's sperm) was responsible for getting poor quality blastocysts is by doing cross-over testing in the IVF lab. Thus, we can fertilise the wife's egg with donor sperm; and try to use the husband's sperm to fertilise donor eggs. In real life, this can be very hard to do in a clinical IVF program, because we don't really have spare human eggs we can use for this kind of testing.

Also, please do remember that this applies only in a good IVF lab - bad labs will create poor quality embryos because of suboptimal lab conditions and lack of technical expertise on the part of the embryologist.

This is why you should go to an IVF lab which does blastocyst transfers routinely . If you allow them to do a Day 2 or Day 3 transfer, you will lose valuable information, and will be no wiser as to what to do in your next IVF cycle.

This is also the reason why it is so important that patients insist on getting embryo photos routinely. They provide invaluable diagnostic  and prognostic information which can be used to modify the treatment plan for the future, if the current IVF cycle fails.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !



Wednesday, July 27, 2016

A happy patient from Africa at Malpani Infertility Clinic

The optimally busy doctor.


Most doctors have a sweet spot for everything we do , including seeing patients. Thus, if we see about 10 patients a day and it takes us about half an hour to see a patients, that means we're busy working for about 5 hours and this gives us a sense of professional satisfaction that we've done a good job, and it allows us to spend enough time with each of our patients , so they're happy as well. If we assume this is our sweet spot, then this is the optimal number of patients we should plan to see everyday. We then need to price our fees so that seeing this number of patients would allow us to earn as much money as we require.

The problem arises at both the ends of the spectrum -  either we don't have enough patients to see, which means we end up twiddling our firms doing nothing; or we have too many patients to see , which means we're so busy , that we really don't have enough time to devote to each patient, and we may end up missing the diagnosis . A rushed doctor creates a lot of patient dissatisfaction, because patients are made to wait for too long, and they don't get to spend enough time with the doctor.

Having too many patients to see paradoxically also reduces the amount of professional satisfaction for doctors. It upsets our work life balance , and if we spend too much time in the clinic because there're too many patients to see, we don't have enough time either for our self or for our family.

The key is to find the optimal middle path. When you're just starting practice and you don't have too many patients, your major focus is on acquiring new patients. Sadly, this is a slow process, and it's not a good idea to take shortcuts . When you have slack time , rather than complain about this, you should learn to utilize it gainfully - for example, by sharing your knowledge online, by publishing patient education articles and creating patient education videos. This will allow you to make use of your knowledge, so you can serve lots of patients, even though they are not physically present in your clinic. It will also allow you to build up your online presence and your digital reputation, but of which are priceless assets.

If you have too many patients, then it's much easier to cut down on the number of patients you see. The tragedy is that most doctors aren't mature enough to realize that there is a price they pay for being excessively busy.  The more senior they get, the busier they want to be ! Often, this is because they don't have any other hobbies or interests; or they're completely focused on maximizing their income. Some doctors are quite masochist, and take a lot of pride in the fact that they are working all the time, and they are so busy taking care of patients, that they don't have any time for themselves or their family, because they're always available for their patients.

While their devotion can be remarkable, I don't think this is in anyone's best interests - either the doctor or the patient. If the doctor is too busy, he is likely to be tired; may miss important information; and is more likely to make errors  because he's not able to devote enough time to each individual patient. It's not good for the doctor either, because while it's true that if you see more patients you earn more money, the quality of time which you spend with each patient deteriorates sharply as well, and this can be a heavy price to pay. You don't have enough time and energy to spend on solving the challenging problems posed by difficult patients, because there are
so many other patients waiting to see you. Doctors do find workarounds for this  - for example , by employing assistants, but the quality of care they provide does suffer.

Senior doctors need to have the maturity to be able to say enough is enough - I need to do more with my life than continue seeing more patients. One way of cutting down your workload is by increasing your fees, so that patients will go elsewhere . An even more graceful method is to refer your easy patients to your juniors ! They will be grateful for this gesture, because you are helping them to grow their practise.

I personally feel that doctors who are too busy just have poor time-management skills, and they are being unfair to themselves, their patients and their family.

Sunday, July 24, 2016

What keeps doctors up at night - the human side of medicine

The panel discussion on " First, Do No Harm: featured the medical legends, Dr Farokh Udwadia, Dr Yeshwant Amdekar and Dr Sunil Pandya.

It gives a rare glimpse into the heart and soul of a doctor - and you can see what makes them keep awake at night worrying about their patients.

The book, Patient Safety - Protect yourself from Medical Errors is now online at www.safetyforpatients.in

You can also download it free at http://www.slideshare.net/malpani/patient-safety-protect-yourself-from-medical-errors

Wednesday, July 20, 2016

Dr Farokh Udwadia on the increasing tension between doctors and patients

Why startups run such a rocky unpredictable course

It would be great if investors could develop a formula to be able to determine which startups will be successful. We'd become rich extremely quickly , and wouldn't have to waste so much money on those which fail. One would expect that over so many years, after investing so many billions of dollars in startups, the super-smart people who run venture capital firms  would have been able to come up with a formula for success , so that we could determine which startups we should be investing in.

However, the fact is that we still don't know which startups will do well. A lot of it is still hit-and-miss, and most investors will accept that there is a major element of relying on gut-feeling when they decide which startups to back. This is not because investors are stupid - it's just that startups are complex adaptive systems ( CAS) , which means they are unpredictable and unknowable.

Two of the most prominent properties of complex systems are self-organization and emergence. This means that no individual agent in the system ( either the founder or the VC) is able to control the outcomes in the system , as these are a consequence of interactions within the system . Complex systems by nature are unpredictable and generate surprises, which is why investing in them can be such a roller-coaster ride.

