Thursday, September 29, 2016

Breaking the pharma doctor nexus by following the money



It's an open fact that many pharmaceutical companies spend a lot of money in bribing doctors to prescribe their particular brands. They have got a good return on their investment so far , because these gifts have been proven to influence the doctor's prescription behaviour ( even though many doctors continue to delude themselves that they are immune to these blandishments).

This nexus is harmful , because it increases medical costs. Doctors are tempted ( and many are blissfully unaware of the subtle influences which play on their unconscious mind ) prescribe needlessly expensive brands, and to over-prescribe.

There are three ways of solving this problem.

One is to get the medical councils involved , and to punish doctors who have taken bribes from pharmaceutical companies. This can serve as a powerful deterrent, but is a time-consuming and expensive process, because you have to go after a single doctor , one at a time.

The second option is to rely on pharma companies to regulate themselves. They have promised to mend their ways for many years, and the government has given them the liberty to do so. Unfortunately, voluntary regulation doesn't work well when some of the players refuses to abide by the guidelines laid down by the pharmaceutical association.  Game theory explains that even if one company defects, then  the other companies will also follow suit , because they feel that they are at an unfair disadvantage. This quickly becomes a race to the bottom, and they all end up breaking their own rules . Even worse, their behaviour becomes completely hypocritical. They pretend to abide by their rules, and higher management takes the moral high ground by turning a blind eye to what their field staff is doing at the ground level. After all, what you don't know can't hurt you !

Let's look at a more effective alternative.

The only reason pharma companies continue to bribe doctors is because they get a tangible financial return on their investment. They know that if they gift the doctor a foreign trip, the doctor is much more likely to prescribe their brand , because of the simple principle of reciprocity.  Sadly, doctors continue to justify these free jaunts by claiming that they go to medical  conferences only in order to educate themselves - and how does it hurt anyone if the conference happens to be in Paris ? They believe that they are upright medical professionals who prescribe a particular brand only because it's the best one. They continue to delude themselves that they are immune to the special treatment which is showered on them by the pharma companies. However, this is just a rationalization which doctors use to justify their behaviour. The truth is that all these favors given by pharmaceutical companies to doctors does change their behavior, and often in ways which are not in the patient's best interests.

This is why the most effective way of breaking the nexus is to make sure that pharma companies no longer get a good financial return on bribing doctors. Once this stops, then they will automatically stop wining and dining doctors, because it will no longer make business sense for them to do so .

Where does the money to bribe the doctors come from ? These expenses are disguised as marketing costs on the income statements of the pharma companies.  They are cleverly camouflaged  as payments to third parties who serve as conduits. The job of these marketing companies is to curry favor with the doctor by giving him whatever he demands.  Since these are business expenses, they are deducted from their total revenue,  which means that the government is subsidizing the bribes which the pharma companies are giving to the doctors. 

The IT  Dept has finally woken up , and is no longer going to allow companies to claim these as these business expenses, no matter how cleverly they're disguised. This has already happened in the case of Liva Healthcare, a small pharmaceutical company in Mumbai.  Pharma companies will realize that spending this money on doctors is going to turn out to be very expensive for them , because once the IT officer goes after them, not only will these expenses be disallowed, they will have to end up paying a hefty penalty as well . It wouldn't be very hard for a diligent officer to follow the paper trail from the company to the doctor , because these payments are done by cheque  - all they need to do is to follow the money to its source !

Once pharma management understands this, they will automatically stop engaging in this behaviour. 

The senior management of most pharma companies consist of ethical people , and they will be happy when they are no longer forced to pay off doctors just because their competitors are doing so. They will then be able to focus on ethically marketing their medicines. I am sure none of them likes paying money under the table - this is a dirty game, and the sooner we stop playing it, the better for everyone. 

This is a win-win situation for everyone. The company will be able to devote its income on research and development and ethical promotion, because it won't be wasted on bribing doctors; the government will earn more revenue ; doctors will no longer be tempted to prescribe drugs for the wrong reasons; and patients they will then have access to affordable drugs .


This is the option which the US government has adopted . They use a stick to make sure everyone plays by the rules , and have enforced these by passing a law ( the US Sunshine Act) and aggressively punishing  pharma companies who flout this.  It's time for the Indian government to follow suit !

Thursday, September 22, 2016

Non medical options for infertile patients


Whenever I counsel patients , I explain all their  possible options to them. I also include their non-medical choices, and emphasize that adoption and child free living are perfectly acceptable alternatives, which they should not reject out of hand.

