Wednesday, November 30, 2016

Why is the Government turning a blind eye to the misuse of new technology for female feticide ?


Ultrasound scanning can be life saving . However, because it was being misused for gender determination and female feticide, the Government introduced the PCPNDT Act and started  monitoring ultrasound scanning more closely, to prevent this abuse.

However , technology moves on, and it is now possible to determine fetal gender at 9 weeks of pregnancy with a simple blood test on the mother, using NIPT technology ( non-invasive prenatal testing) .

According to a new research report by RNCOS entitled, “Indian NIPT Market Outlook 2022, the Indian NIPT market represents a market with remarkable potential for growth.

The UK Govt has already expressed concern that this test is being misused for sex-selective abortions.

However, the Govt of India is not doing anything to prevent the misuse of this technology to prevent female feticide. Blood testing is much easier than ultrasound scanning, and if these blood tests are not carefully monitored, female fetuses will continue being aborted, because the Govt of India is focusing purely on checking ultrasound scanning. The sex ratio will keep on dropping  because government officials are not being proactive.

We cannot afford to miss the forest by getting bogged down in the trees !

Public Private Partnerships to heal Healthcare.


We all know that the healthcare system in India is creaking.  The situation is going to become progressively worse , because we cannot keep up with the demand for medical attention. Epidemics of infectious diseases such as dengue and malaria have become increasingly common, because of poor infrastructure. The rise in non-communicable diseases because of poor life style has created a double whammy, and we are reaching a breaking point.

The government is supposed to provide healthcare services to citizens, but the problem is that the public sector doesn't trust the private sector. We know that there's a shortage of hospital beds, but still the government is hell-bent on passing rules and regulations which are forcing nursing home owners to shut down. That means the shortage of hospital beds is going to become much worse in the future.

We've tried the PPP ( Public Private Partnerships) models, but these have been plagued by political problems.  They've not delivered the results which were promised , because of vested interests.

This is a shame. We should use a blend of both private healthcare facilities along with public hospitals, by combining the strengths of both.  The public hospitals are great at providing cost effective care to seriously ill people. The private small nursing homes have the major advantage of being able to provide care locally , so that it's much more convenient for patients. We need to marry the best of both worlds, but we often end up extracting the worst of both. Poor patients are forced to run to public hospitals for minor problems, which could be much better tackled locally.

We need to set up partnerships as well as linkages , so that there is no unnecessary duplication of services. Both private and public hospitals need to trust and respect each other, so that they can do what's right for the patient. There are many opportunities to create unique models for success , but these are being frittered away. We need to create a robust referral system, to make sure patients get the right care in the facility which is correct for them.  It's high time we learned to develop medical processes and protocols so both the private and public sector can work together and complement each other.

Thus, simple elective surgical procedures such as hernia repair could be done in the nursing homes, so that there's no need for these patients to block up an expensive tertiary hospital bed, which could then be used only for the critically ill patient. If a poor patient goes to a public hospital , and the diagnosis of hernia is made, he could then be referred to the private nursing home nearest to him, which could provide him care at a subsidised rate.

Similarly, public hospitals could outsource lab services to reputed private players  who provide high quality diagnostic reports because they are so well-equipped. This way patients would benefit, because they would get reliable reports, rather than have to depend upon the poorly equipped public hospital lab. Everyone benefits. The public hospital doctors now have results they can trust;  the private lab processes more samples, which helps them to improve their revenue; and the public hospital does not need to invest in extremely expensive lab equipment, saving them a lot of capital expenditure, which could be used to upgrade their ambience.



Tuesday, November 29, 2016

'POINTLESS' IVF TREATMENTS THAT CAN WASTE THOUSANDS

'POINTLESS' TREATMENTS THAT CAN COST THOUSANDS

Endometrial scratch (up to £350)
Scratching the womb is said to release hormones that make it more adhesive, but studies found it does not help women with fewer than two failed implants.
Assisted hatching (£615)
May help repeatedly unsuccessful couples by softening the embryo’s outer shell so it can ‘hatch’ more easily, but no evidence this works for older women.
Time-lapse monitoring (£775)
Camera shows up abnormalities by taking pictures as embryos develop, but no good quality evidence for routine use.
Embryo glue (£320)
Chemical with added hyaluronic acid developed to help the embryo ‘stick’ to the womb lining. May increase birth rates, but can also cause unplanned multiple births.
Intra-cytoplasmic sperm injection (up to £1,390)
Sperm injected directly into egg is said to help fertilisation, but experts argue this is not necessary if a man’s sperm is normal.
Intra-cytoplasmic morphological selected sperm injection (up to £600)
Uses a microscope almost 6,000 times more powerful than usual to identify any defects, but creates no more pregnancies than a basic sperm injection.
Immune therapy (£1,500)
Based on claim a woman may fail to become pregnant because her immune system rejects the embryo. A review found blood level of ‘natural killer’ cells, which fight infection, has no effect on implantation.
Pre-implantation genetic screening (£3,100)
Identifies abnormalities, screening out embryos unlikely to implant. May cut miscarriages, but has not been found to raise birth rates in women with a good prognosis.


Read more: http://www.dailymail.co.uk/news/article-3972968/The-great-IVF-swindle-Couples-desperate-baby-sold-treatments-not-need-8-000.html#ixzz4RPm8N1kM

Fixing healthcare in Mumbai


I just attended a meeting at Freedom for A Billion, where senior medical experts such as Dr. Sanjay Oak , CEO of Aga Khan Health Services, and Dr. Avinash Supe , Dean of KEM Hospital, spoke about their vision for improving healthcare for Mumbai.

Healthcare represents what economists call a wicked problem. There are many moving parts, and there's no one person who is in charge of everything. Thus, doctors will treat an ill child with diarrhea, but how do they make sure that the child does not get diarrhea again ? When he goes back to his house in the slum , how can the doctor ensure she gets clean drinking water ? Another problem is that healthcare is always a very emotionally charged issue, because it is so personal . When someone in the family falls sick, we are willing to move heaven and earth to help them get better, and it's very frustrating when we encounter road blocks because of high costs, red tape , a shortage of doctors, or poorly equipped healthcare facilities .
The truth is that while doctors can treat illness, our health is impacted by many factors which are completely beyond our control - for example, the quality of air we breathe. The big problem is that growth in Mumbai has been completely unplanned , and healthcare facilities have not been able to keep up with the needs of the exploding population.

There were lots of eye openers during the presentation. It's interesting that the problem isn't a lack of money, because the Mumbai Corporation has tons of money - it's a very rich corporation, thanks to the taxes we pay. For example, the Dean of KEM Hospital, a 2250 bed teaching hospital run by the Municipal Corporation has a budget which authorises him to spend Rs 100 Crores every year on upgrading facilities and buying state of the art medical equipment in KEM Hospital.   The problem is political interference. Even though the money is lying in the bank, politicians with vested interests will block him from spending this, because they want him to buy the equipment from their buddy. It's hard for a Dean to stick his neck out, because a few disgruntled corporators will allege that you're corrupt because you are favouring a particular vendor, when all you're trying to do is to buy the best CT scanner to be able to provide better care to your patients.

One way of fixing the problem would be to insist that all municipal corporators ( who control the corporation budget ) should be forced to take treatment only in municipal hospitals. Only when they understand the problems which a patient in a corporation hospital has to suffer through , will they become a little more empathetic . They will then be more willing to give the Dean more autonomy by treating him as a respected senior expert doctor. He needs to be able to exercise his discretionary power so he has the freedom to purchase the best equipment, using his best judgment, so that he can do his job properly.

The problem with the public health system today is that there is no accountability nor transparency . This is why no one is responsive, and the buck keeps on getting passed around from one person to another. It's much easier to do nothing, rather than try to fight politically motivated rivals, who want to take a cut of every transaction. This is why the medical equipment in these hospitals is outdated and poorly maintained , because the money lies unspent. This is one of the reasons why patients are so unhappy with public healthcare facilities . Even though the quality of medical care is very good, the level of hygiene and the ambience - the hotel facility and hospitality care provided in these hospitals - leaves a lot to be desired.

The problem is that we take a top-down approach. We need to take a bottom-up approach and think about what we can do to put patients first . The good news is that there are lots of opportunities to do so, and I'll discuss these in my next post.

Monday, November 28, 2016

Does India really have a shortage of doctors and hospital beds?



One of the commonest solutions which is proposed to treat India's ailing health care system is creating more medical colleges to churn out more doctors ; and building more hospitals. The standard  party line seems to be that we don't have enough doctors , given the large number of patients we have ; and there aren't enough hospital beds. It's usually WHO recommendations which are used as a standard metric to prove that India is short of thousands of hospital beds , as well as hundreds and thousands of doctors.