The startup ecosystem has lots of players -  employees,  customers, other startups, investors, large companies, established competitors, government policies and regulation . The complexity relates to the unexpected emergent behaviour of the overall svstem which can not be predicted from the behaviour of an individual player, nor understood by decomposition of the system. In a complex system,  cause and effect follow a non-linear relationship where small changes  can potentially have a big impact . This is why complexity has been dubbed the “science of surprisc”  and startups have surprised lots of established players in a variety of markets - for example, the Apple iPhone disrupted the incumbent mobile phone players ; and Google transformed the advertising industry.

Paradoxically, a startup has no command and control structure, so that even though it may seem that the founder is in charge, in reality it is the initial core group of early employees who are forced to  create rules and make things up as they to run the business on the fly. Execution as learning becomes the DNA of successful startup cultures, because there are no readymade processes which they can follow. This is why startups follow a chaotic process of discontinuous growth, and the glue which holds them together is the vision and passion of the founder, which guides the activities of the employees during their early journey.

Complex adaptive systems are dynamic self-organsing systems which are able to adapt in and evolve with a changing environment. This is one of the strengths of a startup , which gives it the agility, resilience and flexibility it needs so that it can be far more innovative than a traditional large company .

Complex systems seem to be always teetering on the edge of chaos  - and this is a feeling I am sure lots of entrepreneurs can identify with  !  The dynamics of a complex adaptive system combines both order and chaos, which means there is bounded instability that is characterized by a state of paradox: stability and instability, competition and cooperation, order and disorder.

Complexity theory provides a new perspective through which we can observe the development of new business startups because they do not follow the standard linear life cycle theory of the growth of a mature company.  This is why startup founders need to embrace chaos, encourage experiments, and tolerate mistakes. Given that no one is in charge of a complex adaptive system, the management approach should emphasize collaboration and agility to create desired outcomes.

Atul Gawande  points out that complexity theory divides problems into three general categories: simple, complicated and complex. Simple problems are ones in which the inputs and the outputs are known , and you simply need to follow a set of rules - for example, you use a checklist to make sure your tax returns are filed properly. Complicated decisions involve significant uncertainty. In these situations, the solutions may not be known, but they are potentially knowable, but it can take time and money to find them. Some startups will get tripped up by these because they run out of cash when they get to this stage. Finally, complex situations are those in which the formula for success is unknowable. While you may use rules of thumb to try to improve your chances of success, you do not know what will work, and cannot predict the outcome .  Being a parent is a good example. You can raise children using the best evidence-based rules, but you can never be sure how they will turn out !

The problem is that most investors think of a startup as being a complicated system,  while it is really a complex system. This is why they expect that the entrepreneus should be able to deliver controllable and predictable outcomes if the proper processes are put in place properly and the founder runs a tight ship .   They assume that an intelligent analysis of past events improves their capacity to predict future events. The truth is that in  complex environments that change all the time, we cannot anticipate all situations and we cannot pre-design a system that is always guaranteed to work - all we can do is experiment and correct course intelligently, by trying to fail as quickly and  cheaply as possible , until  we stumble across what works.

Startups are complex systems, and we need to learn to be humble, and not assume that we have all the answers, just because we are domain experts or have tons of money . The best approach to supporting a startup is to accept that everyone is equally clueless but well-meaning , and allow the founder to try something that seems to make sense , based on his knowledge , your instincts , and the available data. You must then jointly measure the results and often repeat the cycle many times in search of the best possible outcome.

Now I am not advocating that investors take a nihilistic " chalta hai ", " anything goes " attitude . After all, as  parents,  even though we know that we cannot control how well our children will do in life, we  do our best to provide them with a high quality education ; and do set boundaries until they are mature enough to make their own decisions.

Complex adaptive systems produce novel, creative, and emergent outcomes, which we cannot predict or control.  Investors who understand  how complex systems work drop the burden of trying to control the founder and instead focus on the small actions they can take to influence patterns of interaction. If we understand our limits, we will be able to do a better job  !

Lokmat newspaper covers the book launch of Patient Safety


Panel discussion on First Do No Harm at Seth G S Medical College and KEM Hospital



The book release was followed by a panel discussion on " First Do No Harm" .  Dr Farokh Udwadia, Dr Sunil Pandya , Dr Yeshwant Amdekar and Dr Urmila Thatte shared many useful pearls mined from their years of clinical experience on what doctors can do to improve patient safety.

It was a great feeling to be back in my alma mater. We had a full house and the Seth G S Medical College and KEM Hospital team did a great job with organising the book launch and the panel discussion !

You can read the book at www.safetyforpatients.in  or download it at http://www.slideshare.net/malpani/patient-safety-protect-yourself-from-medical-errors !

Free book on Patient Safety - Protect yourself from Medical Errors

Tuesday, July 19, 2016

Why startups fail - and the real reason may surprise you !



Along with being an IVF specialist, I am also an angel investor who funds startups. Failures are common in both IVF and angel investing, which is why it's a topic which fascinates me.

One of the major risks any startup faces is that of failure. In fact, this possibility  is built into the very definition of a startup, because a startup is an experiment in order to find out what works in the real world and what doesn't. If it does work, the payoff is enormous, but the reality is that about 90% of startups will fail, because we cannot predict the future . Since failure is expensive, a lot of time and effort is invested in trying to reduce the risk of failure.

Unfortunately, we seem to be going about it the wrong way.  When a startups fails , we want to find a scapegoat to blame, and this is usually the founder. There's a lot of finger-pointing , and people create stories as to what went wrong , and why. How could the founder burn through so many millions so quickly with nothing to show for this ? Surely he must have become too egocentric and refused to listen to reason, which is why he drove his company into the ground.