I always discuss these before I move on to explain their medical treatment options.

Sometimes patients get very upset when I do this. They believe that the fact I have started by discussing the worst case scenarios , means their chances of success are very poor. Some even accuse me of being negative and pessimistic , and feel that I am preparing them for failure.

This is not true.

The reason I discuss non-medical options is to emphasize the fact that they are in control of their life - that they have a choice.  After all, medical treatment for infertility is optional, and that if they choose to come to me for treatment , they should come with a smile, because they hope to get something from here.

Non-medical alternatives should be seen as empowering, because they allow the patient to pick and choose. They should not feel that they are forced into doing IVF - and they should not think of themselves as being helpless and powerless either !

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, September 21, 2016

Hallmarks of a bad IVF clinic

A patient just sent me this email
Now in September, I underwent IVF with donor eggs (frozen). Out of 7 donor eggs that were thawed, we got 2 embryos and 1 blastocyst (all A grade 8 cell embryos) which were transferred on day 3 and day 5 respectively. My endometrial lining was optimum when the transfer happened. My husband's sperm motility has always been very good according to the IUI and IVF doctors. However, bHCG is again negative and implantation did not occur. I have done HSG and Hysteroscopy tests prior to the IVF and everything were found to be normal. When we asked for ways to better our chances next time, my husband has been suggested the sperm DNA fragmentation and blood karyotyping tests while I have been suggested to undertake endometrium TB tests. We wanted to seek your opinion on undergoing these tests and your advice on other options to better our chances during the next IVF. Please feel free to ask further questions if any. Thanks in advance for your time and advice.

This patient is getting very poor medical care, and there are a number of red flags which suggest this.

1. Only 7 donor eggs were used. Good clinics will use at least 10 mature metaphase 2 donor eggs to maximise chances of a pregnancy

2. Her doctor did a sequential ( Day 3 plus Day 5) transfer. This suggests that the clinic did not have any confidence in the ability of their lab to consistently grow embryos to Day 5. Good clinics do only Day 5 transfer

3. When the cycle failed, they asked her to do a battery of tests. These are all useless, expensive tests which confirm that the doctor has no clue what he is doing. He is just mindlessly subjecting the poor patient to a lot of expensive and wasteful tests, which will not change her treatment options at all.  He is shooting in the dark, in the hope that he'll hit something.  The biggest danger is that one of the test results will come back as abnormal - and then the patient will be subjected to even more useless treatment, and will end up wasting even more time and 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 !




Tuesday, September 20, 2016

Do you trust your doctor ?


The heart of clinical medicine is the doctor-patient relationship. When we are ill, we want someone we can look up to - someone whom we can trust. We want a doctor who understands our problems - not just the medical disease we have, but someone who has insights into our personal fears  and worries as a human being as well. Being ill can be a lonely journey, and we want someone  to hold our hand and help us to get better. We need to be able to trust that our personal physician has our best interests at heart - that he will look after us, and will do whatever is needed in order to help us get better.

In the past, trust in the doctor was something which was taken for granted.

Doctors were respected professionals, and it was understood that a doctor could do whatever was needed in order to help you get better. The standard image of the family doctor was a hardworking professional who would get up at 2 am, or who would spend all night holding the patient's hand , in order to  keep a close eye on him to make sure he was getting better. People still have fond memories of what the doctor used to be like. Unfortunately, the only place we can see this kind of doctor today seems to be  in old movies.

Today, very few patients respect their doctor, and as far as the medical profession goes, it clearly doesn't command any respect at all.

We've lost faith in our doctors, and there are many reasons for this. It's true that some doctors are to blame, but the tragedy seems to be that whenever one doctor does something wrong, we extrapolate, from this aberration, and conclude that all doctors are crooked. This is the harm which the media does to the entire medical profession when it highlights the few black sheep in the profession. Sadly, good doctors also end up being tarred with the same brush.

The media loves to bash doctors. This is because we put so much faith in them, that when this trust is betrayed, we are angry and we want to punish these doctors with a vengeance.  This is quite ironic because we never seem to have that same degree of anger against crooked lawyers, or crooked engineers, for example.

Thus, the media will write about crooked bank managers, but this is not something which raises as many  hackles, or causes as much ire. Why is there so much disproportionate unhappiness with doctors?  After all, they are human too - why should we expect them to behave like angels ?