This is the argument which is trotted out when justifying the need to allow private for-profit companies to start medical colleges; and why funds are used to create brand new hospitals.  However, the fact that these solutions are usually proposed by doctors ( who have a vested interest in creating more work for themselves) should make us wary about accepting these fixes at face value.

This reasoning is flawed for many reasons. It's easy to create more doctors, but the problem today is not a shortage of doctors - it's the way they are distributed. Even if we start new colleges, the newly minted  doctors will continue flocking to the large cities, which already have too many doctors. No one will go to the villages , which is where the shortage of doctors creates the biggest problem.

Similarly, creating more hospital beds is not an effective solution because of the problem of supply-induced demand.  If there is a hospital, hospital management will not allow its beds to remain empty, so they will pressurize their doctors to fill up their hospital beds by creating more patients.  This is something which is fairly easy for doctors to do. You just do lots of tests, and you are certain to pick up lots of abnormalities. You thus convert a person into a patient and create many more " worried well" people, who don't really need medical attention.

Often it's doctors who contribute to the problem . We don't have a healthcare system - we have an illness care system, because doctors specialise in treating diseases. We want to increase our work load; and because we look at the world through the prism of  our special interest,  we see potentially sick people everywhere, which is why we create new disease labels such as pre-diabetes.

Another problem with doctors is their medical hierarchy. Superspecialists are at the top rung, because they are the most highly educated . However, they end up knowing a lot about a very  tiny slice of medicine and this is where they focus all their time and energy.  This ends up being a drain on limited resources ,which get diverted into gratifying the specialist's ego.  They love playing with the newest medical technology and want to buy the latest and most expensive medical gadgets and toys - and this ends up making medical care needlessly expensive.

Using a doctor-patient ratio , or a hospital bed : patient ratio as a metric for judging health care services is flawed. It's high time we moved on. Thus, there's really no need for lots of these patients to be in the hospital in the first place. It's much more effective to provide them with the  care they need either in community centers , or within their own homes . Mobile health technology allows doctors to go to where the patients are, rather than force patients to go to where the doctor is. This is far more convenient for everyone and is much more cost effective as well. This in itself will reduce the number of hospital beds needed , because they won't be occupied by patients who don't need them. These expensive limited beds can be utilized far more intelligently only for critically ill patients.

Similarly, the doctor's precious time is not utilized well. A lot of it is wasted in commuting from one clinic to another. By using mobile health technology, doctors can reach out to patients without having to travel.   This way, he does not have  to twiddle his thumbs while waiting for the patient to come to his clinic . This way, you're optimizing the use of the doctor's time , and making the best use of his expertise, because he can then  reach out to many more patients.

We need to make better use of the resources we already have by optimising their use, rather than chasing after pointless metrics.

Sunday, November 27, 2016

Why do most IVF cycles fail ?

The commonest reason for IVF failure is implantation failure. Even when we transfer good quality embryos inside the uterus , we know that most IVF cycles will fail. This is very frustrating for patients,  because they expect that their embryo is going to become a baby - which is why many patients fondly think of their embryos  as being embies !,  When a good quality embryo doesn't implant, they blame themselves . They also demand an explanation from their doctor  - especially when he was very optimistic and hopeful at the time of the transfer ( as so many IVF doctors are, in order to build up their patient's hopes).

The doctors then orders a series of tests , primarily to pacify the patient, even though he knows that the tests are pointless and don't provide any useful clinically actionable information .  This is because the uterus is a biological black box , and in vivo implantation isn't a process we can study or control after transferring the embryos inside the uterus.

However, when 2-3 cycles fail, patients start getting desperate, and start clutching at options such as surrogacy, because they feel this will help them to bypass the problems which the doctor cannot identify.

However, we need to remember that the failure of embryos to implant is the biological norm. The truth is that most fertile women (even those who have sex every single day) will not get pregnant every month they have sex, and the reason for this is that their embryo does not implant. After all, if the woman is young; ovulates regularly; has open fallopian tubes; and her husband has a good sperm count, and they're having sex everyday , this means that the sperm must be reaching the egg , and this must be fertilizing. If the woman still doesn't get pregnant each month she has frequent unprotected sex, this clearly shows that embryo implantation fails in most cycles, even in fertile young women.
Let's not forget that fecundity rates are about 20% per cycle for young women.

It typically take fertile women five to six of regular sex months before they get pregnant, which is why the definition of infertility is not getting pregnant even after trying for a year. This is why we say that human reproduction is not efficient.

There's no reason for us to expect IVF to improve this efficiency  ! What IVF does is allow us to compress time, but the chances of the embryo having a genetic defect remain the same. This is the reason why most embryos don't implant every cycle.

The problem is that when you are having sex in your bedroom, you don't mind the failure of implantation all that much - you can just look forward to trying again the next month !  However, when your precious embryos fail to implant after IVF, it's much harder to deal with this failure.

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 !







Why small town Indian entrepreneurs have a competitive edge



Most of the start up action in India is in Pune, Banaglore, Delhi and Mumbai. This is where the incubators , accelerators and the angel investor networks are, which is why this is where all the ambitious founders go.

However, I believe that entrepreneurs in tier-two cities actually have an edge as compared to startups in Bangalore or Mumbai.

Now, this may seem counter-intuitive, because they are not as polished or sophisticated as the founders in Mumbai . They have less support, because the startup ecosystem in smaller towns is still immature.

However, this is the reason why there is a much better chance for a patient angel investor to find the big winners in these towns. There are many hidden gems here, far away from the media glare.

The founders in these smaller towns have a far better chance of being able to create products successfully for the Indian consumer because they experience the same pain points she does in their daily lives. The beauty is that with the right help, they can go a long way !

Given the fact that internet access has improved dramatically; the competitive disadvantage which they had as compared to the startups in the Big 4 cities has become much less.

These founders should be playing to their strengths , and they have a lot of them - only they are not very obvious ! They think in local Indian languages, and they should be exploiting this edge, rather than trying to polish their English. Their cost of doing business is much less, which means they are frugal and can fail far more cheaply. Finally, their employees are far more faithful, because there are very few local competitors who can poach them !

Zoho has proven that it's possible to create world-class products such as Zoho Desk in a small Indian village. I am sure other companies will copy this trend.

These towns are the cities of the future, because they are far more livable than the Big 4. I predict that we are going to see lots of success stories from these places, as incubators and accelerators start seeding the entrepreneurial ecosystem in these towns.

Wednesday, November 23, 2016

Third-Party Financing Could Support Rooftop Solar in India


India’s government unveiled an ambitious rooftop solar program this year with the goal of installing 40 GW of rooftop solar power by 2022, according to the Ministry of New and Renewable Energy.

This can be funded by third party financing

Great opportunity for clean-tech startups !
 

The one thing founders need to do to scale up their start up

The trick to growing your startup is learning when to say No to customers. This might sound counterintuitive , because when you're a startup, you're so desperate for cash that you are happy to take money from anyone and everyone who is willing to buy your services. However, you will soon learn the hard way that some customers are just not worth the money they pay you. This is especially true of customers who want a free trial, but will refuse to pay for your product. They drain your time, suck away your energy , and stop you from focussing on growing your company.

The trick to being successful is careful customer selection. You need to pick customers from whom you can get recurring revenue because these are the ones who are worth their weight in gold. A mature founder is one who has identified what his sweet spot is - someone who knows what the right customers for him are , so that he can go after them in a very targeted, focused fashion. He then can learn to say no to all the rest of the world , because they will just end up distracting him from serving his ideal customer.

Start by listing all the existing customers you already have , and then ask yourself why they're not using all the services which you have on offer. You need to start making sure that your good customers starting consuming more of the services you offer. The more the value you add to them, the deeper they will be embedded in your system and the more the money they will be happy to pay you. Targeting desirable customers is extremely important, and you need to become a reliable business partner for them. If you delight them, they will become your brand ambassadors, and will be happy to refer their friends ( who are very likely to also be good customers just like they are), and this will create a positive virtuous cycle.

Tuesday, November 22, 2016

Why do entrepreneurs from Tier 2 Indian cities have an inferiority complex ?

I gave a talk recently on angel investing at the Nashik Entrepreneurship Forum . I was very impressed with the turnout. There were over 300 people attending - and most of them were entrepreneurs and prospective entrepreneurs. It seems that becoming a startup founder is now a popular trend, and lots of students are seriously considering this option, which is great news.

The big problem is that many founders in these tier - 2 towns suffer from an inferiority complex   because they haven't graduated from an IIT or an IIM ; and they feel they are at a disadvantage because they are not based in the Indian startup hotspots such as Bangalore and Mumbai.  They compare themselves with the successful founders who are featured in the media, and find themselves lacking.

