Thursday, December 22, 2005

My doctor told me all my reports are normal

I offer a free second opinion to infertile couples on my website. I request them to fill in their medical details, so I can guide them as to their next course of action. Unfortunately, I find that lots of patients are completely clueless about their test results. The commonest excuse they give is - " My doctor told me they were all normal, but I don't know the actual values."

I feel there are two reasons for this sad state of affairs: 1. many doctors take a patronising attitude and believe that patients will not understand their results, so that just telling them they are " normal " is enough.
2. patients don't bother to ask for details.

This is not acceptable, and it's important that you know what your actual results are, for many reasons. Remember that the eye only sees what the mind knows, and even though your test results may fall in the normal range, they still need to be interpreted correctly, and your doctor may not be doing this. For example, patients with a common disorder called PCOD ( polycystic ovarian disease) will often be told that their blood tests for measuring their levels of FSH ( follicle stimulating hormone) and LH ( luteinising hormone) are "normal". However, even though their levels may be in the normal range, they are actually still abnormal when interpreted intelligently, because the ratio of LH to FSH is abnormal. However, because their doctor did not consider this diagnostic possibility, he did not make this diagnosis ! This ends up hurting the patient !

Patients often complain that doctors do not give them the results. The best way of preventing this problem is by making a request in writing. By law, your doctor has to give you a copy of your records, and there is no reason why he should not do so ! However, it's easy for the clinic to "overlook" verbal requests, which is why it's important to document this request in writing !

Good doctors and bad doctors

Even if we assume that all doctors are technically competent, the major difference between a good doctor and a bad doctor is how they handle the patient's emotional status. We all know that patients are emotionally very vulnerable when they are sick, and they rely completely on their doctor for his professional advise. A bad doctor will exploit this vulnerability, and often scare or precipitate the patient into taking action which is in the doctor's best interests ( and not the patient's) - for example, doing bypass surgery because the patient has chest pain and is in the ICU. A good doctor, on the other hand, is one who is empathetic, and will let the patient know that he understands the patient's pain, and will support him in his illness with competent treatment and sound advice.

Thursday, December 15, 2005

Sending books to India

So how does one go about finding cheap books which would be of use to people living halfway across the world ? The best option is to buy books from library book sales. Not only is this a lot of fun, you can get great books very inexpensively ! You can use the brilliant website at to find the nearest book sale. Do your good deed for the year !

Proud to be Indian !

Agatsya - Project Summary: "Imagine the explosion in innovation and creativity if India could unleash the untapped potential of its gifted population by transforming its education system !" Here's a very bright person, who is using simple techniques to educate village children in India ! Success breeds success, and I hope more people will replicate his ideas all over the world. While this may not be as sexy as the MIT $ 100 laptop for village kids, it has the power to do much more good !

Doctor - please tell me what to do !

One of the commonest questions my patients ask me is - " Doctor, please tell me what to do ! " Some phrase this as, " What would you do if you were in my place ?" While it's easy for me to tell people what to do ( I know most doctors enjoy this !), this is not my style. I believe in non-directive counselling , especially when dealing with such a personal and private area as making reproductive decisions, where treatment is elective, and every couple needs to decide for themselves as to what will give them peace of mind. Patients who are mature understand this, and are happy to use me as a sounding board off whom they can bounce off their options. Others, however, want someone who will tell them exactly want to do, and go off in search of a doctor " who knows more" than I do. I guess doctors get the patients they deserve - and patients get the doctors they deserve !

M-Bag - and how this can change the world !

We all know that books can change the world - but books are expensive and difficult to find, especially in the developing world. People living in the US ( especially citizens from India) revel in the wealth of books they have access to in the US - and many would like to send these books to their friends and relatives back home - and even donate them to the schools and colleges they passed out from. After all, books are available in the US for a song if you know where to look - library book-sales, for example, are a great place to find superb books , for pennies on the dollar. However, shipping books from the US can be an expensive proposition, and this deters most people, as a result of which they often trash books which could change the life of a school child in Africa or India.
Fortunately, the US Government has a very special postage rate for book shipped overseas. This is called the M-Bag rate, and it costs only about 1 dollar to ship a pound of books ! Most people are unaware of this special rate, which is why it is still very under-utilised.
Here's how to do it.
Shipping books (Borrowed from Johannes [[email protected]])

" I sent all the books and other printed stuff via M-Bag (US Mail's "Mail Bag") and here are my experiences:

# M-Bag is one of the cheapest shipping methods available
# First go to your local U.S. Post Office and ask them whether they serve M-Bag
# If yes, pick up a few bags for free, don't buy boxes
# Go to a local supermarket and get old cardboard boxes for free (they shouldnt be huge, but sturdy)
# Get some heavy-duty duct tape rolls (the silver or black ones used for construction work or gig wiring) from a local hardware store
# Pack your books and printed papers (and whatever else you like, since noboday really checks at the Post Office -- at least not in NY) into the boxes. A box should not be too heavy, but it should be full and contents should not have room to move.
An M-Bag can have a maximum of 66 lbs, but packing the books into smaller and lighter units makes handling and shipping a lot easier. Your Post office provides you with any number of M-Bags you wish, so there's no need of stuffing big and heavy boxes in a bag.
# Label each box with delivery address and name, since Bags can tear open
# Massively seal and reinforce the boxes with duct tape. (A lot of work, but it pays off in the end: I received all boxes (and books) completely intact, no damages)
# Put one box in each M-Bag, tighten the bag with one or two knots, and fill out the M-Bag label you got from the Post Office (one for each bag). The M-Bag label will attached to the outside of the Bag at the Post Office, after paying.
# Drag the M-bags, filled with your boxes, over to the P.O, and send them: One lb. costs about one dollar ( no visa or mastercard accepted at most Post offices)
# Four to six weeks later the M-Bags will arrive at the destination. Again, in my case, all the bags, and the boxes and books inside, were completely intact and in original condition."
Michael Patterson, my friend who lives in the US, regularly send us books for HELP. He does this purely as a labour of love - I just wonder why more people don't do the same thing ! Sometimes the US Government can be very enlightened - it is the only country in the world which provides such inexpensive shipping for books !

Thank you Amazon. com !