Whenever a startup succeeds , we look for a hero , and the founder is painted as someone who's super-human.  However, the flip side to idolising  extremely successful founders  such as Steve Jobs is that we also paint founders as being villains when the startup fails.  We forget that success or failure doesn't depend on an individual  -  it depends on the system. We need to analyse the failure dispassionately by doing a post-mortem, so that we can learn from it and move on.

Unfortunately , humans prefer reading emotionally-charged stories rather than taking the time and trouble to understand complex alternative histories and counter-factuals.  This short-cut means we end up doing a disservice  to the ecosystem . We gift all the glory to the successful founder , and punish the one who fails by dumping all the blame on him.

In order to reduce failures,  smart VCs  implement systems and processes to make sure that the startup is on the right track.  The founder is required to report reams of data, and they analyze this data to try to pick up patterns and early warning signs of failure.  However, rather than use this data to help the startup to succeed , it is often mid- used for pulling up the founder when the company is not growing as planned.  Because investors are very busy and have lots of startups to track and monitor, they focus only on a few numbers, and use these metrics to judge the performance of the founder. These will decide whether the startup gets the next round of funding, or whether the investor pulls the plug and allows the startup to die.

Now there are three ways to get better numbers:
● The first is to improve the system. To do this, the founder needs to change processes in order to add value at the front line - a difficult and time consuming task, which needs patient capital .
● The second is to suboptimize.  Here the founder focuses exclusively on improving the area being measured, often at the expense of other areas.
● The third is to game the numbers. The founder manipulates the data to make the numbers look better.

Thus, if the major focus of the investor is on tracking GMV (Gross Merchandise Value) , the founder will focus on inflating that number, often at the expense of neglecting more important metrics , and this is what leads to disaster in the long-run. It's easy for a founder to dress up the numbers in order to make them look better - which is why so many e-commerce companies continue to behave in ways which make no sense to an outsider. They sell products at  a loss  in order to get their GMV up, because this is what keeps their investors happy. Similarly, if an investor wants to see growth, they are happy to buy customers, no matter what the cost, so that they can raise their next round of funds from a bigger fool.

Startups are complex adaptive systems which have to tackle unknown unknowns. Investors need to understand that the success or failure of a startup depends on providing them a supportive ecosystem. We need to focus on collect useful metrics which can be used to support the growth of  the company, rather than using them as a stick to blame the founder when things aren't going as planned.

Monday, July 18, 2016

Bouncing back after a failed IVF cycle.


While being an IVF specialist is a lot of fun because we're helping people to have deeply loved babies, the one part of my job which I hate is having to tell patients their hCG is negative and the cycle has failed. This is specially true when the cycle was perfect, we got good quality blasts, the transfer went well, the endometrium was perfect. Because no matter how much we explain to patients that an embryo is not a baby and that IVF doesn't have a 100% pregnancy rate, when the cycle fails their heart breaks. Quite frankly, mine does too. I'd be very happy if we could give them a baby , so that they could move on with their lives, and send lots of their friends to us !

    It's very difficult to counsel these patients sometimes, because they're emotionally very upset, and even if their brain understands that we've given them good quality care, their heart still hurts. Often, they don't know how to cope with this. They either end up blaming themselves, or they blame God, or they blame the doctor. I tell them, "For heaven's sake, don't blame yourself. This is a biological process which no one can control, and you need to learn to be kind to yourself." Blaming the victim is a destructive way of coping with IVF failure.

    Blaming God doesn't help either. I believe in a kind God who wants good things for us. I think it's helpful to have faith in a higher power who we feel is looking out for us. Whether you're religious or not, this belief can help you cope with dark times, even when you cannot make sense of his actions.

    As far as blaming the doctor goes, I don't like being blamed of course, specially when  we have put in a lot of effort , and given patients the best possible medical care. We spend a lot of time counselling patients, and explaining to them what we're doing and why, so they know exactly what's happening. However, I'd much rather that they blame me , rather than themselves, because I have a clear conscience, and I know we've done a good job. Since I know no one could have done anything more, blaming me does not hurt me, and if using me as a punching bag helps to relieve my patient's distress, than I am happy for them to do this . I can deal with that blame, because I know it is mis-directed. I feel that giving them a target to get angry with helps them to vent their anger , so they can move on.

When an IVF cycle fails, the predominant emotions are one of depression and sadness, and this can be hard to deal with. When you feel sorry for yourself , you feel powerless and alone, and get paralysed into inactivity. Compared to this, anger is a better emotion, because you can channel it into doing something else - and I believe this is better than not doing anything at all.

    I tell patients that they need to find the strength to cope with this blow within themselves. While growing up, all of us have dealt with disappointments in our life, and we have sources of solace we can tap into. This could be a spouse; family members; friends; relatives, or a spiritual authority , such as a guru. While I can help them analyze what went right in the cycle and what went wrong , there are still lots of grey areas we can't figure out - what we call the unknown unknowns, because IVF is still not an exact science.  However, no amount of analysis can provide comfort when the cycle fails, and healing finally has to come from their heart.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !






Sunday, July 17, 2016

Freezing time: What career women need to know about preserving their fertility

In the 1950s, contraception allowed women to plan their families, so they could decide how many babies to have and when to have them. Now, reproductive technology empowers them even further, so they can make the right life decisions for themselves. Biology is no longer destiny, and women can compete with men on equal terms, without having to worry about their biological clocks!

Read more at http://www.firstpost.com/living/freezing-time-what-career-women-need-to-know-about-preserving-their-fertility-2895538.html
 

Thursday, July 14, 2016

Young doctors need to leverage their digital expertise in order to grow their medical practice



 Most senior doctors who have an established practice are busy seeing lots of patients in their clinic on a daily basis. They are digital dinosaurs and are uncomfortable using computers. They're very used to seeing patients face to face in the clinic because this what they have done their entire life, and they are happy to continue doing so until they retire.