This is because the heart of healthcare is the patient's personal relationship with the doctor. When a doctor takes advantage of that relationship, he betrays the trust which the patient places in him, and we want to punish him for this . In our heads and hearts, medicine is thought to be a noble profession. When we find that we can't trust doctors anymore, it shakes our faith and belief in all of humanity, not just the medical profession. After all, if you can't trust your doctor, whom can you trust?

The good news is that there are lots of trust worthy doctors - but you do need to spend some time and energy in order to find them. Look for a doctor who respects you, and whom you respect. This is a two way relationship, and you need to find someone who is open and transparent, and is willing to share information with you -  a doctor who has both a head and a heart. A good doctor does not try to cover up when he does not know what's happening, and will share both medical knowledge as well as medical ignorance with you. He  will not abandon you, no matter how serious your illness, and even if he cannot cure or treat you, he will be there to hold your hand.







Monday, September 19, 2016

I'll be talking about Startup Failures at the Vibrant Gujarat Startup Summit


The Vibrant Gujarat Startup Summit will be held in Ahmedabad  on 21 Oct 2016

Am looking forward to this - lots of  great topics !

The website is http://www.vgstartup.com/

Saturday, September 17, 2016

Please don't mess with your doctor's mind


Doctors do their best in order to take good care of their patients because they want their patients to get well. It's in his best interests to do so, because a happy patient will refer lots of others to the doctor, and thus help his practice to grow.

However , in this day and age , unfortunately the trust which patients used to have in their doctor has taken a big beating . This is why patients spend a lot of time on Dr Google , trying to get his second opinions. Now while I am a big believer in the Information Therapy which Dr Google provides, patients need to understand that this is a double edged sword , and they need to be sophisticated users to benefit from this.

One of the worst things you can do to a doctor is to keep on challenging his authority or questioning his advice . He feels disrespected , and he's not going to take as good care of you as he would have if he had felt that you trusted and respected him. The doctor patient relationship is a delicate one and you need to nurture it.

Now this doesn't mean you that you leave your brains at home and do everything your doctor tells you to, just because he is the medical expert. However, you do need to respect the fact that he's a trained professional.

The problem is that trust is intangible. It's not something which you should give away easily , and therefore it's quite reasonable to expect your doctor to work in order to earn your trust. But once he's done that , then you shouldn't keep on playing doctor yourself . You should allow him the autonomy to help you to make the right decisions . This becomes a positive virtuous cycle.

If the doctor senses that you trust him, he respects you as well , and will go out of his way to make sure that you get the best care possible . This is why it's best to follow the middle  path - after you've verified your doctor's advice, let him be the captain of the ship. This means that you should let him know that you accept him as  being the leader of the medical team , but that you are still an important part of the team . He will also reciprocate , and this will help the two of you to craft a win win partnership where everyone benefits.

Thursday, September 15, 2016

Why PGS does not work as advertised - the difference between genes and chromosomes



Lots of patients know that the commonest cause for IVF failure is a failure of the embryo to implant. We also know that the commonest reason for implantation failure is a genetic defect in the embryo. This is why it seems very tempting to do pre-implantation genetic screening ( PGS) for all IVF patients, so that you can select the genetically normal embryos . This should increase the chances of implantation and reduce IVF failure. After all, what's the point of transferring a genetically abnormal embryo back into the uterus ? It will just fail to implant, or even worse , end up in a miscarriage.

This makes logical sense, but unfortunately , in real life , biology is far more complicated. I think we need to remember that when we're doing PGS , we're really not doing genetic screening; we're really just doing chromosomal screening, so that a better name really would have been pre-implantation chromosome screening or PCS.

Why is this important ? All these tests ( for example, CCS and NGS) only allow us to make sure that the cell has a normal number of chromosomes. This means we can make sure it is euploid, so that we can screen out which embryos are aneuploid ( they have an abnormal number of chromosomes) .  Aneuploidy is an important cause for failure of implantation as well as miscarriages, but we also need to remember that counting the number of chromosomes is not enough if we want to identify genetically normal embryos. After all, there are over 30,000 genes , and there are only 23 pairs of chromosomes. This means that even though an embryo may appear to be normal on a PGS, this does not mean that it is genetically normal. Thus, a lot of PGS normal embryos will have a normal chromosomal complement, but they will still have lethal genetic defects will which prevent them from implanting.