The other website I love ( and use a lot of) is I love books - and need to buy lots for HELP - the Health Education Library for People. Unfortunately, books on patient education are very hard to find in India, which is why I need to buy them in the US - the booklover's paradise. The problem is that new books are very expensive, and I just cannot afford them ! A friend of mine, Mr Michael Patterson then pointed out to me that is the world's largest second-hand book store ! I now buy all the books we need for HELP from amazon second-hand ( pre-owned is the politically correct term I believe !) We save a lot of money, and this was we can afford to get many more books than we otherwise would be able to !

Why I love google

I am a big believer in the power of information, which is why I run HELP, the world's largest patient education library. The reason I love google is that it's made so much health and medical information so easily accessible to patients. Armed with just a computer with an internet connection, today's well-informed patient has access to much more medical information than even a doctor in the world's leading hospital did just 10 years ago ! Search engines in the past were complex and difficult to use. Google's simplicity allowed many more people to tap into the vast storehouses of medical and health information available on the internet. Allowing such easy access to information has allowed google to dramatically change the doctor-patient relationship - for the better, in my opinion. Today, patients can be as well-informed as they choose to be - and they don't have to depend upon their doctor anymore for educating them ! Knowing that so much information is available - information which can be reliable, updated and easy to understand ( if you know where to look) can empower patients to make their own decisions !

Wednesday, December 14, 2005

How patients irritate their doctors

I feel I am an empathetic and concerned doctor, and try to take good care of all my patients. One of my patients just called me at 10 pm to report, " The medication you put my wife on 2 weeks ago has been causing her a lot of side effects. What can we do about these ?" I tried my best not to lose my temper, but I was curt on the phone and not very helpful. While I was not very proud of my bedside manner, it's the patient who was actually responsible for getting such poor medical advise. If he had been a little more considerate and respectful of my time, there was a lot I could have done to help his wife. Unfortunately, this is not going to happen, and I really don't want to have to deal with such a patient in the future. I am going to request him to find another doctor, who does not mind being troubled at such a late hour by someone who has no consideration for the doctor's personal life. If you don't respect the doctor, why should you expect the doctor to respect you ?

What sort of patient are you ?

Pre-infertile - the worried well

I am now seeing an increasing number of couples who do not have any medical problem, but are worried about their fertility. I call these couples "pre-infertile". This is not a word described in a medical textbook, but I think it describes them well. They are worried that they may have problems conceiving, which is why they are seeking medical advise . These are the "worried well" - they don't have an illness, but are concerned that they might. All they really need is an explanation about the fact that Nature takes time to make a baby, and some reassurance; and for most, this is enough to help them promptly get pregnant on their own ! Others will want tests done to confirm that all is well, and even though I don't feel this is an appropriate use of medical testing, sometimes it's worth it for the peace of mind it gives them !

Dealing with your doctor - professional or technician ?

I have noticed there are two kinds of patients: those who treat their doctors as professionals; and others who treat their doctors are technicians. Actually, both models are fine, depending upon how sure you are about your own medical decision ! You pay a technician to carry out a certain skilled procedure with technical competence, and this is one of the key functions of a doctor. However, a doctor can also provide you with guidance and advise, and this is where he behaves as a professional. Finding good technicians is relatively easy - finding a doctor who is a professional is a little harder !

Tuesday, December 13, 2005

How demographic "experts " mislead us

There is a hue and cry going on in India about the unbalanced sex ratio and how it will adversely affect "girl children" in the future.( As an aside, aren't all girls children ? isn't using two words when one will do ridiculous ? it's like saying "men adults" !) These demographic experts warn of increased instances of rape and prostitution, and their scare techniques have resulted in miles of newspaper coverage.
It amaze me how short a memory we have ! Just a few years ago, these same demographic experts were warning us of the danger of unbridled population growth; about how the "population explosion" would kill the country; and how we needed to aim for ZPG -" Zero Population Growth". In just a few short years, these same "extra" citizens have become our most promising asset, and " shining India" now reaps the benfits of this "demographic sweet spot" it finds itself in - thanks to the fact that the average citizen blissfully ignored the "expert's " advise !

The world's largest eye care delivery system

The world's largest eye care delivery system. " Started as a modest 11 bed eye hospital in 1976, Aravind has grown rapidly to become the world's largest eye care system. In the year 2004, Aravind Eye Hospitals handled 1,635,599 outpatient visits and performed 228,894 surgeries."
Not only are they extremely efficient, they are also very service oriented, and as a result of a unique fee system and effective management, Aravind is able to provide free eye care to two-thirds of its patients from the revenue generated from the other third of its paying patients !
Aravind follows the principle that large volume, high quality service result in low cost and self-sustainability. Aravind's network of hospitals has the distinction of being the most productive eye care organisation in the world, in terms of surgical volume and the number of patients treated.
The world's hospitals can learn how to provide quality and affordable medical care to patients from Aravind !
Why aren't more hospital managers and doctors visiting Aravind ?

Monday, December 12, 2005

Why Your Doctor Thinks I'm Crazy!

Why Your Doctor Thinks I'm Crazy!: "Many doctors look down on self-educated patients.

At one point in my treatment, my regular practitioner suggested I visit another doctor to get a second opinion. So my husband called his internist and asked, 'who is the best person you know to deal with thyroid disease.' 'Me, of course,' said the internist. (Doctors are so modest!)

'But up front, I want you to know that my wife is very informed about things, she reads a great deal about thyroid disease,' my husband said.

'Aha,' he said. 'She's a petit papier woman,' said the doctor.

My husband inquired as to what the doctor meant by this. The doctor explained that women who come in with papers, notes, etc. to show to the doctor are often referred in a derogatory way as 'petit papier' (little papers, in French) women. He said most doctors did not like 'petit papier women,' as we're too 'high maintenance.'"

Should You Change Doctors?

Should You Change Doctors?: "'C' if your needs are being met.

A doctor/patient relationship is a lifelong relationship for someone with chronic arthritis. Since the illness is chronic, and without a cure, regular appointments are scheduled with your doctor to diagnose and problem-solve. It's a process and a journey you take together with your doctor. It is imperative that your needs are being met. Consider the 6 C's"

How To Avoid Long Waits at the Doctor's Office

How To Avoid Long Waits at the Doctor's Office: "Hate waiting around at the doctor's office? Here are a few simple steps that can help you avoid a long wait and expedite your trip to the orthopedic surgeon's office."