Because they have acquired a reputation as being the leader in their field, patients are happy to come to their clinic to see them . Of course, this is not very conducive to creating a great patient experience , because patients often have to wait for weeks in order to get an appointment; and then wait for hours in the clinic once they do get the appointment. Finally, they are lucky if they get to spend a few minutes with the senior doctor , simply because he's so swamped with patients who are clamoring for his attention.  This means that  his patients are often dissatisfied, but they put up with this because feel they don't have a choice . There are only a handful of brand name senior doctors , and patients are not willing to risk their health going to anyone else.

Now, this is a huge opportunity for the younger generation of doctors who are digital natives. They're often extremely well-trained and have a lot of expertise , but they cannot demonstrate this because they are not able to attract patients. It can takes years to build a reputation, and what do they do till then ?

It's a chicken and egg problem, and until they start getting a steady stream of patients to display their clinical skills , how do they establish a word of mouth reputation? This is why young doctors are often so frustrated . They are forced to work in a large corporate hospital which has a huge captive patient base ; or they need to offer kickbacks and cuts to other doctors to refer patients to them.

These young smart doctors will find that they have a lot of time in their hands, but rather than getting upset that they have nothing to do, they need to be smart and leverage this spare time and their digital skills so that they can reach out to patients , rather than wait for patients to come to them. All patients are online these days, and clever young doctors need to use digital technology in order to go to where their patients are.

Patients have changed, and lots of them are online. They want instant gratification, and don't want to have to wait forever to see a doctor. They want a quick resolution to their problems, and are happy to connect with a doctor who is available and affordable , because he provides online services.

Many patients will use digital consultations as a complementary solution, which means they will go to a real world doctor and will often seek a second opinion from a digital doctor to make sure they're on the right track. Young doctors need to tap into this huge market , so that they can keep themselves busy and establish a reputation for themselves online. This will then automatically translate into to a good real world reputation as well. This is an untapped niche area where there is little competition from senior doctors , because they're so busy in real life that they don't have the time or the energy to explore digital outreach channels. This is where young doctors can learn to shine - by playing to their strengths !







Wednesday, July 13, 2016

Book Release - Patient Safety - Protect yourself from Medical Errors


Please do come to our book release - Patient Safety - Protect yourself from Medical Errors on July 19 at KEM Hospital at 2 pm. This will be followed by a panel discussion by Dr Farokh Udwadia, Dr Rustom Soonawala, Dr Sunil Pandya , Dr Yeshwant Amdekar and Dr Urmila Thatte on - First, Do No Harm !

IVF is much more than just an infertility treatment.



Most people think of IVF as being a treatment option which maximizes their chances of getting pregnant. However, the reality is that IVF can be a lot more. Thus while the primary purpose of an IVF cycle is of course to give the couple a baby, it also provides a  lot of diagnostic information as well as prognostic information.

We often diagnose infertile couples as having unexplained infertility . This means we are telling them we don't know why they're not getting pregnant in their bedroom, and many find this lack of a diagnosis very frustrating, because they are worried that if we don't know what the problem is, how will we be able to find a solution ? When we do IVF , we actually get a chance to see what the eggs look like ;  whether they are mature ; and whether the sperm are capable of fertilising the eggs . Thus, some couples with unexplained infertility will have sperm dysfunction , which means that even though their sperm count, motility and morphology are completely normal, their sperm are not able to fertilise the eggs. The only way of making this diagnosis is by documenting total fertilisation failure in the IVF lab. This is invaluable information which we really can't get any other way.  While this does mean that we will not have any embryos to transfer in the IVF cycle, it also means that we can now tell them why they have not been able to get their wife pregnant in the bedroom.  We can use this diagnostic data to do ICSI for them in the next cycle, so that we can help their sperm to make embryos in the lab.

Similarly , the prognostic information IVF provides can be vital as well. Thus, we know that older women have a reduced chance of getting pregnant , but every older woman is different , and they all have different ovarian reserve. It's not fair to lump all of them in one basket ! Doing an IVF cycle allows us to actually check their ovarian response, and this is the best test for functional ovarian reserve - how well does she respond to superovulation ? Does she make good quality embryos in the lab ? If we can get good quality blastocysts for her, even if she does not get pregnant, we can tell her she has a good chance, and can keep on trying IVF with her own eggs.  On the other hand , if we embryo quality is poor, we can infer that the problem is poor quality eggs , and there's really no point in repeating the IVF cycle , and she would be better off considering third party reproductive options , such as using donor eggs .

IVF can provide priceless information , and this is why it's important that every IVF cycle be properly documented . Embryo photos should be routinely provided to every patient, so that this data can be used for guiding her intelligently in the future. Even if the current IVF cycle fails, we can still extract useful information by analysing it thoughtfully, so we can tweak the treatment plan as needed. You just need an intelligent doctor, who is willing to mine the IVF data to look for the gems hiding there !


Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




A doctor whom I admire


All of us have role models in our life and one of the doctors whom I look up to is a good friend , Dr. Rupin Shah, who is about five years senior to me .

He is an andrologist , and specialises in treating infertile men. He is truly a doctor's doctor , because he's done pioneering work in the field of male infertility . He is considered to be India's number one andrologist, and is invited to give lectures all over the world. He is great demand, and travels all over the world because IVF clinics ask him to perform surgical procedures such as testicular sperm retrieval to help their infertile patients to have a baby.