It's true that they don't speak English as fluently, and their presentation skills are not as polished as MBA grads.  However, I believe that entrepreneurs in these tier-two cities actually have an edge as compared to startups in Bangalore or Mumbai.

Now, this may seem counter-intuitive . Yes, the startup ecosystem in the larger cities is far better, but the founders in these smaller cities have  a far better chance of being able to create products successfully for the Indian consumer.  In one sense , a large city like Mumbai is very similar to any other  large city in the world, such as London or New York. Often founders in Mumbai live in their own little Westernised bubble, and have no sense of the pain points which the average Indian consumer living in villages or small towns has to face.  However, the founders who live in these small towns have to cope with the same problems which their customers have to tackle on a daily basis, which is why they are much more likely to come up with clever solutions.  They are much less likely to have competition, because founders in Mumbai aren't interested in solving the problems of consumers in Indian villages.

Given the fact that internet access has improved dramatically; and infrastructure has become so much better, they really don't have a competitive disadvantage as compared to founders in Mumbai .

They should be playing to their strengths , and they have a lot of strengths ! They can come up with solutions at a fraction of the cost, because real estate is so much cheaper in these towns. It's also much easier for them to find qualified employees, because all these places have lots of engineering colleges, and the competition to find talent is much less.  Their employees also charge much less, and are much more likely to stick with them, because their job options are far more limited than they would be in Mumbai.

I think one problem is the fact that we call these tier-two cities and tier-three cities. The name itself  suggests that they're second grade or second class , which means they are not as good as the tier-one cities.  This is ridiculous.

We should stop calling them tier-two cities, because  many founders from these towns will use this as an excuse for failure , saying, "Well, if we're tier-two, then obviously we're more likely to fail." Maybe we should call them cities of the future, because I think that's what they're going to be ! They are far more livable than Mumbai or Bangalore or Delhi are, and we are going to see lots of success stories from these places, as incubators and accelerators start seeding the entrepreneurial ecosystem in these towns.


Pregnancy success story from Malpani Infertility Clinic to Tanzania


We are married couple from Tanzania and being married for seven years, starting a family immediately after a marriage was not an option we wanted to wait for few years though no birth control was used, luckily we discover that we are suffering with severe oligospermia and we can never be able to get pregnant without scientific methods.

While growing up I saw a tv documentaries  tittled ' A womb for sell' another one was 'Baby factories in Mumbai' all these programs showed how an IVF was conducted to make babies to the desperate couples, some information was scary but I remember said to my self if I happen to be in this position too then I would like to go for an IVF.

We Google for the IVF clinics in India, Malpani Clinic catched our eyes due to accessive information available regarding the clinic, we were more impressed with the the quick responds that we received from doctor Malpani for each doubt that we had plus the active interactions happening online between the doctors and patients. We were also moved by the success stories dropped here by those who have visited the clinic.

Our first visit to the clinic for the IVF treatment was in 2013, and we had a positive pregnancy results, we lost the pregnancy due to missed abortion on our first trimester, it took us long to forget the lost but still we did not forget how beautiful being pregnant felt. Again we had our second IVF treatment attempt this year(2016). We are now on our 17 week pregnant, and going strong, alhamdulilah.

We are thankful for Malpani Infertility Clinic for their efforts in helping us reaching our dreams. We thank each and everyone for their help, no day pass by without remembering all your efforts and care we have received towards our success. God bless you all, and continue to receive all the need ones.

And for those who are struggling to archive this goal trying is what is count, do not loose hope.

We are looking forward for our April 2017 baby, God Bless You All.



mwatimaissa@yahoo.com

Monday, November 21, 2016

Cleaning up corruption in India - looking forward

One of the major reasons India has remained a poor country inspite of the natural riches it is blessed with is because most of us are corrupt. If we want to give our children a better future, we need to change that behavior . Getting corrupt people to become straightforward and honest is  not going to be easy , because changing behavior is hard and causes a lot of pain - especially when it is the rich and powerful who are the ones who are the most corrupt. This  is why the demonetization move is a step in the right direction. It has created fear in people's hearts , and they realise that they can't continue to get away with stashing their black money. If they do try , they will get into trouble - if not now, then further down the road, as the IT Dept tightens the noose. The demonetization is just the first step.

Now that people have felt the pain of watching their ill-gotten gains go up in smoke , they're going to think twice about doing this again. They've paid a heavy price, but hopefully have learned their lesson. Most would prefer paying their taxes , so that they can sleep better at night. Childbirth is painful, but it's well worth it because you want a baby. Yes, this move has also caused pain, but it will be worth it in the long run . The problem is that we've put up with rubbish for so long, that corruption and bribery have become ingrained in our habits . We don't even realise that we're cheating when we accept cash and don't account for it. It's become the accepted norm, so that the people who pay taxes honestly are considered to be fools, because they aren't smart enough to conceal their income .

Honest tax payers resented the way the crooked got richer by bribing bureaucrats and stealing from the Government.  However, they felt helpless . Everyone aspired to be a part of the charmed inner circle, where you could get away with borrowing thousands of crores from the bank because you had the right connections. Crony capitalism had made a mockery of democracy and merit.

Lots of political leaders are shedding crocodile tears over the " harassment and inconvenience " caused to the " poor honest villager " and housewife who was forced to stand in long lines for hours in order to withdraw money. They feel that the move has disrupted the life of the poor Indian citizen, and want it rolled back. This is the height of hypocrisy ! It is these guys who have kept Indians poor by siphoning off the nation's wealth. Fortunately, the poor have become much smarter and aren't getting carried away by their rhetoric.

Demonetisation was a brave step by someone who is bold, honest, and doesn't have any vested interest. It required a single person with courage to be able to pull this off. Critics are worried about the adverse affects this will have on GDP . They feel that cutting off the circulation of money - the lifeblood of the economy - will crimp growth and hinder progress. However, you don't need cash for money to circulate - electronic money ( in the form of NEFTs , e-wallets and credit card payments ) will do just as well.  In fact, the black money never contributed to growth because it was part of the parallel informal economy. The demonetisation has strangled this. Once this is shut off , it's place will be taken by white money, as a result of which the economy will boom.

It's great to see how the clever new FinTech companies have stepped in so  quickly and have helped small shopkeepers to accept electronic payments. Indians are resilient and will adapt quickly because they can see it's in their best interests to do so !

A common criticism is that this move is unlikely to help, because it is only a one-time step. With the introduction of the Rs 2000 currency notes, most people believe Indians will go back to their bad old ways of using black money to grease palms.  It's sad that most Indians have such a poor opinion about the honesty of other Indians - and this is partly because all of us are so crooked ourselves.  The fact that Indians who settle in the US don't bribe the IT officials and  police officers there is proof we can learn new habits and stop being corrupt !

It's true that similar  moves to clean up the system in the past did not work well. However, times have changed. Today, we have the technologic option of transferring money by using RTGS, NEFT, and other forms of electronic payments , which means people now have a viable option to using cash.  Transferring money using the mobile is going to become the norm in a few years  as the UPI ( United Payment Interface) changes the way we carry out financial transactions . We need to think of where we are going to be a decade from now, rather than remaining stuck in the past.

Carrying cash  will hopefully become obsolete, so that you no longer have the ability to bribe the cop who gives you a ticket for speeding. Once we stop offering bribes in our daily life, this will have a ripple effect, and we will start treating the giver of a bribe as a criminal as well - after all, the bribe giver is as much a crook as the bribe taker . My hope is that bribing people will become so increasingly hard that people will just stop offering money under the table !

Yes, things could have been done better, but that is true of any action.  It's easy to be wise after the event, and the government is taking steps to correct their errors . Let's stop being armchair critics please.  When you want to do something which needs such strict secrecy, you can't wait for perfection. After all, this was emergency surgery which was done to treat a festering abscess, so you can't complain that the operation was painful because  anesthesia wasn't given. When a patient is dying , anesthesia is the last thing you think about when performing life-saving surgery !


Why do IVF doctors write such irrational prescriptions ?


This is a standard prescription from a leading IVF clinic in India.
There are 8 medicines described for luteal phase support after the frozen embryo transfer.
This is a textbook example of needless polypharmacy and irrational prescribing.

The only 2 medicines which are needed for luteal phase support are estrogen and progesterone - which are Susten and Progynova. This much is rational.

Duphaston contains progesterone, as does Gestone. Why prescribe 3 different medicines which serve exactly the same purpose and contain the same hormone ?

Pregynl contains HCG and has no role to play in a frozen ET because there is no corpus luteum in a frozen thaw cycle.

Cutenox is Enoxaparin - low molecular weight heparin, which is painful and unproven and expensive.