Patient Education - Can You Know Too Much?

Patient Education - Can You Know Too Much?: "Patient education is for better understanding. It may be time to find a new doctor if you genuinely feel you are smarter than your doctor and are unable to build good rapport. Consider, though, that patient education may have improperly empowered you. Recognize that patient education is for the purpose of better understanding. Patient education must not diminish the role of your doctor who ultimately must lead, direct, and decide the best course of medical treatment for you. In the end, you must be able to trust your doctor and respect his advice. It is with that trust and respect that you build a strong doctor-patient relationship."

Sunday, December 11, 2005

Port in the Storm: How to Make a Medical Decision & Live to Tell About It

Port in the Storm: How to Make a Medical Decision & Live to Tell About It: This is one of the wisest books I have seen, dealing with one of the most complex topics in medicine - how to make a decision.
Dr Giller eloquently describes the 6 key steps in making a medical decision:
Step 1 - Identify your options
Step 2 - Identify the tradeoffs
Step 3 - Discovery of Data
Step 4 - Interpretation of Numbers
Step 5 - Gathering your Beliefs
Step 6 - Contemplation of Meaning
The book is very well and lucidly written, and empowers patients to make their own decisions for themselves.
Realise that everything has risks, but armed with the information in this book, at least you will be able to take on the risks intelligently !

Friday, December 09, 2005

How useful are consumer health libraries in the age of google ?

I run the world's largest free patient education library, HELP ( Health Education Library for People) in Bombay, India. We are trying to find corporate partners who will help us to reach out to more people, so that more people will make use of the free services we provide. However, a common refrain I often hear is - " Now that so much information is available online and can be found so easily with google, what's the need of a library like HELP ? "
Actually, the need for real-world libraries like HELP will increase even more. I feel both online information and print libraries have complementary roles, and they are not in competition with each other ! After all, the very fact that google now wants to digitise millions of books and put them online simply corroborates the fact that books are alive and well !
In fact, the person who searches google to confirm that what their doctor is telling them is correct is exactly the sort of person we want to reach out to !
HELP can offer many additional services to such patients, who are seeking more information.
Often patients get lost on the internet ! They end up at unreliable sites and may end up misinforming themselves, because they are not sophisticated enough to separate the wheat from the chaff. Morever, since so much of the information is US-centric, they cannot find information which is relevant to Bombay !
Also, while it is true that information on websites is instantly available, 24/7, much of it is not detailed or comprehensive enough. A published book, from a reliable author, on the other hand, is a complete information-rich educational product !
Also, a librarian is a "learned intermediary " who can help you hit pay-dirt quickly ! After all, no one wants to waste time searching - you want to "find " stuff !
Just like law books will not make lawyers redundant , the easy availability of information on the internet will not make libraries redundant either !

Lab tests - what you need to know

What you need to know about lab tests : "Understanding why a medical test has been ordered can improve your attitude and preparation for the test. Being well prepared also helps you feel more relaxed and in control of the situation. Ask your physician to explain the reasons for your test and how the test will be conducted."

Thursday, December 08, 2005

A look at the modern doctor who doctors ethics

A look at the modern doctor who doctors ethics:
“Thou shall not steal,” The good Lord said,
But look, I need rich meals.
Besides, I have a better head,
His patients I should steal.
“Like brothers you must treat your mates,”
The good God stoutly said.
Come to my clinic, read my rates,
I charge my patients that much less,
To lure them from my mates.
“You simply cannot advertise,”
The law so very clearly states.
My trumpet I shall so disguise,
With cunning words I’ll self-inflate,
What fault will you then find?
'As doctors you’ll not give kickbacks,”
Our Code has disallowed.
Be practical, look here old chap,
I’m young, I must erase this vow.
To live I must kick-back.
“You swore the Hippocratic Oath!”
The Lord in grief did weep.
“In dishonour you are deeply steeped.
You stole from mates for tarnished gold.
Do you know you’ve lost your soul?”

R. F. CHINOY, Department of Pathology Tata Memorial Hospital Parel, Mumbai 4000 12"

Issues in Medical Ethics

Urban medical practice
The doctor, fashionably attired,
With a long string of alphabets trailing his name,
Emerges from a fancy, air-conditioned limousine,
Driven by a liveried chauffeur.
He sees ‘cases only by appointment’,
In his air-conditioned consultation room,
But, despite the appointment, has little time to spare.
Fancily designed, attractive waiting room,
With television, video- recorder and glossy journals,
And, perhaps, toys for his jaded paediatric clients,
Is presided over by young, beautiful secretary,
Who prefers talking to her computer or the phone.
She collects sizeable fees before patients can enter the sanctum sanctorum,
And instils awe and fear in the already demoralised patient.
Nagged by outrageous competition,
The entry of young whipper snappers into his field,
And, to make matter worse,
The clutches of the Consumer Protection Act,
The doctor routinely lists a score or more of tests,
And prescribes an equal number of pills, potions and pokes,
Thus playing the game of safety - which
incidentally increases his revenue.
Listening desultorily to the patient,
Whilst he dreams of his club, his wife and other attractions,
Prods here, pushes there and lends an ear to the lub-dub
Ere he agrees, with ill-concealed glee,
To accede to the humble request for an
unmerited sick leave certificate - for an
extra cost, of course.
Finally, with a belch that's poorly suppressed,
He dismisses the patient with an airy wave and awaits the next.
Strange thought though it may seem, his patients
admire and adore him,
For he acquiesces to their demands,
And 'cures' rather than prevents.
And the richer he gets,
And the more opulent his materialism,
The greater the throng awaiting him each evening!
Is this really what the public desire?

P Thirumalaikollundusubramaniam, Gizan, Saudi Arabia,
A Uma, Madurai Medical College, Madurai 625 020

Tuesday, December 06, 2005

The doctor as salesman

It may upset many patients, but the fact does remain that one of the roles a doctor plays is that of a salesman. After all, the doctor needs to convince the patient to follow his medical advise. Now, many doctors are extremely good at this; and if you have the good fortune to have a good doctor ( who is a professional and will put your best interests first), this is great, because he will skillfully convince you to do what is in your own best interests.
However, if you are unlucky and have a bad doctor, this same skill can be very destructive, because he may end up convincing you to undergo unnecesary surgery, for example.
This is why it's so important to behave like an enlightened customer when seeking medical care . Caveat emptor - let the buyer beware - is equally applicable to medicine !

eMedicine - develop a differential diagnosis

eMedicine develop a differential diagnosis: "Develop a Differential Diagnosis"
Is your doctor stuck and can't figure out what your problem is ? Ask him to check put this site for more suggestions, if he is stumped !