Unfortunately , most patients don't understand this difference. When they end up spending a lot of money in order to transfer a PGS-normal embryo , and then still end up with a failed IVF cycle or with a miscarriage, they're obviously very bitter and angry and feel they've been misled. This can create a lot of dissatisfaction.

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, September 13, 2016

The PCPNDT Act and double standards


The PCPNDT Act was passed with good intentions. The government hoped that it would help to improve the sex ratio, and the government has been extremely aggressive about ensuring that the act is implemented properly. This is why they monitor ultrasound scans very closely. Their major aim is to ensure that infamous Form F which doctors are meant to fill every time they do an ultrasound scan for a pregnant woman gets filled properly. In fact, doctors are being arrested for committing clerical errors when filling in the form !

What I don't understand is why the government has such double standards about implementing the PCPNDT Act. Just like the Act requires that doctors fill in the forms properly , a lot of government officials are involved in ensuring that the Act is implemented.

For example, states have supervisory boards which are meant to meet on a regular basis, as laid down by the Law. However, the truth is that most of them don't meet as frequently as they  are supposed to. Why shouldn't the officials who are on the supervisory board, who have such an important regulatory role to play, also be put in jail when they fail to abide by their commitments under the Act ?

In fact, it's possible to understand that a doctor who's busy taking care of his patients might make clerical errors in filling up the form.  However, the officials refuse to be sympathetic and understanding, and any doctor  who doesn't fill up even a single form out of hundreds properly is considered to be a criminal. In fact, he has to prove that he is not a criminal, which obviously he can't do because no one is claiming that he's helped to commit fetal feticide - all they are saying is that you haven't filled in the form properly, which is why you should be jailed !

A government official  is appointed under the PCPNDT Act as a member of the supervisory board. If he doesn't hold the meetings he is required to, as laid down by the law, then isn't he being derelict in his duty? Shouldn't he also be hauled up and locked up for breaking the PCPNDT Act?


Monday, September 12, 2016

Misuse of blood tests for female feticide


The PCPNDT Act was passed in India in 1994 and amended in 2002 with good intentions. It was framed in order to prevent gender selection, control female feticide and balance the sex ratio. Since ultrasound scanning was being misused to determine fetal gender , the Govt of India started insisting that all ultrasound scanners be registered, and ultrasound scans were closely monitored.

However, medical technology has moved on , and it has become possible to determine the sex of the fetus by testing only the mother's blood. This means that ultrasound scans are no longer needed for sex selection !

This new blood test is called NIPT which can be done at 8  - 10 weeks of pregnancy. The lab separates the fetal  DNA ( cell-free DNA) from the maternal blood, and does a genetic analysis on this fetal DNA . NIPT ( non-invasive prenatal testing) technology  is readily available in India today . 
This test is reliable , accurate and simple.  It was first developed to screen the fetus for genetic diseases such as Down syndrome, but since it tests the DNA of the fetus, it can also be misused to determine the gender of  the fetus.

If the Govt is serious about controlling female feticide, then just monitoring ultrasound scanners is no longer enough in this day and age . The Govt should register all pathology labs as Genetic Laboratories under the PCPNDT Act. They should be made to fill in Form E of the Act every time a blood sample is drawn from a pregnant woman , so that these samples can be tracked.  We need strict monitoring to ensure that these blood samples are not being misused for gender determination illegally. Otherwise, we will end up wasting lot of time, money and energy in tracking the wrong technology, while female fetuses continue being aborted under our eyes.

Section 8 of Form E of the PCPNDT Act already has a heading for maternal blood. Why is this loophole not being plugged ?

Saturday, September 10, 2016

Advances in medical technology require the Govt of India to amend the PCPNDT Act



The PCPNDT Act was passed in India in 1994 and amended in 2002 with good intentions. It was framed in order to prevent gender selection, control female feticide and balance the sex ratio. At that time , the major technology which was being used to determine fetal gender was ultrasound scanning, and the Govt of India started monitoring all ultrasound scans.

Sadly, the fact remains that the Act is outdated because medical technology has moved on ! The Act now needs to be updated and amended because it is now possible to determine fetal gender by testing the mother's blood.

NIPT ( non-invasive prenatal testing) technology  is readily available in India today .  This is a simple and cheap test, which just involves taking a blood sample from the mother when she is  8  weeks pregnant. The lab then separates the fetal  DNA ( cell-free DNA) from the maternal blood, and does a genetic analysis on this fetal DNA .