MCBM69 contains Folic Acid, Mecobalamin, and Pyridoxine . Isn't folic acid enough ?

M2 Tone is an ayurvedic medicine and I can't understand why a Western medicine doctor will prescribe this. Isn't this a kind of cross-pathy ?

Sadly, this kind of prescribing has become institutionalised, and other junior doctors copy and paste the prescription and start advising the same medications for their patients, which is how these stupid practices spread.

I wonder why doctors don't use their common sense when prescribing ? The poor patient spends her entire day taking medicine - and the risk is that if you write so many medicines, she may get overwhelmed and may forget to take the important ones.

Also, this just needlessly add to her bill, without improving her pregnancy rates.

Do clinics prescribe so many medicines to show patients how careful and thorough they are ?

Or is it that they need to keep lots of pharma companies happy ?

Sunday, November 20, 2016

Why do health laws in India leave so much to be desired ?


Since doctors are medical experts who treat patients on a regular basis, one would expect that their inputs would be very helpful for the government when they're designing healthcare policy. However, we find that doctors very rarely get their voice heard in drafting these policies , and that's because doctors don't perform well in committees.

This is because most doctors want to be effective and act - they want to do constructive things with their time - concrete stuff which has tangible results . They think that just talking in a meeting is a waste of time , which is why they don't like attending committee meetings which sometimes go on forever and ever. They hate having to listen to a lot of hot air and wisdom spouted by bureaucrats.

Also, they are naive and don't understand a lot of the backroom politics which go on during these committee meetings to draft policy. This is why they're very easy to manipulate.  They are sometimes goaded by activists as a result of which they lose their temper , and also their clout. Often they're used as patsies by the bureaucrats . These officers who sit in meeting all day long are masters at manipulating them, because that's all they do. They are experts at recording the minutes and then manipulating them to suit their hidden agenda,  which is why they find it very easy to get the doctors to act as puppets.

For example, they will put a doctor's name down as part of the official committee appointed to draft the policy, thus paying lip service to the fact that they have invited inputs from the medical profession. The selected doctor is very pleased with himself because this means that he's been recognised  by the Government as being a wise and influential voice in the medical community, and has been selected amongst his peers. However, the bureaucrats will then change the venue or the timings of these meetings at the last minute. They know that doctors are busy clinicians, who will not be able to attend the meeting because they have prior medical commitments.

This means that the doctor often just acts as a dummy figure head  who is a committee member. He is manipulated so cleverly that he is not able to provide any useful inputs to the deliberations of the meeting , as a result of which the policy draft is very one-sided. Doctors get outmaneuvered by the bureaucrats and activists, who are much smarter politically , and much savvier than doctors as regards these matters. By the time the doctor gets wise to their tricks, it's too late because the damage has been done.


This is the reason why so many health laws in India leave so much to be desired. Because they are hamstrung by these machinations, the doctors on these committees are not able to represent the voice of the medical profession and their patients effectively.


Friday, November 18, 2016

Why India's youth is thrilled with the demonetisation


There seems to be a major difference in the way the younger generation has looked upon the move by the government to demonetize high currency notes.

Many older people are quite resentful and angry about this sudden and unexpected turn of events - especially the ones who have lost a lot of their ill gotten wealth which they had hoarded as cash over the years . Since they can't openly say that they are upset because all their money has disappeared, they therefore shed crocodile tears on behalf of the poor villagers who have to stand for hours in line to collect their cash; or worry about how this is going to affect the kirana store owner; or the housewife who had stored money under her mattress for emergencies.

The reality is that they never felt that anyone would have the courage to get rid of black money in India. After all, the rich and powerful in India all had lots of black money, so who in their right sense would make it impossible to hoard it at the stroke of a pen? Now that it's happened, they need to come to terms with it. The old style of getting their work done by greasing palms is not going to work, and they are going to have to learn how to be upright .

The younger generation doesn't have this baggage. All of us raise our children to be moral and upright citizens. When they see us bribing the police officer; or hoarding money; or giving them cash to spend on buying expensive baubles, I wonder what they think of us. They are confused, because what we do and what we say are so different. I am sure they must be laughing behind our backs at our hypocrisy - and perhaps this is one of the reasons why the youth do not respect their elders - because they can see how corrupt and crooked we are.

On a short term basis, many rich kids are now learning the value of money, because they can no longer splurge it. They are learning to stay at home instead of hanging out at malls and bars ; and eat at the vada pav stall, instead of the Starbucks, and this is all for the best !

Lots of the brightest Indian students still want to migrate to the West , because they can not put up with the daily corruption which characterises daily life in India . They are sick and tired of the special privileges which are doled out to the rich and politically connected. These students are very pleased that this move will help to reduce black money and corruption . They now have a much better chance of becoming rich in this country without having to be crooked. I am confident lots of them will not migrate; and that many students in US and UK universities will want to come back to India, once the system gets cleaner, fairer and above board.

Cleaning up the Indian Economy


It's now been a week since the Prime Minister demonetized the Rs 500 and Rs 1000 notes and it's time to reassess the situation. I for one have been very impressed by his ability to pull off a pretty dramatic move but lots of my friends have completely different opinions. Some of them think that instead of inconveniencing the ordinary man he should have gone after the high profile politicians and businessmen who are known to have lots of black money stashed away. Others believe that these stunts are designed to please the masses. By positioning himself as a brave, larger than life Robin Hood who is out to snatch the ill-gotten gains of the rich, he is improving his chances of being re-elected as PM.  Their belief is that if he was really serious about ridding the country of corruption, he would strike at the underlying cause of black money generation , which is the excessively high rate of taxation the government levies. They feel that if the government reduced the tax rate, most citizens would be willing to pay more , as it wouldn't be worth the hassle to hide their income.

Many feel that he is bitten off more than he can chew. He got poor advice, and didn't have time to get a thoughtful second opinion . It's only now that he's realizing some of the unintended consequences of his action, but it's too late to fix these.  They believe that because of all the unnecessary hardships which ordinary people are being made to face, they will boot him out of power.

I guess it's always possible to point out flaws in any action - it's easy to be wise after the event. And it's true that some of the challenges were misjudged, and that things could have been done in a better way. 

However, being an armchair critic is hardly fair - at least he had the courage to act, which is far more than we can say of the vast majority of our political leaders .

Also, I feel it's not fair to look at this one single step in isolation. I think it's the first step towards his journey of cleaning up the system. It's an important first step , because it shows that you are serious about causing pain to the powerful corrupt people who've shamelessly hoarded black money over the years.

Another criticism is that all the black money is not stashed away as cash - a lot of it is in the form of benami properties , gold and Swiss bank accounts.  Yes, this is true,
but just because people have stashed away money in Swiss accounts doesn't mean that you shouldn't go after the black money which they've stored in cash.

Some people feel sorry for the average housewife who's stashed away money under the mattress, but the fact still remains that this was unaccounted for money , on which tax wasn't paid. Not paying tax is hardly something which an honorable citizen should be doing.

The trouble is that we've all got used to cheating the government . It's become a bad habit which has become a part of our culture, simply because we've been able to get away with this kind of cheating for so many years . In fact, we look down upon the simpletons who pay all their taxes, and think of them as being stupid and clueless. We admire and envy the rich, because of the clever unscrupulous ways in which they have  been able to dodge taxes and acquire tons of wealth without fear of being caught or punished. 

However, it's high time we started adoption a zero tolerance policy towards corruption. After all, we weren't born corrupt . Most of our freedom fighters were honest. It's only after independence that the cancer of corruption has spread so virulently. There are lots of countries where everyone is honest , and we can learn from them.

In India, the problem is that corruption has become so prevalent, that we have started taking it as much for granted as the air we breathe.  Power, corruption and money have gone hand in hand, and this has become a negative vicious cycle.

It's high time we started changing , and this is a  great starting point. Cutting off the air supply is going to cause pain, and some people will suffocate, but hopefully this will allow us to kill this cancer . Our next generation will now no longer have to look upto crooked rich people as their role models ! How this is going to play out is going to be an interesting story , and I'm keeping my fingers crossed.


Thursday, November 17, 2016

Why do IVF doctors tell patients not to google ?

When I see patients who have failed an IVF cycle, I ask them basic questions such as, "How many eggs did you grow?" and " What was your embryo quality".

The standard response is, "Our doctor didn't tell us anything."

Interestingly, many patients believe that doctors are allergic to patients who ask questions. In fact, a lot of IVF doctors tell them at their first consultation, "Please don't Google, because you will just get confused and anxious. A lot of the advice on Google is not very good, so don't waste your time and energy googling.  Also, please don't ask us questions . You need to learn to trust us. If you don't trust us , then you should go find another doctor."