The McKinsey Quarterly: A foundation for public health in India

A foundation for public health in India

* India's public-health system, much improved since the country's independence, is now threatened by a shortage of quality personnel.
* By improving the quality of public-health education and making the career path more attractive, India can encourage more professionals to enter and stay in the field.
* Plans are under way to develop a foundation that will launch new schools of public health and work to improve the quality of education in the existing schools..".

Monday, December 05, 2005

Recycling Drugs, A New Strategy

Recycling Drugs, A New Strategy: "Recycling Drugs, A New Strategy
by Jerry Flanagan. " It is estimated that $1 billion of unused prescriptions drugs are discarded each year while 1 out of 4 seniors must often choose between buying their prescriptions and paying for food and rent. Oklahoma, Louisiana and Ohio might have hit upon the kind common-sense solution to ease the pain of high-cost prescription drugs that could become a national model: reuse, recycle. Legislation in these states has implemented programs to collect unused drugs and get them to those in need."
An even easier way of saving billions more would be to buy the drugs from India - where they are available at one-tenth of the cost ! I wonder why the US government goes out of its way to protect the US "big pharma" industry at the cost of the well-being of its citizens ?

Business 2.0 - Magazine Article - Printable Version - The $50 Million Giveaway

Business 2.0 - Magazine Article - Printable Version - The $50 Million Giveaway: "$8M HOME PATIENT MONITORING
WHO: David Aslin and Paul Badawi, 3i, Menlo Park, Calif.
WHO THEY ARE: Aslin is a partner in 3i's West Coast office. Badawi, a former genetic researcher for the National Institutes of Health, joined 3i last year as an entrepreneurial fellow. 3i invests $1.6 billion a year in buyouts and venture deals, the majority in health care and IT.
WHAT THEY WANT: A wireless home-monitoring network for recuperating hospital patients.
WHY IT'S SMART: No one likes extended hospital stays. Not patients, not hospitals, and not insurance companies paying bills that can exceed $5,000 a day. For the critically ill, there's no way around lengthy visits. But thousands of other patients could be sent home early if they could be monitored at home or at a lower-cost facility. Badawi and Aslin envision a wireless transmitter that would attach to existing hardware such as portable ECG machines and heart-rate and blood-pressure monitors. The device would send data through a wireless router to a cluster of back-office servers. The servers would function like a call center, routing a patient's vital signs to the right nursing station or on-call physician. Trimming just two days off the typical 10-day hospital stay for stroke victims would be a service worth $2.7 billion.
WHAT HE WANTS FROM YOU: Between you and a partner, you'll need expertise in medical device technology and database management to get a working demo ready to pitch to HMOs or insurance companies. Half a million dollars in seed money should be sufficient to get that far. 'It's not the technology, it's the complexity of navigating the health-care system that's going to be difficult,' Badawi says. If you can sign up an HMO to test the system, 3i promises $7.5 million more to bring it to market.
SEND YOUR PLAN TO: [email protected]"
Want to become a millionaire - and improve healthcare at the same time ? Here's a great opportunity !

The Health Record Network

The Health Record Network: "Starting a Consumer Revolution

The ability instantaneously to access accurate and complete patient health care information is the key to the efficient delivery of quality health services. Despite unprecedented advances in information collection and dissemination technology over the past decade, and recognition of the importance of timely, accurate health care information to the successful provision of the most efficacious treatment, the health care industry in the United States, for the most part, still adheres to paper record keeping. The costs of this failure - untimely and even erroneous diagnoses, repetitive and often incomplete record development, an inadequate ability to monitor health care trends on a timely basis either on a individual patient or on a broader societal basis - need no longer be tolerated. The capability exists to develop a consumer-driven and controlled information data base that necessarily would improve immeasurably the ability to meet individual health care needs on a more timely basis while simultaneously providing a platform for the creation and delivery of innovative health care products and services."

Seductive promises - sounds like the e-healthcare siren song of 1999 all over again ?

informing healthcare | Yasnoff on eHealth

informing healthcare | Yasnoff on eHealth: "There are three categories of evaluation criteria that communities should consider in evaluating a potential health information infrastructure:
# Requirements – does the system do what is needed?
# Feasibility – can the system be built and operated?
# Financial – is there a way to pay for the system and sustain it?

Let’s start with requirements. To answer this question, the functions of the system (at least at a high level) must be defined. Folks experienced with the development of information systems know that there must be a statement of requirements before you start or you’ll never know when you’re done. In plain English, a requirement is something that you will be able to do AFTER you have implemented a system that you cannot do now.

There are at least five requirements in this context:
# 1) privacy
# 2) transition from paper records
# 3) access to information
# 4) incremental steps
# 5) universal availability"

A very good overview of how communities can go about implementing EMRs.

My Family Health Portrait

My Family Health Portrait allows you to create a personalized family health history report . " Information you provide creates a drawing of your family tree and a chart of your family health history. Both the chart and the drawing can be printed and shared with your family members or your healthcare professional. Used in consultation with your healthcare professional, your family health history can help you review your family's health history and develop disease prevention strategies that are right for you." A free rudimentary PHR from the US government. I am sure someone can polish it and make this much better ! A good idea for an IIT summer project !

Thursday, December 01, 2005

Moving Towards Collaborative Health - Microsoft's perspective

Collabortive Health - Microsoft's perspective aTechnology is transforming the healthcare industry at a rapid pace. But healthcare organizations need to
be able to take a more measured approach that balances the benefi ts that specifi c solutions offer against
issues such as cost, the potential for disruption, the impact on existing systems, and more. We recognize
that no healthcare organization can afford to take an all-or-nothing approach to technology adoption,
and that each organization has its own requirements, restrictions, and institutional needs.

Web Based Education for Physicians - Learning from Mistakes

Web Based Education for Physicians - Learning from Mistakes "Physicians historically do not learn from each other’s mistakes. Wu reported that only a minority of house staff informed attending physicians of mistakes. In another study, although ten of eleven physicians involved in major malpractice claims changed their practice in some way after an event, none talked to colleagues about the changes. Most experts agree that both individual and organizational learning from near misses and adverse events is important to creating a sustained improvement in patient safety." Here's a great and painless way of learning how not to make mistakes !