This is a non-invasive test, and is extremely safe, reliable and accurate. While it was first developed to screen the fetus for genetic diseases such as Down syndrome, it can also be misused to determine the gender of  the fetus.

If the Govt was serious about controlling female feticide, then it should insist that all pathology labs should be registered as Genetic Laboratories under the PCPNDT Act. They should be made to fill in Form E of the Act, every time a blood sample is drawn from a pregnant woman.  We need strict monitoring to ensure that these blood samples are not being misused for gender determination illegally .

Section 8 of Form E of the PCPNDT Act has a heading for maternal blood, and all blood tests should be reported and monitored as well ! Why is this loophole not being plugged ?

Friday, September 09, 2016

Brun Health is featured on the Govt of India website !


Brun Health is a company I am an angel investor in.It is a connected health company focusing on healthy pregnancies. Pregnancy is a state of health and our mission is to ensure that the mother and child are adequately monitored from the first kick to the final push. Brun Health focuses on novel user centric technologies for healthcare institutions, physicians as well as pregnant families to ensure adoption of best practices for fetal and maternal care.

Read more at https://blog.mygov.in/brun-health-private-limited-innovative-pregnancy-tool/

Their website is  http://brunhealth.com/
 

The surrogacy boom

One of the unintended consequences of the government's decision to pass a bill to ban commercial surrogacy is that lots of patients are now clamouring for us to do surrogacy for them before the ban comes into effect.

Lots of IVF clinics are also taking advantage of this situation, and offering to do surrogacy left, right and center, even for patients who don't need it ! I guess it makes sense to make hay while the sun is
shining !

Thursday, September 08, 2016

IVF success story at Malpani Infertility Clinic


As busy and happy professionals my husband and myself felt the desire to grow our family much later in our married life, about 2 years ago, after I quit working. After trying to conceive naturally we decided to explore IVF as an option. 

There were two main hurdles, firstly to accept IVF as it brings in lot of intervention, apprehension on how embryos are stored, side effects of medicines etc. Secondly after we explored some of the leading IVF specialists in the city it was not easy to zero in on the doctor (IVF specialist).

In some clinics, given the number of patients undergoing IVF procedures the treatment was not personalized. There were a number of assistant doctors but there was no mention of the lab or embryologist of the clinic and we got very little time with the renowned doctor we came for.

Some other doctors advised to undergo a laparoscopy to be treated for hydrosalphyinx before undergoing the IVF. It wasn’t clear by how much my chances would improve after this laproscopy. It left us confused, that’s when my husband scoured the web for information on IVF and came across Dr. Malpani ‘s clinic - cited as one of the top 5 IVF clinics in India/ Mumbai. His website is very informative and explained everything about hydrosalpinx and IVF in general in a very open transparent manner. We booked an appointment and there have been no regrets since then. 

There were many firsts in this clinic, which are most relevant to be cited here. Only Dr. Aniruddha & Dr. Anjali Malpani handle your case; there were no assistant doctors. Apart from their rich experience they are both extraordinary individuals who hand hold you through the IVF journey in the most responsible, open and caring way.

On our first visit he mentioned his state of the art laboratory, which is key in all infertility treatments. At the clinic we met Dr. Sai Prasad, a qualified embryologist, he answers all questions you may have and gives you a patient hearing.

The staff is friendly and competent; the clinic is run in a very efficient manner, the rooms are clean.

Before starting out, in response to my specific question on number of cycles, Dr. Malpani informed us we should be prepared for four cycles. My husband was of the view that we should be prepared for at least three cycles if we go ahead but I was ready for one single cycle.

When my very first cycle did not yield a positive result I was surprised but thought my system needs to get used to it and that we did get to the embryo stage after all! However, when I did not conceive in the second cycle, I was disappointed and angry. I desperately wanted to change something such as genetic testing etc. and find out if there was a problem. Dr. Malpani dissuaded me from any such wasteful testing and assured me repeating the cycle was the right way ahead as there were neither complications nor reasons to worry medically. Importantly he said he still believed that I needed up to 4 cycles to get there.

Had it not been for the positive reinforcement and care of the doctors I would have given up at this point, instead we did the third cycle and I still didn't make it. I was very sad, it occurred to me that this might not be happening cause its not meant to be! I stopped thinking and decided to take a break from IVF. For three months I pursued my hobbies seriously, things I had control on and enjoyed doing. We took a long and adventurous vacation and I thoroughly enjoyed my medicine and restriction free time!