I think this is bad advice. Infertile patients have lots of questions because they're confused and have lots of doubts.  They have heard a lot of old wife's tales, and are not sure how to separate facts from myths. They want to do their best to get the best possible treatment, and they want their doctors to clear their doubts.

We all know that IVF doesn't have a 100% pregnancy rate, and this is why it's important for a doctor to be upfront and clarify their patient's doubts as much as possible.

I know this takes a lot of time, and sometimes doctors do get irritated when patients ask the same questions repeatedly.  However, refusing to answer a patient's questions is not a very enlightened approach. In fact, this can come back to haunt the doctor afterwards, especially when the cycle fails and the patient feels cheated and let down.

I always emphasize to patients that the only thing which we can control is the process, and that's why patients need a doctor who's willing to be open and transparent . He should share the details of the IVF process with you - both what he can control and what he can't control - so that you don't have unrealistic expectations. After all, the outcome of every IVF cycle is always uncertain.

Even if the cycle fails, if the doctor has been upfront with the patient and answered all her questions patiently, the patient will at least have peace of mind that you've given her good quality treatment, and she'll be happy with you. On the other hand, if you refuse to answer questions, the patient will be angry and suspicious , and will distrust you. These angry patients can end up ruining your reputation. That's why doctors need to change their attitudes, and be willing to spend time in communicating openly with their patients.

Looking for a doctor who is happy to answer questions ? 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, November 15, 2016

The three people to meet when your IVF Cycle fails



Failing an IVF cycle can be heartbreaking, and it can be difficult for the doctor to advise the patient what to do next. This is true when the cycle has gone very well; and even when it hasn't .

Let's take the example of a patient with a poor ovarian response. You know that her best medical treatment option would be to use donor eggs, but the patient is adamant , and has decided she doesn't want to use donor eggs under any circumstances. You believe that repeating the IVF cycle with her own eggs would be an exercise in futility, and you're very reluctant to make her waste her money, but she's not willing to agree with your opinion.

What do you do next ?

You can't force your decision down a patient's throat, because IVF treatment is elective, and patient preference is extremely important.

When we reach this impasse, there are three things we recommend our patients do, so they can move on with their life, and don't get paralysed into inactivity.

We suggest that they meet a counselor - a  psychologist or a reproductive health specialist - someone who can help them look into their own heart,  so they can make a decision which they can live with.

If they are religious, we suggest that they seek guidance from their spiritual leader. This can be helpful because he can help you put the problem in the right perspective.  A failed IVF cycle is not the end of your world, and while a failure causes grief, there is a lot which you can do to help you bounce back. A spiritual perspective will help you regain your resilience.

Finally, we suggest that they get a second opinion from another IVF clinic. This is helpful , because if two different doctors tell them the same thing, then it's easier for patients to accept the medical advice they are hearing, even if they find it unpalatable.  Even if the truth is bitter, you need to accept it.  On the other hand , if the other doctor has a better alternative, I'm very happy for the patient to consider this option, because I have nothing more to offer her in any case.


Saturday, November 12, 2016

The dreaded D word for the older infertile woman.


Most women know that their fertility declines as they get older because they run out of eggs. It's true that life is unfair - while men continue producing sperm all their life,  women are born with whatever eggs they're ever going to have, which means they never produce any new eggs after birth.

Sometimes women find this confusing, because don't they produce an egg every month? Isn't that called ovulation? The truth is that the egg which you ovulate every month was actually manufactured when you were a baby fetus in your mother's womb. This egg is  recruited after years of dormancy , and it matures and is released when you ovulate during your cycle. Think of this like Prince Charming waking up Sleeping Beauty every month . The hormones which do this are called FSH and LH. Thus, there really are no new eggs being produced, and this is why, as a woman gets older, her eggs get depleted and she finally becomes menopausal. This is also the reason why a 35 year old has lower fertility as compared to a 25 year old. Her eggs are much older, which is why both their quality and quantity have taken a beating.  The egg pool is finite, and we cannot reverse ovarian aging.

While women understand that the menopause represents a well-defined stop to their dreams of having a baby with their own DNA , they often don't realize the major impact this declining ovarian reserve has on their ability to have their own genetic baby after 35 . After all , even if your calendar age may be 40, you will always think of yourself as being 25 in your heart of hearts .This is true especially if your periods are regular - you naturally expect that your fertility will also be fine. However, just because your egg quality is enough to produce enough hormones to get regular cycle, this doesn't mean it is sufficient to make a baby. However, regular cycles lull you into a false sense of security.

General gynecologists and family doctors are also not aware of how quickly fertility drops after the age of 35, even in a woman who looks completely healthy.

Since most doctors do not check the woman's ovarian reserve, many older women keep on putting off having a baby . However, the tragedy is that by the time they're ready to start their family, their eggs may have become too old. Now they understand with their head that the best option for them to have a healthy baby is to use donor eggs. They know that older women have fewer eggs; that these eggs are of poor quality; and that their risk of having a miscarriage and a baby with a birth defect increase as they get older.
However, it's very hard for their heart to accept this. It's very difficult for them to come to terms with this, because everyone wants to have a baby who looks and talks and smiles like them - someone , who carries their own DNA.

It can be quite heart-wrenching to make a decision to use donor eggs. This is why a lot of older women who have failed many IVF cycles end up doing surrogacy, rather than using donor eggs , even though donor eggs would give them a much better chances of having a baby. While surrogacy is much more profitable for the doctor, the pregnancy rate for the older woman doing surrogacy with her own eggs is actually no better than transferring her own embryos into her uterus. After all, the bottle neck for the older woman is never her uterus - it's her eggs, which is why swapping a uterus makes no clinical sense. However, she is often pressurised by the IVF clinic to opt for surrogacy. She ends up wasting a lot of money , and loses confidence in all IVF doctors . She deprives herself of her best chance of having a baby because she has frittered  away
valuable time barking up the wrong tree, simply because she cannot come to terms with the fact that the major bottleneck is her egg quality .

Older women need to be open-minded , and be willing to consider using donor eggs. They should at least weigh the option carefully and thoughtfully before rejecting it out of hand.

I know this is easier said than done, and it requires a lot of soul-searching. You need to ask yourself - what do I want from having a baby? Do I want to be a mom , or do I want to transmit my DNA?  Normally, the propagation of your personal genetic heritage; pregnancy and birth; and parenting all come together as a single package. However, you now find that you have to choose between them, and decide what your priorities are. The answers to these hard questions will provide you with a lot of clarity as to your next steps.
Yes, it is a hard decision, but the good news is that other women have tackled this successfully.  The article at http://www.nytimes.com/2011/01/02/magazine/02babymaking-t.html  is very insightful and provides a lot of food for thought.

Interestingly, I find that the women who worry the most about making this decision are usually the ones who end up making the best parents, because they have played out all the worst case scenarios in their head, and are well-prepared to love their baby.


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, November 11, 2016

You need to become the CEO of your own medical care !


Because of the recent technological advances in modern medicine, every doctor seems to have become a superspecialist. They have a lot of expertise in their particular domain, but they often don't have a holistic picture of the entire patient. While they know a lot about the particular organ system in which they specialise , they don't care about the other body systems which the patient also has. Patient care starts getting fragmented, and this is why your diabetic specialist has no interest or clue as to what your nephrologist is doing.

This is why it's so important that patients learn to become experts on their diseases. Otherwise you will end up getting completely messed up because of the crossfire between them. Tests will be needlessly repeated; multiple drugs will be prescribed, which may interact with each other and cause side-effects; and the lack of coordination will mean your medical bills will grow exponentially.

The patient needs to become the CEO of his personal medical team.  You have to be decision-maker, medical researcher, record keeper, medical secretary, coordinator, and financial manager. All the doctors you go to need to trusted team-players he pays to help you to achieve your goal - treat your disease as efficiently as possible, so that you can get well soon.

Often you will find that one specialist has no clue what the other one is doing. They are completely focused on the organ which they have an interest in , as a result of which there is no one who's in charge of coordinating all the efforts and putting all the doctors together in one page.

This problem is going to get worse as we start living longer. Most older people have multiple chronic illnesses, but there is no one doctor who is responsible for their overall medical care - it's all over the place, because each specialist is myopic , and is not only interested in dealing with his area of special interest ( after all, this is why he is called a specialist !)

This is why patients need to step up. While they don't need to become doctors themselves, they need to understand exactly what each doctor is doing and why. They need to make sure that every doctor knows exactly what's happening.

The good news is that there are many useful tools which you can use to help you do this. Prepare a one-page summary before the visit, so your doctor gets an overview of what is going on; create a timeline which describes your story and your progress; design an Excel spreadsheet or a project management chart , which will help all the doctors to make sure they're on the same page when treating you. There are also lots of online tools and apps which you can use. And if you get stuck, you can also employ a patient advocate to help you through the process.