TIME Magazine -- When Doctors Say, "We're Sorry" Print Page: TIME Magazine -- When Doctors Say, "We're Sorry"" More and more hospitals are following the lead of pioneers like the Veterans Affairs Medical Center in Lexington, Ky., and Johns Hopkins in Baltimore, Md., in establishing formal policies requiring medical staff to promptly admit and apologize for mistakes. At a time when hospitals and doctors are desperate to reduce the rising costs of malpractice insurance and litigation, apologizing for medical mistakes may seem to some like legal suicide. But to a widening coalition of players on all sides of the issue--from doctors, hospital administrators and insurance executives to patient advocates, politicians and even trial lawyers--it may actually be a step in the right direction. Since many of these players believe malpractice lawsuits are motivated as much by feelings of frustration as by the almighty dollar, in their view, honesty may indeed be the best policy."
This is so much healthier for both doctor and patient - and wil help to restore the trust patients have in their doctors !

Wednesday, November 30, 2005

Medspeak - making sense of medical jargon

I recently had a patient who had a hysterosalpingogram done and she commented - " How do people think of names like this !" Medical jargon can be intimidating, but it wasn't invented to keep patients in the dark !

Patients often complain that they can never understand anything their doctor says. This usually because doctors use medical jargon --- but you should never get intimidated by this! You just need to remember that such jargon is simply a convenient shorthand which doctors ( and other health care professionals) use to communicate with each other. Since these words are often derived from the classic languages ( Greek and Latin), they may sound unfamiliar and difficult to understand, but if you devote enough time and take enough trouble, you can definitely do so. Remember that it's not a secret code which is being used to keep you in the dark! If you have difficulty in understanding medical terms, you can ask your doctor to help you. Nurses, or family members in the medical profession, can also provide guidance. However, the easiest way to go about making sense of the jargon is to sit and decipher it with the help of a medical dictionary and a medical encyclopedia: the effort can prove very worthwhile! Spelling counts, and the first and most important step is to find out the proper medical terms and their spelling. Therefore, ask your physician (or the nurse or assistant) to write these down, as related to your specific case.

The words - or terms - which make up the language of medicine are referred to as the terminology of the medical field, or medical terminology. Like every other language, medical terminology has changed considerably over time, but the majority of the terms are derived from Latin or Greek.

As with all words, most medical terms can be broken down into one or more word parts. Basically, there are four possible parts, and any given medical term may contain one, some or all of these parts:

1. Roots,
2. Prefixes,
3. Suffixes, and
4. Linking or combining vowels.

Thus, if we analyse the word hysterosalpingogram, we see:
hystero = uterus
salpingo = tubes
graph = picture, which means that this is the name for a procedure which is used to take pictures ( X-rays) of the uterus and tubes !

You can also learn how to make sense of medical jargon !

This Man Wants To Heal Health Care

This Man Wants To Heal Health Care: Brailer, is the "national coordinator for Health Information Technology in the Health & Human Services Dept. Yet his task is sweeping: Give every American an electronic record of their health care by 2014, and link all the records into one giant medical Internet, called the National Health Information Network Inc. (NHIN)." What a challenge - and what an opportunity !

HealthBlog - following in Microsoft's footsteps ?

HealthBlog: "Microsoft is leading the way in using technology to open the lines of communication between our employees and the doctors who care for them. Prior to joining Microsoft in 2002, I co-founded a company that did some pilot work with Microsoft on technology allowing MS employees to access medical information, securely exchange e-mail with their personal physicians, and even schedule and hold 'virtual office visits' with their doctors using video web conferencing. We learned a lot during the pilot. First and foremost, we learned that patients really like being able to correspond with their physicians by e-mail, and physicians enjoy providing clinical cognitive services electronically when they get paid for doing so. We also learned that such technology enhances the physician-patient relationship, and more importantly, that our employees didn't abuse physicians with unnecessary or unwarranted communication." If Microsoft can do this, why can't we ? "To help you remember to schedule your regular screening tests and blood donations, the College of American Pathologists encourages you to sign up for an e-mail reminder today. You can choose any date you like, and a message will be sent to the e-mail address you specify reminding you to schedule your screening test and/or blood donation appointment. " Clever use of technology - make use of it !

Really Personal PHRs - iHealthBeat - Daily News Digest on Health Care Information Technology

Really Personal PHRs - iHealthBeat - Daily News Digest on Health Care Information Technology: 'a marketing plan is crucial,' and health IT for consumers should be marketed as such.
We should look to a Procter & Gamble-type mindset of rich consumer insights to understand just what might make PHRs ( Personal Health Records) desirably 'personal' to consumers. P&G understand consumers' demands, as do the pharmaceutical companies that, whether you like it or not, have convinced consumers that they need prescription drugs for sleep deprivation and sexual dysfunction. " Sometimes patients may not know what's best for them - we need to educate and explain to them how PHRs can help them get better medical care !

Save the Patient card - print , clip and keep !

Save the Patient card Here's a useful resource you should carry in your wallet - it's likely to be more useful than a credit card when you visit your doctor !

At A Tipping Point: Transforming Medicine with Health Information Technology

At A Tipping Point: Transforming Medicine with Health Information Technology We are now seeing a renaissaince of interest in e-healthcare. Now that the technology is much more mature, and internet penetration far greater, are we ready to apply this technology to improving medical care ? Or are we going to make the same mistakes we did 5 years ago ? Are there enough doctors around who remember the lessons from the last time, to make sure we do a better job this time around ?

Healthcare Informatics: Customer Service

Healthcare Informatics: Customer Service: "'What patients wanted was to be able to talk to us, and we found patients are a lot smarter than we give them credit for,' says Barbara Walters, M.D., senior medical director. 'The patients write thoughtful, well-composed, insightful notes that to us are very surprising.' The quality of the emails also suggests that patients understand physicians' time constraints and inability to answer a bevy of messages from them, she notes."
I am glad that doctors are finally learning that patients are smart and intelligent - and capable of taking care of themselves ! As doctors, we need to give our patients the tools so that they can do so - and technology can help us to do this more efficiently. Doctors need to learn to use the web intelligently to reach out to many more people !