What I admire about him is that he's extremely open and transparent , and is willing  to teach and share information generously. Not only is he a great surgeon with superb technical skills , he's also academically very sound. He is well-read and well-informed , and has a point of view which he can support with facts and figures.

Even better, he is flexible and has adapted his surgical techniques over time, so that he improves year after year. He has devised lots of extremely clever solutions for the infertile man , so that using his techniques it is possible for Indian doctors to retrieve sperm from men with testicular failure at one-tenth the cost of what doctors in the US charge.

Not only is he a great surgeon, he also has lots of other interests which he pursues passionately, and this seems to keep him young and fit. He loves hiking; is an expert meditator; has mastered malakumbh; and is now learning Sanskrit.

My only complaint is that even though he has so much clinical experience , he doesn't share it with the rest of the world . I have been prodding him to keep a blog and upload his surgical videos to youtube, so that doctors all over the world can benefit from his expertise. I am hoping to be able to goad him into writing a book , because he has so many stories to share !

Tuesday, July 12, 2016

Why I prefer treating educated patients


Lots of doctors find educated patients a pain in the neck. They feel that these patients think they are smart. That they spend a lot of time online. That they do a lot of research as a result of which, they ask lots of questions. They come with a long list of doubts, and they consume a lot of the doctor's time because they often don't trust what the doctor is saying and have their own opinion. They want the doctor to listen to them and clarify their doubts, rather than just provide his professional opinion. Lots of iWave doctors would be much happier treating either ignorant illiterate patients, who don't ask any questions or patients who are willing to put so much faith, trust, and confidence in their doctor that they are happy to let the doctor make all the decisions for them, so that they don't provide any inputs or personal preferences at all.

Now that's not my style. I prefer treating intelligent educated patients who've done their homework and research and have their own. After all I'm not a veterinarian. I'm a doctor and I learn a lot from these patients because they've done a lot of research, and ultimately I'm just trying to help them to have a baby, so they have a particular world view, which maybe unique to them based on their life experiences. Since I'm not a mind reader, I don't know what their choices are going to be. I feel my role is to help them to achieve their goals rather than try to force my views down their throat, because after all infertility treatment is elective and there are always lots of options.

Who am I to tell them which option they should be following? I like these patients because not only do I learn a lot from them, because of all the research which they do, but because of all the intelligent questions which they ask me, which help me to think a little more deeply about some of the advice I give. More importantly they have very realistic expectations. They understand that I'm not a magician or a miracle worker. Means it is easier to manage the ups and owns of an IVF cycle and deal with failure because they understand that the outcome of a cycle is not in my hands or theirs. Also they are much sophisticated. They appreciate the work we are doing, and they are mature enough to realize what makes us better than other IVF doctors because we are open and transparent and share information with them.

I think this mutual trust ensures us to get along very well along with these patients. Even better they are opinion leaders because they make intelligent decisions and have done their home work and are great sources of referral, because they carry a lot of clout in the patient community, and people look up to them. They've done their homework, and this is very helpful for our reputation. What I really like about them is that they make their own decisions, and they are not passively dependent on me or expect me to make to decisions for them. I can create a partnership with these patients, because they are empowered, and this is really what makes medical practice so fulfilling for me.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !






Monday, July 11, 2016

What every infertile woman needs know about time and the biological clock



Time is one of the most important variables which affects the success rate of infertility treatment,  but unfortunately this is something which most infertile couples are not aware of . This is partly because time is something which we all take for granted . It doesn't figure into our calculations  , until it silently creeps up and gives us a wake-up  call - for example , when the alarm on your biological clock goes off when you turn 35 and you realize that you aren't any closer to achieving your goal of having a baby.

Time is a pervasive, ubiquitous silent spectator, which is why we fail to factor it in. Infertile patients often don't worry about it , because in our heart of hearts , all of us think of ourselves as being 25 forever !  Older women easily get lulled into a false sense of security , and often suffer from the misconception that if they have regular cycles , this means that their fertility is fine. This can be an expensive delusion !

Time has two important components which affect decision-making , and we need to look both backwards as well as forwards when thinking about time.

Looking backwards means factoring in the " trying time" - how long have you been trying to have a
baby ?  If you haven't been trying for too long , then you have lots more opportunities , and you can continue to explore your options. However, if you've tried for a long time and nothing has worked, you need to start becoming more aggressive and move on.

Looking forward means you need to think about how much time you have left. Thus , if you're 25, you have lots of options , but as you get older , your options start getting constrained  !  Sadly, many gynecologists also fail to factor in this critical variable, partly because they help 40 year old women to give birth all the time. What they fail to realise is that the biological behaviour of a 40 year old infertile women is completely different from  a 40 year old who has got pregnant in her bedroom.

Remember that it's not just the chronologic time which we  infertility specialists worry about - it's your biological time. More specifically, it's your  ovarian age - the age of your eggs .Of course, this is not something which women are aware of, and this is why women need to be track how fast their biological clock is ticking by checking their AMH levels as well as their antral follicle count , so that they can make well informed decisions .  You never want to have regrets later on that you didn't give baby-making your best shot because of your ignorance.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




The Holy Trinity for achieving IVF success



IVF is a complex process , and the success rate is not 100 percent, which is why every patient wants to know what they can do to maximize their chances of having a baby.

There are three important variables - the patient , the doctor and the laboratory. Let's look at them one by one.

As far as the patient goes , it's great if the patient is young with good ovarian reserve, because she's going to grow lots of eggs , so we can make lots of embryos for her. Of course there's very little one can do about a patient's age, which means we will still treat older patients, and those with poor reserve as well. Even these patients can improve their chances of success by doing their homework , so that they can spend time and energy in selecting the best IVF clinic , and preparing themselves optimally for their IVF cycle.