Thursday, November 10, 2016

How IVF clinics take patients for a ride


It breaks my heart when I see how IVF clinics cheat their patients.  Patients do IVF treatment with a lot of expectations .  However, because patients are not well informed , it's very easy for unscrupulous IVF doctors to fool them.

Many clinics paint a rosy picture to attract patients. At the time of the first consultation, the “brand name doctor” is very sweet and obliging. When they are trying to “sell” their services to the patient, they inflate their success rates,  and talk about pregnancy rates of “ between 40% to 50% “ . They have no actual proof of this – and without independent auditing, it’s very easy to manipulate statistics by cherry picking patients and selecting a convenient numerator and denominator.

A lot of IVF clinics are often unscrupulous about the advise they offer to their patients . Thus, when an IVF cycle fails ( sometimes because of poor IVF lab conditions), the doctor will “blame” poor quality eggs for the failure, and advise that the patient use donor eggs to improve her chances of success.

Often, they overpromise success at the time of the embryo transfer, by saying that the embryos are perfect Grade A embryos ( without ever providing a photo for actual documentation). Then when the cycle fails, they tell the patient that her uterus is “rejecting” the embryo and that she needs surrogacy to “treat” her implantation failure. Some even blame the patient for the failure, by saying that she did not rest properly, which is why her embryos “fell out” of her uterus.

Other clinics will fool the patient into thinking she got pregnant by giving her HCG injections after the transfer. The HCG in the injection appears in her blood stream, which is why her beta HCG blood test for pregnancy  comes back as positive. She is overjoyed she is pregnant, and when her HCG levels start dropping,  the doctor tells her this was a miscarriage, and that she was just unlucky. He then adds insult to injury by recommending that since the cycle " worked" ,  she should repeat another cycle with him. Infertile patients are emotionally vulnerable and often get snared by this tactic.

When one cycle fails, often the reason for the failure may just be a poor quality lab which created poor quality embryos. Rather than change eggs or the uterus, the patient would be much better off just finding a better IVF clinic !  However, doctors are understandably reluctant to refer their failures to better IVF clinics. They would much rather hang on to their patients ! They offer options which are designed to maximize their profit , and are not necessary in the patient's best interests .

Poor quality IVF clinics will often blame “ bad sperm “ for poor quality embryos. They will bamboozle the patient by talking about high sperm DNA fragmentation rates , or abnormal sperm morphology , and claim that this was the reason for the poor embryo quality. This is patently false, because when the same patient does ICSI at a better clinic ( with exactly the same sperm !) they make Grade A embryos !

Because patients are clueless, some of the “high-end” clinics take patients for a ride by doing expensive immune testing and running panels of genetic probes – all of  which just create lots of random noise and provide very little useful clinical information. However, patients are suitably impressed by computerized reports which are full of scientific gibberish. Sadly, doctors take advantage of the fact that patients are willing to clutch at straws because of their desperation,

Thus , women with a positive TB PCR test are “treated “ with antiTB treatment for months on end. Not only is this treatment completely uncalled for, it exposes them to a lot of toxic side effects – and wastes precious time .

When the embryos are poor quality, some doctors will tell the patient that we will transfer donor embryos into your uterus, so you don’t waste this cycle. By this time, patients are often fed up and frustrated. They fell helpless and powerless , and are happy to do whatever the doctor advises, because they so badly want to have a baby. They are happy to pay whatever extra fees the doctor charges, so that they can get pregnant, without thinking of the long-term implications of their decisions.

Bad doctors exploit their patient’s ignorance and vulnerability. Because the patient is desperate, they take advantage of this. They package their advise of using donor embryos as a technique to maximize the success rate, and patients are made to feel grateful for this. While this may work in the short term, these kind of decisions made on the spur of the moment under pressure may have long term adverse consequences for the patient. When doctors take eggs from patients and use them someone else without getting informed consent from either of the couples , they can improve their pregnancy rates – but will harm their long term reputation.

Patients are not stupid , and they exchange notes and talk to each other – and to the clinic staff as well. When they realize that the IVF doctor  resorted to these hanky-panky tricks, they get upset and angry.

IVF doctors need to get their act together . We owe this to our patients. We need to be honest and upfront with them , by providing better quality documentation and high quality counseling services .

Wednesday, November 09, 2016

Scrapping Rs 500 and Rs 1000 notes will reduce medical corruption


We all know that the Indian healthcare system is riddled with corruption. This exists at many levels. Doctors demand cash payments from patients under the table ( sometimes even while the patient is in the Operation Theater, when the family is desperate and vulnerable); corporate hospitals and diagnostic centers incentivise doctors to refer patients to them; doctors ask for kickbacks from specialists in order to send patients to them ; and pharma companies bribe doctors to prescribe their brands.

Now that these notes have been scrapped, the healthcare system will get its act together. This is good news for good doctors, because it will be harder for crooked doctors to ask for bribes, or to give them.

I am very excited with this move. The healthcare system was moribund, and needed an external shock to get it back on track. I am thrilled Dr Modi has provided this !

The doctor's dilemma: damned if you do, and damned if you don't


I was talking to a leading cardiologist about the recent controversy over treating patients with statins in order to lower their elevated cholesterol level.  He finds himself in a bind, because he doesn't believe in prescribing them routinely. However, if he decides not to "treat" the patient's high cholesterol level, since he doesn't feel the need to "fix" abnormal lab reports, then some patients feel he is being sloppy and casual, because he has overlooked this finding . On the other hand, if he does feel the need for prescribing a statin, other patients believe he is needlessly overtreating them !

Part of the problem is that the public has started thinking of doctors as being greedy and commercial mercenaries who no longer put their patients' interests  first. 

Along with the gratuitous and ubiquitous media-bashing, two other trends have contributed to this trust deficit. One is Dr Google, which means it's become extremely easy for patients to get information from websites. The problem is that a lot of this is wrong, unreliable and outdated, which is why it's hard for patients to translate what they read into actionable wisdom. They often lack the ability to interpret what they read in the right context, because they need to apply this to their personal circumstances, and this requires a lot of medical expertise and clinical experience - something which patients lack . To add to the poor patient's confusion, every doctor they go to has a different opinion. Lots of doctors are extremely good at bad-mouthing other doctors  and dissing their opinion, because they want to play the game of one-upmanship. By disagreeing with the earlier doctor, they want to prove that they are better. Every doctor positions himself as being the true expert , because they want the patient to come to them for treatment , rather than go to someone else.

This is why doctors find themselves in a bind. For example, he had a patient with a life-threatening cardiac arrhythmia, who needed a pacemaker put in. However, the patients' daughter felt he was advising this expensive and invasive procedure only in order to make money. Thus, though he was following textbook recommendations, and was sure that the patient would  benefit from this advanced life-saving technology, the patient was very distrusting.  This is why doctors find themselves between the devil and the deep sea, and it's become very hard to earn the patient's trust.

While patients are understandably worried about the risks, expenses and side-effects of medical interventions, they do need to remember that not doing anything also carries a risk - and sometimes this could be much higher . Choosing not to do anything is also an action - and is sometimes the worse option.


While a good doctor will try to factor in the patient's personal preferences, at some point, it's the doctor who needs to make the decisions, because the buck stops with him .  A senior doctor used a great analogy. He said that when  patients ask me why I have chosen a particular course of action, I remind them that when they buy a ticket to get on an airplane, they have the right to sit in their seat, but they don't have the right to ask the pilot questions about why he turned left, or why he turned right !

I think it is important that patients use Information Therapy to do their homework, so that they can quiz their doctor until they find a doctor they can trust. Once you have found this doctor, then you should respect his professional expertise and allow him the autonomy to do what he feels is right for you. This is the only way to create a win-win situation.


Tuesday, November 08, 2016

My IVF experience at Malpani Clinic

I never faced any major disappointments in my life, be it my family, friends, education or career, the first time i experienced one was in the form of miscarriage of an early pregnancy immediately after marriage and then never conceiving naturally  for several  years thereafter . It was emotionally very draining to accept that life can be so harsh on you. There is always an expectation that since i conceived  once, it may happen once again naturally. But all the efforts went without any positive results .

I started thinking of medical options, initially i did not understand the significance of choice of doctor and clinic. Therefore, i went to a doctor who was referred to me by one of my colleagues. When i visited the doctor for consultation, i had a few questions on process and procedure of treatment, which any patient would have, i was snubbed by the reputed doctor, he told me openly, don't try to be a doctor, its not necessary for you to know so many details..i was so disappointed, that i decided to discontinue the treatment.