My Medical Record .com Patient Controlled Patient Managed Medical Record Information

Patient Controlled Patient Managed Medical Record Information: "The seven patient and consumer principles endorsed by the Personal Health Technology Council are:
1. Individuals should be able to access their health and medical data conveniently and affordably.
2. Individuals should be able to authorize when and with whom their health data are shared. Individuals should be able to refuse to make their health data available for sharing by opting out of nationwide information exchange.
3. Individuals should be able to designate someone else, such as a loved one, to have access to and exercise control over how their records are shared.
4. Individuals should receive easily understood information about all the ways that their health data may be used or shared.
5. Individuals should be able to review which entities have had access to their personal health data.
6. Electronic health data exchanges must protect the integrity, security, privacy, and confidentiality of an individual's information.
7. Independent bodies, accountable to the public, should oversee local and nationwide electronic health data exchanges. No single stakeholder group should dominate these oversight bodies, and consumer representatives selected by their peers should participate as full voting members.

'When all Americans have the ability to review their own medical records online, we then will begin to see a health care system that reduces disparities in medical care, and increases the quality of care for all Americans,' said John R. Lumpkin, M.D., M.P.H., senior vice president and the director of the Health Care Group for RWJF. 'People want to take advantage of health information technology, but they need to trust that the new information environment respects their privacy and ensures the security of their information. Therefore, the new health information technologies that are being created, as well as the health information environment itself, must focus on consumers' concerns about privacy, security, and personal control.' "

Sunday, November 27, 2005

Will praying help to improve a low sperm count ?

A patient just asked me if praying would help to improve a low sperm count. My knee jerk response was - Of course not ! But then I thought a little bit more about my reply, and modified it. " While praying may not help to improve the sperm count, it can definitely help you to cope with the problem - and its consequences - far better".

I feel that prayer, and belief in a higher being , provides hope and succour when doctors may fail - and as a doctor, I try to encourage my patients to make constructive use of these beliefs.

Saturday, November 26, 2005

Redesigning hospitals

While hopsitals can be very comforting, the biggest complaint patients have about hospitals is the fact that they are impersonal and bureaucratic.

I feel the best way of working around this problem is by allowing doctors to run the hospital. Today, hospitals are run by administrators, who are often only interested in the "bottom-line". Doctors, on the other hand, understand how important it is for them to keep their patients happy !

The best model would be a co-operative hospital, which is run by managers, but where the doctors are owners. Doctors could be treated as the shop-owners in a mall - the hospital would lease them consulting room space; as well as provide their patients with in-patient rooms, nursing care and theatre and lab facilities, for which they would be charged, but the ownership of the patient ( customer) would reside with the doctor.

Traditionally, most hospitals were started as small facilities, by individual doctors, to serve the needs of their own patients. This was a very successful model, because it allowed the doctor to provide his patients with personalised care very inexpensively, beause there were few overheads. However, as medical technology started growing by leaps and bounds, the capital equipment costs, space and infrastructure needed for taking care of seriously ill patients became so humoungous that these needs could only be met by large hospitals, which were very expensive to setup.

This is where governments, and then universities stepped in. While the purpose of government hospitals was to provide care to their citizens; and the goal of university hospitals was to further medical research and to train medical students and residents, corporates got on to the bandwagon and started setting up hospitals to earn profits.

We need to reinvent the hospital, and we can learn a lot from the hospitality industry, which offers tourists a wide range of options - all the way from inexpensive "bed and breakfast " accomodation to luxury upmarket 5 star hotels. It's a good idea to offer the patient a choice - and often for simple procedures ( such as childbirth and elective surgery), a simple basic hospital is far more cost effective.

This is why custom designed "day care surgery units" have done so well in the US. Why can't we extend the model and use it to manage simple medical problems which require hospitalisation ? We could have Level I hospitals, which would take care of the "bread and butter" basic problems; and the Level II hospitals, which would take care only of the seriously ill patients with complex problems. This would be a much more effective use of limited resources, and help to keep costs down !

This has been successfully done in India for many years; and an excellent example is the 100-bed Shusrusha hospital in Bombay, which provides very high quality medical care very inexpensively. Unfortunately, the current craze is to ape the West, and everyone is competing to build 5-star deluxe corporate hospitals , which cost the earth, and are prohibitively expensive !

Thursday, November 24, 2005

The doctor's power

Patients hang on to every word a doctor says, which means doctors wield immense power with what they say - and with what they don't as well ! Unfortunately, most doctors don't realise the importance and impact of their body language, because this is not something anyone teaches them, as a result of which they often mess up the verbal and non-verbal signals they transmit. Every doctor should remember that they are an "actor" in the consultation room, and they are performing for an audience of one - their patient !

OR-Live: Live and On-Demand Medical Healthcasts

If you've wanted to know what goes on in the operation theater, here's a website you'll love ! The Independent comments: "Major surgery has always been mystifying as well as frightening. A life hangs in the balance while the surgeon deploys his or her skills - but always in secret, behind closed doors. Now, anyone can get a grandstand seat at the operation itself. Like armchair travel, armchair surgery is a reality. Thanks to modern technology and the internet, it is possible to see for the first time how surgeons insert a knife into a patient's chest and stitch new blood vessels on to their failing hearts. Surgeons perform 3 million operations a year in Britain and most people about to go under the knife never question the competence of the person holding it. The website offers video footage and live broadcasts of operations as they should happen, but without the swooning relatives, bitching interns and conscience-stricken surgeons trying to do what's right for their patients."

Tuesday, November 22, 2005

The Indian healthcare industry is maturing !

This is from the Business Standard . " The Anil Dhirubhai Ambani Enterprise (ADAE) group is planning to foray into retailing of pharmaceutical products. Industry sources said most organised players in the market such as Planet Health, Apollo Pharmacies or Zydus Cadila group’s Dialforhelp had over 1,000 to 2,000 sq ft stores. A number of MNCs and other local companies is exploring the possibility of entering this highly lucrative retail business. Some of them are also scouting for partners and may enter the country very soon."

An organised drug distribution network will be very valuable for patients, as it will help to reduce the menace of spurious drugs.