When it was time to take a decision I reassessed, we still wanted the baby, and if I had come this far we must do the last fourth cycle and find out if its meant to be. During this cycle Dr. Anjali said I have to get pregnant in this cycle and I had no other choice. I was to treat this as a fresh start and think about the school my kid will go to eventually. I did just that and made sure to convert any negative thought along the way into a positive one. We did the 4th cycle no major change in treatment except for Dr. Anjali’s Midas touch and I got pregnant and yes it was meant to be! Perseverance pays lesson learnt !

I would like to emphasize that with all the uncertainties of conception through IVF or even otherwise, you give yourself the best chance for it with the help of competent and genuine doctors.

Embryo transfer procedure was done in the same professional and transparent manner on all the four occasions. Each time Dr. Sai showed us the embryos on the screen, with the labeling before transfer and in the last cycle he was most excited to inform us that they had thawed the embryos a day prior of transfer as this was giving them better results, he was genuinely excited you could tell. The doctors are very dedicated to constant improvement for better results and that is very reassuring. They were always there to reassess the situation each time and change course of action only if required. Dr. Aniruddha promptly responds to emails at all times. He called to check on me after the beta HCG test result each time. Above all both doctors don’t treat you like a patient but as a healthy individual who needs assistance or help in baby making.

Wednesday, September 07, 2016

Why implantation failure is a useless diagnosis



When an IVF cycle fails, the first question the  patient asks the doctor is, "What went wrong?". The standard reply is, " Your diagnosis is failed implantation." The patient is happy that the doctor has finally made a diagnosis , and he is comforted that now that the doctor knows what the problem is, he'll be able to find the solution.

However, the reality is  that 'failed implantation' is a wastepaper basket diagnosis. It's just medical jargon which doesn't make anyone any wiser . All it does is convey to the patient the impression that now that the doctor has a handle on the problem , he will be able to fix it.

This is false solace. The truth is that this "diagnosis" provides us with no useful actionable information, and doesn't change any of the medical decisions which we can make as far as the next cycle goes.

This is because implantation is a black box. Once we put an embryo inside the uterus, we have no idea what's going to happen to it. After the embryo transfer, we're groping in the dark. We need to share this ignorance honestly with our patients . The truth is that just like we don't know why some embryos fail to implant, we don't know why some embryos will implant. However, no successful IVF patient has ever asked me - Why did my embryo implant ? They just take it for granted that they will !

The good news is that while the " failed implantation " label is a coverup for our lack of ability to study implantation, this doesn't mean that we can't offer effective solutions. We may not be able to identify the problem , but we can often solve it effectively by bypassing it !


Panel Discussion: Medical Errors: Media Reports and Doctors' Viewpoint

How I overcame my fear of the speculum


This is a guest post from a patient.


I am from Bangalore and in IF land from past 11 years. We had tried multiple stimulation cycles, IUIs, and an IVF without success. We had even tried alternative medicines like ayurveda, homeopathy and Unani but without success. We finally decided to take our next IVF treatment at Malpani Clinic. The treatment from start to end was so smooth here.

During the cycle, when doctor told me that embryo transfer will be done without GA,I started shivering and asked doctor to do it under GA only because I am so scared of speculum. Doctor said whichever way I am comfortable but he assured me that ET without GA is really painless. And Sister Lissy also had assured me the same. This gave me the confidence and I decided to try a mock transfer. I was clear that if I had any pain during the mock transfer, I will take with GA option .

But why am I so scared about the speculum? There are some horrific stories behind it. My first encounter with speculum was during first IUI cycle in Bangalore. That doctor left me with the speculum inside for one hour in an air conditioned operation theatre after the IUI . It was quite painful, I was not able to walk after that for rest of the day.

Second IUI was at a different renowned clinic. I made up my mind to face the pain with speculum and started breathing exercises to keep myself calm. The doctor doesn't like this and she asked me to stop it. Another encounter with speculum was during my first IVF mock transfer at a different popular clinic. Jr. doctors and nurses tried different instruments on me to do a mock. There was no human touch in that and for them I was a specimen. I screamed out like anything with pain. So for first IVF, I opted for ET with GA.

These 3 incidents formed a very scary picture on my mind and speculum word itself brings shiver to my spine. BTW, till now all the clinics wherever I went, either nurses or Jr. Doctors only prepare the patient for procedure. Finally, on the day of mock transfer at Malpani Clinic, I was so scared.