 Then, i went to another doctor who also claimed to be infertility specialist, but when i went for consultation, i realised that his primary interest was maternity and natal care, and he practices in infertility only in a limited way. Moreover, he used see  patients side by side, one his assistants would be attending in the same room and one he would be responding, i felt very uncomfortable due to lack of privacy. At this stage i realised i am going to wrong places. I realised that i need some real specialist and a doctor who practices only infertility and has a good success record.

 then i began my research  to find the best clinic, my only objective was to find the best doctor in town and clinic which would help me identify the problem correctly and help me have my baby at the earliest as i had already wasted lots of precious time going to wrong places.

I recollected at the first instance itself of  Dr. Malpani's philosophy of patient information and awareness. I had  heard him once in one of conferences talking about how he believes in educating patients about the entire process and working as team rather than just treating his patients keeping them in dark unaware of what is going on with them , he also talked about several initiatives of creating patient education he had taken over years. Once i reached home i subscribed to his weekly mailers.

I found his approach quite impressive, and he became my immediate choice. But i did not want to rush to a decision, therefore i started reading almost all the material available on his website, mailers and blog, which i found quite useful. I also read and understood information from other sources. I also found that the information provided by him is not exaggerated and is in line with  several research outcomes from across the world.  It increased my confidence levels.

Now, i decided to write a mail to Dr. Malpani with my history and seek his opinion. Since i had already read feedback of other patients that he responds to mails promptly, it was not a surprise to me to receive a detailed response to my mail on the same day.

The exchange of mails continued for some more time and i got all my small and big queries resolved. I had still neither seen nor met the doctor in person, but my trust and confidence increased each time i got response to my questions.

Then we decided to take an appointment and meet him in person, i found that the doctor gave us enough time, encouraged us to ask questions and patiently responded to all my queries, a list which i had prepared and taken.

The tests prescribed were also minimum required and once he analysed them, gave us the options of treatment available to us, leaving the decision to us. I always worried about my career taking a hit during the process of treatment, as i had heard of many stories of ladies resigning from jobs as they were not able to manage treatment schedules and work simultaneously. But Dr. Malpani assured me that i can continue with my normal personal and professional routine during treatment. Initially i did not believe it, but once my treatment started i found that the number of visits and Procedures all were so systematic and planned, that it did not affect my work much. I continued with normal life.

I was briefed at every stage about what process i am undergoing, and why. Also the medication prescribed and what they intend to do. The process of monitoring my cycle  went on smoothly, with doctor changing the course of treatment as per my biological response.

The staff at the clinic also are very  cordial. The best part i liked is that when you phone clinic for some purpose, and tell your name, they immediately recall, inspite of having so much work pressure, this quality of staff is really admirable. This gives a sense of belongingness, that we are not just another number on register for them but a living person.

Then came the day of embryo transfer, it was first time i met Dr. Anjali that day. She assured me that the process will go on smoothly and there is nothing to worry about. The positive vibes she spread was truly contagious. While the transfer she kept on telling me that its going on fine, and asked me to relax. Her reassuring words were quite helpful. The process was so quick and smooth that i did not even realize its over. It was exactly opposite to the horror stories i had read  about experience of other patients in several other clinics.  Dr. Anjali made me feel comfortable through out, i think its her sheer dexterity that played the magic. I was told to relax for some time and then ready to go.

I followed normal work and personal routine normally for the next two weeks. I was in regular contact with doctor over mail. The doctor was always there. He ensured that i don't get obsessed about anything, put my anxiety to rest on several occasions and always assured me that things are moving fine and going right.
The treatment was successful the very first time, one of the two embryos had attached. After 6 weeks when i saw and heard the heart beat, tears rolled down, the feeling was inexpressible. I never expected that i would experience this day in my life. I thanked god for his blessings and Dr. Malpani for facilitating the same.

bharathi.g.shan@gmail.com





Monday, November 07, 2016

Healing healthcare by speaking up

Lots of doctors find what I say uncomfortable. I've found that calling a spade a spade makes you unpopular, because even while people may agree with you in their heart of hearts, they're not sure they want some of these dirty secrets being laundered in public. That's why doctors are uncomfortable when I'm willing to talk openly about some of the unethical practices which have tarred the reputation of our profession, such as kickbacks and commissions. They feel I shouldn't ruffle the feathers of the powers-that-be.

And, yes, I have paid the price for this. You do get hurt when you stick your neck out, but  I have accepted this reality.  Keeping quiet is much safer, but it makes it harder to live with yourself. How can you turn a blind eye to the flagrant abuse of the powers which patients have entrusted doctors with ?

I agree it's an uncomfortable topic, but I think not talking about it is the biggest mistake. In one sense we are engaging in the conspiracy of silence, and by keeping quiet we're allowing the bad doctors to continue to get away with underhand sneaky tricks, which harms the entire medical profession. It damages the good doctors as well. It's because of these unethical doctors that the entire profession gets tarred with the same brush.

In the past, the default setting between patient and doctor was one of trust, and a doctor had to really commit an egregious error before he was considered to be a bad doctor.

Today, most patients distrust doctors, and you have to work twice as hard in order to prove to him that you're not a crook. Only after you've done that will he then start trusting you. It takes a long time , and it's an uphill battle, and that's why it's important for us to speak up.

I'm fortunately at that position in my life where I'm financially well off. I practice medicine because I enjoy it. I don't need to do it in order to make a living anymore, and I guess I'm senior enough that I can afford to express my opinion . If I don't speak up, then why should I expect anyone else to do so ? And if I don't, then who will?

I agree it's much more comfortable to air your woes in private, and to moan and gripe about how the profession has gone to the dogs. I don't think that helps anyone. If there is a problem, the only way to solve it is by exposing it. We need to discuss it openly , so that we can work together to find a solution.

The reason that I'm willing to be politically incorrect is because I'm optimistic and hopeful. I think there are enough good doctors that we can find constructive solutions, and get rid of the malpractices which have riddled our profession.  I think we can get rid of the corruption if we're willing to stand up and make our voices heard.


Sunday, November 06, 2016

Why did this IVF patient receive such poor quality care ?

I received this email from a patient.

Greetings!! I am a regular follower of your blogs and appreciate the importance you give to availability of free information to your patients. I want advice from you regarding my failed IVF cycle here in Delhi,

I am 34 years old and went through my third IVF cycle in a renowned Delhi clinic. My second IVF cycle which happened earlier this year was a success (transferred 2 AA embryos on day two), however, it ended in a miscarriage at 7 weeks due to detection of no heart beat.

I underwent my third IVF cycle recently and was given the prognosis of poor ovarian reserve. My AFC on day two  typically lies between 10-11. I was given gonal-F (350 IU) for 11 days and 10-12 eggs were retrieved, out of which only 2 were deemed good enough (AA quality) to be transferred. Since only my two embryos were good enough,  2 (AA quality) donor eggs were fertilized using my husband's sperms and they were transferred as well. The doctor told me that sometimes through 'co-culturing'  of both mine and donor eggs,chances of implantation increases. So in total 4 embroys (all grade A) were transferred on day 2. My endometrium lining was described as 'beautiful' and 'perfect' by the doctor.

As a rule the clinic does embryos transfer only on day 2. They has also used special 'GLUE' which would increase the implantation chances. According to them, they had done all best they could do to maximize pregnancy in my case. But still, I fail to understand why my IVF failed....when everything looked so perfect.

I seek your valuable advice  as I am feeling very helpless and dejected. 


Can you identify all the reasons why this patient received poor quality treatment ?


Here are the red flags which show that this doctor is taking her for a ride.

A patient can have either 10 eggs or 12 eggs - you cannot have 10-12 eggs !  Why is her doctor fudging numbers ?

There is no medical technique for grading egg quality - eggs are either mature or not.  Her doctor seems to be making up these " AA quality " grades !

No good doctor will ever transfer embryos from both a patient's eggs and donor eggs at the same time - this is against the ICMR rules !

Using embryo GLUE sounds very clever, but has never been shown to work. It just allows the doctor to charge a lot more.

Finally, no good doctor transfers embryos on Day 2 !

The biggest tragedy is that it continues  to be so easy for IVF doctors to take even intelligent patients for a ride !






Saturday, November 05, 2016

DoSelect raises a seed round

Dr. Aniruddha Malpani, a Mumbai Angel investor stated, “We’re very excited about investing in DoSelect. Hiring great coders is the key to every company’s success in this day and age, where technology is becoming an organisation’s competitive advantage. DoSelect’s cutting edge platform is aiding HR teams understand in granular detail, why they should or should not, hire a particular engineer.”

Friday, November 04, 2016

Why do doctors charge so little ?



Both doctors and patients have completely different perspectives as regards how much they should be paying for medical services.