However, this is going to be a very competitive space, and the retail drug network which pampers the patient is likely to thrive. Patients are going to demand amenities such as free home delivery, and this is unlikely to be a USP or differentiating factor. However, the network which invests in patient education ( for example, publishing printed materials about drugs and common diseases; offering their customers websites with a personal health record option so patients can access their medical data online; a drug-information helpline; SMS services on mobiles to remind patients to take their drugs on time; patient support groups to facilitate patient to patient networking; and real world events such as lectures and presentations by doctors on disease management ) will do very well !

Can you really trust your doctor ?

The secret of getting good medical care rests upon being able to trust your doctor - but how do you know if your doctor is really trustworthy ? There are 3 types of doctors:
1. honest and competent
2. honest and incompetent
3. dishonest

All of us would like to find a doctor who is honest and competent; and all of us fondly imagine that our own personal physician is in fact honest and competent ! But the sad fact is that some doctors are neither - and it's very hard for a patient to judge !

Thus, going by reputation or hospital affiliation is too dicey ( for example, the Head of the Department may be the head just because he is the hospital trustee's son-in-law ! ) A good bedside manner also is not enough ! Honest and incompetent doctors have excellent bedside manners, but poor clinical skills - and can mess up your treatment !

The most dangerous doctors are the ones who are dishonest. They may very well be competent and technically skilled, and they often have an excellent bedside manner ( because they need you to trust them unconditionally); but they only have their own interests at heart.

The only way to protect yourself, is to follow the axiom , "Trust, but verify !". You need to countercheck your doctor's recommendations , and this is why time spent doing some homework and research on the net or at your public library is so important. If what he says is corroborated by trusted authorities, then you can afford to be more trusting !

Sunday, November 20, 2005 Let's Put Consumers in Charge of Health Care Let's Put Consumers in Charge of Health Care " Businesses spend billions on health insurance. And what do they get for their money? A lot of unhappy employees. Workers fret about the quality of the care they receive, the burden of their out-of-pocket expenses, and the gaps in their coverage. For businesses, health care has become a lose-lose proposition: They pay way too much, and they get way too little. The problem is that the health care industry has been shielded from consumer pressure--by employers, insurers, and the government. As a result, costs have exploded even as choices have narrowed. But if companies embrace a new model of health coverage--one that places control over both costs and care directly into the hands of employees--the competitive forces that spur productivity and innovation in consumer markets can be loosed upon the inefficient, tradition-bound health care system. Moving to consumer-driven health care requires that companies revamp their health benefits in six ways: Give employees incentives to shop intelligently; offer a real choice of insurance plans; charge employees prices that accurately reflect the company's costs; let providers set their own prices; adjust payments for each enrollee based on need; and provide relevant information. " Here's a business case for why it makes economic sense to provide patient-centric healthcare ! Not only will we get happier patients, and happier doctors, we'll also end up saving money ! Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises: Books: Richard A. Deyo,Donald L., Ph.D. Patrick

What is wrong with American health care and how can we fix it? " Many recent books try to address this question. One of the central points of "Hope or Hype" is that "...the major reason for rising health-care costs and shrinking insurance coverage is the rapid introduction of new medical treatments, often before they can be adequately evaluated for effectiveness, safety, or cost."
The authors, a medical doctor and a social scientist, have had years of experience studying health care in the larger societal context. "Hope or Hype" focuses on what happens when we allow the hype in the media and the marketplace to overtake the good that medical advances can bring us. It tells the story of overmedicalization, wasted resources and greed. If you are thinking - problem, what problem? Start by reading "Part III - Useless, Harmful or Marginal: Popular Treatments that Caused Unneccessary Disability, Dollar Costs, or Death." The stories are first-hand accounts of what happened to medical researchers when they got in the way of special interest groups and big drug companies. The back stories surrounding those drugs and devices you see advertised on television are very interesting.
Deyo and Patrick have written this book for the general public, as well as for students and health care researchers. They provide an historical overview of our love of "technoconsumption" and our infatuation with the latest medical breakthroughs.
The final chapters address how we all can do better. For example, they suggest that decisions about using new drugs and devices could be "evidence-based" and that consumers could be better informed to help prepare them to participate in shared decision making. Finally, they suggest that the government could create a "Fed" for health care, a regulatory agency mandated to oversee the integration of new technologies in medicine while minimizing waste and potential harm."

Saturday, November 19, 2005

How does one market a free health education library ?

I run the world's largest free health education library, called HELP , in Bombay, India ( Our major problem is that very few people make use of our services - even though they are free ! What are we doing wrong ? How can we get more people to use HELP ? Is it that people don't value our services because they are free ? I don't want to charge for what we do, because I feel patients should have free access to health information !

Thursday, November 17, 2005

How a medical expert can reach out to patients using the web

Brachial plexus injury is a rare injury which sometimes occurs after birth. Obstetricians and pediatricians usually advise parents that they just need to "wait and watch" and the problem will resolve on its own. While this is forunately true for the majority of these children, there will be a minority who will suffer a life-long disability, because of severe nerve damage. This can be surgically corrected in these children, provided it is detected in time, and the children operated on early enough. Unfortunately, there are few experts who know much about this condition, as a result of which the parents are often misled by the well-meaning advise given to them by their pediatrician. In the past, as a result, these children would often end up receiving poor quality care; and by the time they reached a knowledgeable expert, a lot of time had been wasted.
I recently met a plastic surgeon who had treated over 150 of these children, and he was complaining about how pediatricians refused to learn. By the time he treated these children, their nerves had already been irreparably damaged, and parents were understandably angry and upset with their pediatrician for not referring them earlier. When I asked him what he had done to try to improve the situation, he claimed that he had given numerous lectures on this topic to pediatricians at medical conferences, but few of them bothered to listen, because this was not a very "sexy" topic !
However, rather than complain about how poorly informed pediatricians were, he could have tried to redress the situation by trying to reach the parents directly. The internet provides an excellent method by which concerned parents can reach out directly to the expert, without having to wait for a referral from their local doctor ( who may know very little about such a rare condition). An excellent example of an expert is Dr Nath, who has done a brilliant job in reaching out directly to affected parents. This is a win-win situation. Affected parents can directly contact an expert for a second opinion; and the expert becomes even more expert as he accumulates even more experience in dealing with this specific problem !
Doctors have a responsibility to educate their patients - the word doctor is derived from the root "docere", which means " to teach". Why do so many of us do such a miserable job of it ?