Entire staff is very very nice and made me so comfortable in OT. Dr. Malpani came in and heard my stories and he assured me that everything will be fine. He called my husband also inside the OT. Doctor asked his assistant to play Tom & Jerry cartoons for me on a tablet ! I was watching Tom & Jerry, my husband was standing next to me for support. What more can I ask for? I was totally relaxed. The mock transfer took about 15 mins and all I did was follow Doctor's instructions . At one point of time, I had a cramp on my left hip, and he immediately paused the procedure. He asked me to relax and resumed only after I was OK. After the mock transfer there was a slight discomfort for a few mins and I was fine.
I decided to do the Embryo transfer without GA.

From my experience, I noticed that some Yoga also helped in the overall process by making hips flexible enough. Two asanas helped me in the process: Titli (Butterfly) asana & Sarvanga (Shoulder stand) asana. Hope this should be useful for other women as well.

While this patient may feel she was being a coward because she was scared of the speculum, the reality is she was very brave, and was willing to go through the IVF treatment, even though she was petrified. This is my definition of courage !


Some patients so have vaginismus. You can read more about this at www.drmalpani.com/articles/vaginismus

The site at http://web.archive.org/web/20110725075247/http://www.vaginismus-awareness-network.org/  is very helpful !













Tuesday, September 06, 2016

Angst amongst doctors in India

This post has gone viral amongst  doctors in India

We live in a country where you can easily have services of a qualified doctor at midnight in 200 Rs but you can't get the services of a plumber or electrician at night for same amount.

We live in a country where a hospital is ransacked if one seriously ill patient dies unexpectedly but nothing happens when thousands die because of hunger,poverty and malnutrition every year.

We live in a country where patients are in extreme hurry while in a hospital but their patience is unmatched when they are in a court of law where their cases linger for generations.

We live in a country where doctors are called cheaters when they ask even for a reasonable fee  but corrupt bureaucrats and politicians are treated as celebrities despite siphoning off millions of tax payers hard earned money.

We live in a country where people generously spend  lacs in celebrating birth of a male child but feel cheated while paying Rs 5 thousand to  the hospital that  conducted safe delivery of the same child.

We live in a country where no hotel will offer you its airconditioned room in Rs.1500 for one whole day but many hospitals will offer you a bed in its airconditioned ICU with medicines,investigations,nursing care and a doctor whom you can thrash in case something goes wrong in Rs 1500 ( Thanks to schemes like RSBY).

We live in a country where a mob disappears in minutes when they are requested to donate blood for their loved ones but they appear in milli seconds when their beloved patient dies in the hospital , in order to abuse/beat the medical staff.

Violence against doctors - Why doctors don't trust patients anymore

Monday, September 05, 2016

What happens to the embryos when they don't implant ?

Lots of IVF patients wonder what happens to their embryos when their IVF cycle fails. Some treat the failure as a miscarriage because they confuse an embryo with a fetus.

Please remember that an embryo is a microscopic ball of cells. It forms a fetus only after 6 weeks.

If the embryo does not implant, it stops growing, because it is not able to establish a blood supply from the uterine lining.The cells dies, and are silently reabsorbed. Cells die in the body all the time, and the body reabsorbs these quietly and efficiently. There are no external symptoms or signs of the death of an embryo.

Some women get a heavy period after the failed IVF cycle. They see clots and tissue in their menstrual flow, and think that they have aborted a fetus. This is not true. The tissue is simply the uterine lining which is being shed; and the clots form when they blood loss is heavy. You cannot see an early embryo with the naked eye.

Please don't let your mind play games with you.  Please also remember that there's nothing anyone can do to "save" the embryo - this is a biological process we cannot control.

Communicating with the patient - why doctors need to go beyond the bedside


We all know the importance of the doctor patient relationship , and this is why so much stress is laid on the doctor's bedside manner .  Good doctors can communicate care and compassion to the patient , and patients are comforted , because they know that not only is the doctor competent, he also cares about him , and will do his best to help him to get better.   Good bedside manner is an intangible skill which is often something mysterious, and is hard to emulate.

While this still remains extremely important , I think we need to move beyond the bedside, because a lot of the care we provide is now done digitally. This could be through Whatsapp or by email , and we need to cultivate equally good manners for these channels of communication with our patients as well. Doctors need to learn good digital manners as well !