The public, the press and the politicians feel that doctors have become greedy and mercenary, and are just out to make money.

A doctor has a completely different perspective ! After all, he is potentially saving a human life, and how can anyone put a value on human life. Isn't that irreplaceable, and shouldn't that make his services priceless? He can't understand why a patient grudges paying the doctor his professional fees.  Isn't he providing a service which goes far beyond delivering monetary value ?

When we are healthy , we don't think about the medical services we may need . We expect to remain well, which means we take our health for granted . We save money in order to plan our holidays, but we don't budget for having to spend any money just in order to remain healthy. This is why when we fall ill,  it comes as a bit of a shock , because it is unexpected.  We go to a doctor to help us to get better, but it seems a little unfair that he charges us just to get us back to normal ! After all why should we pay so much money just to go back to being healthy , which was our default status ?

This is the crux of the issue . Health is priceless , and that's why it becomes so hard to put a price on it. Doctors don't practice medicine just in order to make money. They want to be healers, and they're happy when their patients get well . However, they do expect to be paid for their services - after all , this is their profession , and their only source of earning their daily bread and butter.

They also can't understand the fact that when doctors are found to be medically negligent, the courts will charge them an arm and a leg for their deficient medical services, because of the harm they have caused to the patient. However, but when the doctor salvages the patient's arm ( for example, after a traumatic injury) the patient pays his fees very grudgingly - and this is a tiny fraction of the penalty a court levies ! Why these double standards?


The problem is that patients believe that healthcare is a right, and they should not have to pay for it. They feel entitled to their good health,  and it hurts them to have to pay for something they have taken for granted all their life. We don't mind paying for an expensive TV , because we think it adds value to our life - but we grudge every single paisa the doctor charges us, because we think it has gone down the drain.

Let me end with this great story. A doctor saves the life of a very rich man who was choking on a bone in a restaurant by performing the Heimlich maneuver skillfully. The grateful man asks him - Thank you so much for saving my life doctor. How much do I owe you ? And the doctor says - Just pay me half of what you were willing to when you were choking to death !


Both doctors and patients have completely different perspectives as regards how much they should be paying for medical services. The public, the press and the politicians feel that doctors have become greedy and mercenary, and are just out to make money. A doctor has a completely different perspective ! After all, he is potentially saving a human life, and how can anyone put a value on human life. Isn't that irreplaceable, and shouldn't that make his services priceless? He can't understand why a patient grudges paying the doctor his professional fees. Isn't he providing a service which goes far beyond delivering monetary value ? The problem is that when we are healthy , we don't think about the medical services we may need . We expect to remain well, which means we take our health for granted . We save money in order to plan our holidays, but we don't budget for having to spend any money just in order to remain healthy. This is why when we fall ill, it comes as a bit of a shock , because it is unexpected. We go to a doctor to help us to get better, but it seems a little unfair that he charges us just to get us back to normal ! After all why should we pay so much money just to go back to being healthy , which was our default status ? Health is priceless , and that's why it becomes so hard to put a price on it. Doctors don't practice medicine just in order to make money. They want to be healers, and they're happy when their patients get well . However, they do expect to be paid for their services - after all , this is their profession , and their only source of earning their daily bread and butter. They also can't understand the fact that when doctors are found to be medically negligent, the courts will charge them an arm and a leg for their deficient medical services, because of the harm they have caused to the patient. However, but when the doctor salvages the patient's arm ( for example, after a traumatic injury) the patient pays his fees very grudgingly - and this is a tiny fraction of the penalty a court levies ! Why these double standards? The problem is that patients believe that healthcare is a right, and they should not have to pay for it. They feel entitled to their good health, and it hurts them to have to pay for something they have taken for granted all their life. We don't mind paying for an expensive TV , because we think it adds value to our life - but we grudge every single paisa the doctor charges us, because we think it has gone down the drain. Let me end with this great story. A doctor saves the life of a very rich man who was choking on a bone in a restaurant by performing the Heimlich maneuver skillfully. The grateful man asks him - Thank you so much for saving my life doctor. How much do I owe you ? And the doctor says - Just pay me half of what you were willing to when you were choking to death !

Read more at: https://www.docplexus.in/#/app/posts/e4014c3b-da0a-44cf-bf1b-c35c7b3358eb
Copyright 2016 © Docplexus
Both doctors and patients have completely different perspectives as regards how much they should be paying for medical services. The public, the press and the politicians feel that doctors have become greedy and mercenary, and are just out to make money. A doctor has a completely different perspective ! After all, he is potentially saving a human life, and how can anyone put a value on human life. Isn't that irreplaceable, and shouldn't that make his services priceless? He can't understand why a patient grudges paying the doctor his professional fees. Isn't he providing a service which goes far beyond delivering monetary value ? The problem is that when we are healthy , we don't think about the medical services we may need . We expect to remain well, which means we take our health for granted . We save money in order to plan our holidays, but we don't budget for having to spend any money just in order to remain healthy. This is why when we fall ill, it comes as a bit of a shock , because it is unexpected. We go to a doctor to help us to get better, but it seems a little unfair that he charges us just to get us back to normal ! After all why should we pay so much money just to go back to being healthy , which was our default status ? Health is priceless , and that's why it becomes so hard to put a price on it. Doctors don't practice medicine just in order to make money. They want to be healers, and they're happy when their patients get well . However, they do expect to be paid for their services - after all , this is their profession , and their only source of earning their daily bread and butter. They also can't understand the fact that when doctors are found to be medically negligent, the courts will charge them an arm and a leg for their deficient medical services, because of the harm they have caused to the patient. However, but when the doctor salvages the patient's arm ( for example, after a traumatic injury) the patient pays his fees very grudgingly - and this is a tiny fraction of the penalty a court levies ! Why these double standards? The problem is that patients believe that healthcare is a right, and they should not have to pay for it. They feel entitled to their good health, and it hurts them to have to pay for something they have taken for granted all their life. We don't mind paying for an expensive TV , because we think it adds value to our life - but we grudge every single paisa the doctor charges us, because we think it has gone down the drain. Let me end with this great story. A doctor saves the life of a very rich man who was choking on a bone in a restaurant by performing the Heimlich maneuver skillfully. The grateful man asks him - Thank you so much for saving my life doctor. How much do I owe you ? And the doctor says - Just pay me half of what you were willing to when you were choking to death !

Read more at: https://www.docplexus.in/#/app/posts/e4014c3b-da0a-44cf-bf1b-c35c7b3358eb
Copyright 2016 © Docplexus
Both doctors and patients have completely different perspectives as regards how much they should be paying for medical services. The public, the press and the politicians feel that doctors have become greedy and mercenary, and are just out to make money. A doctor has a completely different perspective ! After all, he is potentially saving a human life, and how can anyone put a value on human life. Isn't that irreplaceable, and shouldn't that make his services priceless? He can't understand why a patient grudges paying the doctor his professional fees. Isn't he providing a service which goes far beyond delivering monetary value ? The problem is that when we are healthy , we don't think about the medical services we may need . We expect to remain well, which means we take our health for granted . We save money in order to plan our holidays, but we don't budget for having to spend any money just in order to remain healthy. This is why when we fall ill, it comes as a bit of a shock , because it is unexpected. We go to a doctor to help us to get better, but it seems a little unfair that he charges us just to get us back to normal ! After all why should we pay so much money just to go back to being healthy , which was our default status ? Health is priceless , and that's why it becomes so hard to put a price on it. Doctors don't practice medicine just in order to make money. They want to be healers, and they're happy when their patients get well . However, they do expect to be paid for their services - after all , this is their profession , and their only source of earning their daily bread and butter. They also can't understand the fact that when doctors are found to be medically negligent, the courts will charge them an arm and a leg for their deficient medical services, because of the harm they have caused to the patient. However, but when the doctor salvages the patient's arm ( for example, after a traumatic injury) the patient pays his fees very grudgingly - and this is a tiny fraction of the penalty a court levies ! Why these double standards? The problem is that patients believe that healthcare is a right, and they should not have to pay for it. They feel entitled to their good health, and it hurts them to have to pay for something they have taken for granted all their life. We don't mind paying for an expensive TV , because we think it adds value to our life - but we grudge every single paisa the doctor charges us, because we think it has gone down the drain. Let me end with this great story. A doctor saves the life of a very rich man who was choking on a bone in a restaurant by performing the Heimlich maneuver skillfully. The grateful man asks him - Thank you so much for saving my life doctor. How much do I owe you ? And the doctor says - Just pay me half of what you were willing to when you were choking to death !

Read more at: https://www.docplexus.in/#/app/posts/e4014c3b-da0a-44cf-bf1b-c35c7b3358eb
Copyright 2016 © Docplexus

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