The doctor has an important role to play , not just in advising the patient as to what their treatment options are, but also in selecting the optimal superovulation protocol , to maximize the egg yield and optimize the endometrial environment , thus improving the chances of implantation . The doctor also has a key role to play in counselling the patient and providing emotional support, so that she has realistic expectations, and has the courage to be emotionally resilient and to bounce back even if the cycle fails , because it may require 3-4 IVF cycles before the patient has a baby. Also, the doctor should be flexible enough so that he can optimize the protocol for each individual patient , rather than use a rigid one size fits all for everyone. Also, the doctor needs to be technically skilled for doing both the egg collection as well as embryo transfer, and each egg and every embryo should be treated as an individual patient. Also, it's important that the doctor be ethical, and not mix and match donor eggs and donor sperm , simply in order to inflate their pregnancy rates.


Finally, the embryologist is the unsung hero of IVF treatment, because the IVF lab is the heart of the IVF clinic . We can give him good eggs, and it's his skill which converts these eggs into high quality embryos in the lab. A full-time experienced and expert embryologist is the key to IVF success, and smart patients ensure that the IVF clinic they select has a great embryologist heading their lab.

If all these three variable are favourable, then the success rate jumps dramatically . Now if you have a young patient with lots of eggs, then even if the doctor and the lab is bad, you will still get pregnancies, because the patient can compensate for both of these. This is why even bad IVF clinics continue to get pregnancies, because they attract a lot of young patients , by advertising aggressively, and offering bargain low-cost rates. They make up for their poor quality by doing large volumes , which means they will have lots of successes , even though their percentage success rates are low.

Similarly , even if you have a patient with poor ovarian reserve, but the doctor and lab are good, this can compensate for poor egg quality. This is what can make a world of a difference , specially when you're dealing with a challenging patient. While many clinics will refuse to treat these patients, because they don't want them to affect their success rates, good clinics will be happy to show their mettle by treating these difficult patients. In some clinics, the doctor may be good , but the lab could be bad, because they have to depend upon a travelling embryologist. This can reduce their success rates dramatically.

The trouble is that it's very hard for the patient to make out what's happening in the lab, because all they know is that their cycle has failed, but they don't have enough data to be able to determine the reason for the failure, because the clinic does not share medical records or embryo photos, which means patients are left groping in the dark.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !






Friday, July 08, 2016

How the Medical Council of India can promote Indian medical services by encouraging doctors to go online


The Tamil Nadu Medical Council has issued letters to doctors,  saying that they're not allowed to list their names on online doctor listing platforms, such as Practo, because they believe that this is tantamount to advertising. They have asked doctors to remove their names or they will take action. This has become a sticky issue for many reasons. Doctors have always been considered to be trusted professionals, and one of the jobs of the medical council is to make sure that medicine is practiced ethically. Lots of senior doctors believe that listing names on directories cheapens the medical profession, because then doctors will be treated as business men rather than professionals. They feel that this is below a doctor's dignity , and what doctors should focus on is taking good care of their patients. Their reputation , earned after a lifetime of taking good care of their patients, will help them to attract more patients.

This is the counsel of perfection , and it made a lot of sense in the past , when doctors were few and far between. They basically just had to hang out their shingle and patients would line up to see them. However, I don't think this is a reasonable attitude in this day and age.

We need to differentiate between advertising and providing information, and this where confusion arises , especially in this digital age. By not allowing doctors to reach out to patients digitally, the medical council is actually doing a disservice, not only to doctors but to patients as well. It is because doctors have not been able to connect with patients directly, that we now have so many middlemen who ask for kick-backs and commissions , in order to refer patients to specialists. This has now become endemic , and it is this kind of corruption which is causing society to lose trust in the medical profession.

The good thing about a digital platform is that it bridges the gap between doctor and patient, and it allows patients access to far more information about their medical options than they could get in the past. This is  a healthy trend, which should be encouraged. While it's true that sometimes this can be abused, I think it's dangerous to throw the baby out with the bath water. There are lots of advantages in encouraging patients to use online platforms to connect with doctors, because once a doctor is online, he's forced to be open and transparent. This is a great way of creating trust, because when a doctor says something on his website, it is public information which can be monitored, and the council can make sure that the information which is being provided is accurate. Fees can be published online, thus helping to reduce sticker-shock.  This will help to keep costs down , and make medical care more affordable.

Why are council members , who are usually senior medical doctors, upset about doctors going online ? Part of this is because they are conservative, and there is always resistance to something new. Senior doctors are often uncomfortable with the idea of an online presence, because they feel this lowers the medical profession's dignity. It is true that sometimes doctors will take undue advantage of this platform and provide information which is misleading. I think rather than refuse to allow doctors to have an online presence, it makes much more sense for the council to move with the times and become patient friendly as well as doctor friendly, by providing guidelines which explain what doctors are allowed to do and not allowed to do, so that they can create a win- win situation. It makes no sense that they use an Act which was passed over 50 years ago in order to draft guidelines, because that act is often irrelevant in today's day and age. The council needs to move with the times and help doctors to take better care of their patients - this is what its major duty is.

This is actually a great opportunity for the council to help India to become a global medical powerhouse. We need to capitalise on the expertise and experience of our doctors. We can export medical expertise without exporting doctors by helping them to use telemedicine to reach out to patients from all over the world. This would be a great way of revitalising the medical profession, and earning valuable foreign exchange for the country. Indian doctors have a great reputation all over the world - let's make use of it by marrying  IT and their medical knowledge. Computer engineers made India proud during the IT boom. It is now the turn of the medical profession, and the Medical Council can play a proactive role in doing this by encouraging doctors to go online, so they can display their clinical skill and expertise . For example, surgeons can upload videos of their surgical dexterity; and doctors can provide medical second opinions online very cost effectively. This is a huge opportunity, and if promoted and regulated properly, will also lead to a boom in medical tourism. Rather than clip the wings of Indian doctors, the council should encourage them to help  patients all over the world by going online.