This can be easy to do, because it's just a question of applying etiquette to digital communication.  Thus, email queries should be replied to promptly , so that patients aren't left hanging in the dark ; telephone calls should be returned by end of day; and Whatsapp messages answered. Even if you can't do all this yourself, you need to identify staff members and assign them these responsibilities, which you need to monitor.

In some senses , this can be harder as well, because when the patient is sitting in front of you, you can look into his eyes, which means it's much easier for you to demonstrate that you are concerned and compassionate.  However, digital communication tends to be a little more impersonal, especially when this is a new patient whom you've never seen before.  The reason I like email is that everything is documented, and this reduces the scope for miscommunication and error; and encourages openness and transparency.

Many of my patients complain that my email replies are too short, and they believe I am curt , but the truth is that I am a one-finger typist, and it's much easier for me to provide quick and dirty replies, especially when this is a patient whom I have never seen before, and  who has reached out to me through the internet. I tell my patients that the quality of my answer will depend upon the quality of their questions !

Similarly, at the end of a phone conversation, patients may feel that the doctor is uncaring , and didn't answer all their questions properly, but this could just be because the phone line was bad, and he couldn't hear you clearly; or didn't have enough medical details to provide intelligent answers. Also, many patients expect the doctor to provide a free consultation, and doctors are naturally reluctant to do so, because their time is precious ! I don't like phone calls personally because the signal to noise ratio is poor and there is no documentation.

However, both face to face and digital communication are complementary channels , and doctors will need to master skills in both these settings if they want to continue being able to take good care of their patients in this day and age.


Thursday, September 01, 2016

Why are systems in hospitals so broken ?


My father in law just got admitted for surgery at a leading hospital because he broke his humerus and he needs to get this fixed.  Being at the receiving end of medical care can be quite an eye-opener for doctors, and I was very disappointed by how broken so many of the hospital's systems and processes were.

We were told to get admitted at 8 pm, and had the admission papers signed by his consultant with us. In order to get an elective admission completed, we were told to go to the casualty, where the casualty medical officer asked him to lie down on a stretcher, while he took a perfunctory history. He then sent us to the billing department, so we could complete the paper work, pay the admission deposit, and get his indoor papers. We were then told to go back to the casualty and wait, until the cashier sent the completed file ( with proof of our payment) back to the casualty , where the medical officer instructed a ward boy to take him to his room.

After 30 min, the anesthetist came to the room for the pre-op examination, and then sent him back to the casualty so he could get a routine pre-op Chest X-ray done. A new ward boy then had to ferry him back to the casualty for his X-ray, and then bring him once again to the room. It seemed like the left hand had no clue what the right hand was doing , and unnecessarily cavorting him around the hospital just wasted everyone's time and energy.

It seemed that the hospital's system were broken even more badly than his humerus . What's even worse is that it would be so simple to fix all these issues if someone just applied their mind. While I did complain to the manager on duty, his just shrugged his shoulders, claiming that he was following standard hospital policy laid down by the management, and couldn't do anything about it other than sympathise with me.

If a patient is getting admitted for elective surgery, it would be so simple to inform them in advance as to what the procedure is, so they know what to expect.  They should be sent a standard checklist
( perhaps by WhatsApp and email) , so they are fully prepared, and there aren't any unexpected surprises . Patients need guidance to help them remember to bring everything they need ( such as their medical records and their insurance card, along with enough money). There should be someone to welcome them; and to hand-hold them during the process , because patients are usually anxious and upset. A hospital can be a scary place, even if your son-in-law is a doctor and is accompanying you.

All the unnecessary running around sapped his morale, and he became irritable and tired - hardly the best frame of mind to be in before planned surgery.  A lot of my time was wasted as well, and it took the better part of 2 hours before he was finally settled down in bed and ready to sleep - at which point the resident doctor came in to take his signature on the consent form.

What's tragic is that this happens on a daily basis with all the patients , and no one seems to be bothered , even though it would be so easy to fix these minor issues.

I think it should be mandatory for the CEO of every hospital to get admitted anonymously in his own hospital as a "mystery shopper" , so he can see for himself how well ( or badly) the system works. Hopefully this will provide him with enough incentive to want to fix it. The good news is it's not very difficult to improve it -  it just requires a desire to make sure that patients are treated as respected guests.


The processes are much worse in most IVF clinics, where patients are made to run around from pillar to post for scans, blood tests, medications ! Why can;t systems be designed around the patient, rather than around the doctor ?


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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