Thursday, July 07, 2016

How can I be sure that my IVF doctor is not fooling me ?


I just received this email from a patient.

Hello doctor, can you please tell me how can I trust my IVF doctor - that he is not making a fool of me in the egg donor process. How do I know if he is showing me photos of a model , but is actually using her eggs or someone else's  ? How can I trust him ? Is there any rule or law that doctors cannot make a fool of their patients ?
This is an important question, and a difficult one to answer.  There are lots of stories about how IVF clinics have fooled their patients, and the truth is that if a crooked IVF doctor is out to cheat you, he will be able to, and this is why you need to be on your guard.
It's deplorable that the level of trust between doctors and patients in India has fallen to such abysmal levels that patients need to ask this kind of question. However, it's we doctors who have contributed to this sad state of affairs. Most doctors are straight-forward,  but we all know that there are some crooked ones as well. However, it's because the good doctors don't speak up about the mlapractices which the few bad doctors indulge in, that all doctors get tarred with the same brush. While lots of IVF doctors know very well which IVF clinics take their patients for a ride, sadly they will keep quiet about these clinics. This is partly out of a misplaced sense of professional courtesy, because they don't want to be ostracised by the medical community for pointing fingers at other doctors; and partly because they feel it's none of their business. After all, it's not a doctor's job to police other doctors, and they feel that as long as they are doing a good job in their own clinic, they don't have a duty to point out when other doctors are fooling their patients. Part of it is also out of a sense of fear - after all, they believe that people who live in glass houses shouldn't be throwing stones, and that it's not the pot's job  to call the kettle black.

I wish there was a list of certified IVF clinics in India who had met basic quality control standards; and that the Indian government would ask clinics to publish their success rates, so that patients could use this as a guide. Sadly, there isn't, which means you need to do your own spadework for yourself !
Most patients are not able to differentiate a good doctor and a bad doctor, and most will end up going to whichever IVF clinic their family doctor sends them to.  IVF patients are very vulnerable, and it's easy for doctors to take them for a ride , which sadly some of them do, because there is so much money at stake.

The good news is that there are lots of good clinics out there. However, there are plenty of bad ones as well, and you do need to put in some effort to find one you can trust.

Here's a secret. Try making friends with one of the IVF clinic staff. They know exactly what's going on, and they will be able to share insights into the modus operandi of the IVF clinic, and whether they indulge in dodgy practices.

It's a good idea to talk to other patients in the clinic while you are waiting ( and sadly, there will be a lot of waiting in most IVF clinics ). This can be a good opportunity to  share notes, so you can compare your experiences with others who have taken treatment in the clinic.

If your doctor refuses to answer your questions, or tries to put you in your place by reminding you  that he is the doctor, then this should be a red flag. A good doctor  will do his best to earn the patient's confidence, because he knows that patients have lots of queries and doubts, and he will try to allay these before starting the treatment.

You don't need to become a doctor when you're evaluating an IVF  doctor . However, it's a good idea to get a second opinion , so you can ask more intelligent questions and select the right doctor for yourself.

It's true that this takes time and trouble and effort. Isn't it just much easier to go to the first one who you pick or the one who's closest to you or the one you've read about in a newspaper article? Yes, it's easier but can often be the wrong decision, which can prove to be expensive.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

Wednesday, July 06, 2016

The two most important questions every doctor needs to ask every patient at every visit.

 This is a post I wrote for an online doctor site

Most medical students learn to take a medical history fairly quickly , and they are taught how to do a clinical examination and interpret lab reports.  However, their soft skills are often lacking , and while they are good at asking questions which allow them to drill down and come to the right diagnosis, the commonest complaint patients have about doctors is that they don't listen to them.

Being a good doctor involves a lot more than just making the right diagnosis and prescribing the right treatment - it requires you to establish an emotional connection with the patient , so that the patient can trust you and knows that you have his back - that your understand his problems , and empathize with him.
It's not very hard to do this - all you need to remember are these two key questions.

The first question when you first see the patient should be - How can I help you ?

This is a great open ended question , and you're giving the patient permission to unburden himself , so he can share what's on his mind. Please don't interrupt him - let him talk. You may think patients will go on and on , but most will tell you what they want you to know within a minute, if you allow them to do so.

The last question you need to ask before the patient leaves is - Are there any other questions I can answer for you ?

This is important , because again you're giving the patient permission to clarify his doubts and you're letting him know that you are keeping the channels of communications open. We tend to forget that patients are often scared of doctors , and that because they are nervous and anxious , they often forget half of what we tell them.  This lets them know that we're happy to answer any queries they have, so that we can reinforce the message we want to give them.

This is a very useful set of bookend questions for both starting the consultation and ending it. Some doctors may worry that their patients may end up wasting a lot of their time if they encourage them to ask questions.  However, this is not true, and it actually ends up saving you time because it reduces the patient's doubts and lessens confusion. These questions allow you to make sure that you're both on the same page, and you know exactly what the patient wants from you.  This way you don't fall into the common trap of assuming that the patient's presenting complaint is what his top priority is, because often the patient's real problem surfaces only after a few minutes of talking to them. This technique stops you from trying to guess what's bothering the patient, and you don't jump to the wrong conclusion because you've given the patient a chance to express himself.

If you don't do this, you may end up focussing on a problem which is not relevant to the patient . He may feel that you've not bothered to listen to him, and will end  up walking out of your clinic and go to your competitor down the road.

These simple questions will help you improve the care you provide to your patients, because they will feel cared for. These simple questions  will help you to stand out from other doctors, and appreciative patients will be happy to refer more patients to you, which is great for both your reputation and your practice.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




Tuesday, July 05, 2016

The cost of not doing IVF


We all know that IVF can be an expensive treatment , which is why so many infertile couples are reluctant to do it, even though they know that it maximises their chances of having a baby.
It's not just the financial cost , it's the emotional toll it exacts as well. The uncertainty , and the horrible 2 ww can often be intolerable , and their fear is that if the cycle fails, they will be back to square one, and will have to start all over again - with a much smaller bank balance, and a broken heart to cope with as well !

Yes , doing IVF can be challenging, but when weighing the pros and cons, patients sometimes forget to consider the cost of not doing IVF. They feel that the only risk is deciding to do IVF, and if they choose not to go down the IVF path, they will have selected the risk free option. However, they are deluding themselves , and not doing IVF exacts a price as well - both an emotional cost , as well as an opportunity cost .

Choosing not do to IVF means that they deprive themselves at their best chance of having a baby, and this sense of loss will often come back to haunt them in the future, because they will kick themselves for the fact that they didn't give themselves the best chance of having a baby by not taking advantage of the IVF technology.  You need to consider the long-term regret factor when making a decision, rather than only focus on the short-term costs. The truth is that as you get older, you usually regret the things you don't do , rather than the things you do. As you mature, you understand that all you can control in life is the process, not the outcome, which is why you need to give your baby making effort your best shot.

Interestingly, there is a financial cost for not doing IVF as well. When patients don't do IVF , they continue doing ineffective treatments,  such as IUIs , or using alternative options such as Clear Passage Therapy. These seem attractive, as they are sold as being inexpensive alternatives to IVF. Yes, these do cost less, but because they do not work, this means the poor patient sends up spending a small amount of money in dribbles over many years - which ultimately adds up to a small fortune, which they could have used for doing IVF in the first place instead.

They finally realise that they have wasted a lot of money doing many ineffective treatments over many years, while they would have been better off just doing a single IVF cycle . However, by the time they understand this, it's too late, and all their money has gone down the drain in their futile effort to try to save money.


Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




Monday, July 04, 2016

How to select the best IVF clinic

You know that which IVF clinic you choose for doing your IVF treatment can have a big impact on the outcome of your cycle. This is why you spend a lot of time in trying to find the best IVF doctor.  However, sadly most patients are not able to differentiate a good doctor and a bad doctor, and most will end up going to whichever IVF clinic their family doctor sends them to.

In the past this was a safe bet, but this is no longer a reliable method for selecting an IVF clinic the medical profession is riddled with corruption. This is why you need to do your own research before blindly trusting anyone. It's a good idea to check out the IVF clinic your family doctor goes to, but please also check out at least one more.

The truth is that there is no one best clinic, There are lots of good clinics out there, and lots of bad ones as well, and you do need to put in some effort to find one which works well for you. The secret is to find a doctor you can trust.

I wish there was a list of certified clinics in India; or that the Indian government would ask clinics to publish their success rates, so that patients could use this as a guide. Sadly, there isn't, which means you will need to do your own spadework for yourself !

If you go to a clinic which makes you routinely wait a long time, that's a red flag, which means they don't respect your time and they're not well organized.

If you don't get a chance to talk to the main doctor, that's a cause for concern as well, esepcially if you have failed many IVF cycles in the past, and are looking for individualized, specialized, personalized care from a senior experienced expert.

It's a good idea to talk to other patients in the clinic while you are waiting ( and sadly, there will be a lot of waiting in most IVF clinics ). This can be a good opportunity to share notes, so you can compare your experiences with those of others.

Similarly, if you have a doctor who seems to be too trigger happy , and orders a laparoscopy and hysteroscopy for every patient, in order to "rule out any problems" , then this can be a red flag as well.  One size does not fit all, and you don't want a clinic which follows mindless protocols for all their patients.

You don't need to become a doctor when you're evaluating an IVF  doctor . However, it's a good idea to get a second opinion , so you can ask more intelligent questions and select the right doctor for yourself.

You can get a good sense of the doctor's philosophy when you visit his website. Does he want to educate you  about infertility, so you know more about your problem , and can make well-informed decisions ?

You can learn a lot when you finally meet the doctor. Is he in a rush ? Or is he willing to sit down and discuss your concerns ? Does he address them all ? Is he optimistic and hopeful ? Is he willing to share information? Is he willing to empower you?

If your doctor refuses to answer your questions, or tries to put you in your place by reminding you  that he is the doctor, then this should be a red flag. A good doctor  will do his best to earn the patient's confidence, because he knows that IVF patients have lots of queries and doubts, and he will try to allay these before starting the treatment.

Money is always an important issue. IVF can be an expensive treatment, and there is no certainty whether the treatment will work or not. While it's true that the most costly clinic is not always the best, you should worry if a clinic charges too little, because it's quite likely that they may be cutting corners in order to reduce their costs. This may turn out to be much more costly for you in the long run.

If the doctor asks for cash payments; or money under the table; or does not give you a receipt for your payment, then you need to worry. No  honest doctor will do this - and if the doctor is willing to cheat the government, why do you think he won't be willing to cheat you as well ?

Finally, how well does the doctor treat you at the end of your cycle ? Does he provide you with complete documentation proactively and routinely ? Does he provide embryo photos ? Or does he  abandon you if your cycle has failed ?

It's true that this takes time and trouble and effort. Isn't it just much easier to go to the first one who you pick or the one who's closest to you or the one you've read about in a newspaper article? Yes, it's easier but can often be the wrong decision, which can prove to be expensive.

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

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