Why don't Indian doctors do a better job of marketing themselves ?

Everyone acknowledges that Indian doctors are extremely competent and skilled. A significant proportion of doctors practising in the US and the UK are of Indian origin; and Indian doctors have proven that their abilities are world-class. However, even though doctors in India are equally skilled, and offer their services at a fraction of the cost of what doctors in the US charge, why aren't they able to attract patients from the USA ? After all, if a patient from New York is willing to fly down to Mayo Clinic for treatment for a complex problem to get world class care from the "best" surgeon, then flying down to India is really not much more difficult, is it ? And Indian doctors have far more clinical and surgical experience than their Western counterparts , simply because of their huge workloads ( the one thing India is not short of is patients !)

I think the problem is simply one of perception - Indian doctors have unfortunately not done a good job branding and marketing themselves. In the past, this was because marketing in the West was an expensive proposition which was well beyond their reach. Also, Indian doctors did not get a chance to publish their experience in medical journals, because most of these were published in the West, which was not very interested in articles from Indian doctors.
Today, however, the internet has dramatically changed things ! Patients are now actively looking for information on their medical problems, so they can seek out the most experienced doctor for themselves. There are few geographic limitations; and Indian medical care is a bargain ! The internet is very democratic, and which means all websites have an equally good chance of showing up - doctors with bigger budgets no longer have an unfair advantage, since publishing a website is so inexpensive.
Unfortunately, this is an opportunity Indian doctors have not woken up to as yet. Though they pay lip service to "medical tourism", there is little they do to actually display their skills and expertise on the web.
An excellent example would be the Muljibhai Patel Urological Hospital in Nadaid, Gujarat. Even though urologists worldwide acknowledge this hospital is a world-leader in providing state of the art care for complex kidney stones, you would never figure this out by visiting their website ! Not only is it boring, there is very little information about kidney stones; and it's hard to find out much about the hospital. Not only is the website just brochure-ware , to add insult to injury, it's a very boringly done brochure ! It should have been written for the patient; with the focus being on educating the patient about their disease; and then explaining why the hospital is the best choice for treatment. Why are Indian doctors so good at hiding their skills and expertise ? What a wasted opportunity !

Championing "patient education " in India

Though everyone agrees patient education is vitally important, it's still treated as a step-child in India. Doctors only pay lip-service to it, and pharmaceutical companies use it purely as a tool to increase their sales. This is such a shame !
An investment in patient education is one of the most cost-effective ways of improving healthcare in India. Well-informed patients will take much better care of themselves - and information therapy will help to make medical care much more patient-centric.
This is a major opportunity for health insurance companies who are just entering the Indian market. It's a market which is all set to explode, as the Indian economy is booming; and more Indians are now clamouring for health insurance, because of the increasing costs of medical care.
The company which champions patient education can "own" this segment in India - and this can be financially very profitable as well !
It is true that this is a challenging area , and there are still many problems.
1. There are many different regional languages
2. Many people are still illiterate
3. Few patient educational materials have been published in India so far

Actually, this represents a major opportunity !

Producing high quality educational materials in India is easy, given the wealth of medical talent we have; as well as a huge pool of talented English writers. They just need to be married together, to be able to work as a team !
Translating the materials into regional languages is relatively easy, once they have been produced.
Innovative formats such as animated graphics can be used intelligently, to reach out to illiterates and semi-literates.
All this material can be sold; and also given away for free through the internet, so it can reach out to anyone who wants to access it. This will mean that the distribution costs are virtually zero - it's only the production costs which will need to be incurred.

A national network of patient education resource centers can provide the "real-world" underpinning to patient education, by acting as a reference center; and training patient educators and doctors. Ideally, every hospital should have its own patient education library - and this could be as simple and basic as a librarian or nurse, armed with a computer connected to the internet, who can help to answer patients' queries.

We have all the resources and manpower we need - now all we need is the desire to do so !

The title of this blog

My daughter asked me why this blog was titled The Patient's Doctor. " Aren't all doctors patient's doctors ? " Good question ! Actually, the title is a play on the term, "The Doctor's Doctor." This refers to the "super-doc" who takes care of other doctors; and to whom other doctors turn to for advise when they are stumped ! My blog is for doctors who understand that the sole purpose of their practise is to serve their patients - everything else comes afterwards !

When patients are ignorant - stop blaming the doctor !

I sometimes cringe when I see how little patients who have gone through an IVF cycle know about their own treatment. When I ask them simple questions like - " How many eggs did they collect ? What was the grade of your embryos ?" , the stock reply is - " We don't know, because the doctor never told us !" I feel there's little point in blaming the doctor. It would be far more constructive to say - " We don't know because we didn't ask !"
There's no point in criticising anyone - you cannot control anyone else's behaviour. However, you are responsible for your own actions - it's far more constructive to imporove your own behaviour !

Wednesday, November 16, 2005

Why do patients have such a low opinion of their own intelligence ?

Most patients are in awe of their doctors. They feel doctors are extremely intelligent, hard working experts, who are the fountainhead of all medical wisdom. This is why they often fail to cross-question their doctor; and I often get the impression ( when I review my patients' files ) that they seem to leave their common-sense and brains at home when they go to the doctor's clinic ! Why do patients have such a major inferiority complex ? Most of them seem to take it for granted that what the doctor tells them will "go over their head"; and asking their doctor questions is rude ! I tell my patients, " If you don't understand what I am telling you, the fault is mine - I am not doing a good job explaining." Remember, that nothing is so complex that it cannot be explained ! And if you don't understand what your doctor is saying, this does not mean he is smarter than you - it just means that he is not a good communicator, and needs to polish his professional skills !

The top 10 preventable health risk factors globally

The top 10 preventable health risk factors globally

A report from the World Health Organization (WHO), Comparative Quantification of Health Risks, which estimates deaths and disability from preventable causes of major diseases , compares the impact of 26 major risk factors, and lists the top 10 globally as:

* Childhood and maternal underweight.
* Unsafe sex.
* High blood pressure.
* Tobacco use.
* Alcohol.
* Unsafe water, poor sanitation and hygiene.
* High cholesterol.
* Indoor smoke from solid fuels.
* Iron deficiency.
* Overweight/obesity.

It's a sobering thought, but most efforts which would help to improve health globally have little to do with what the doctor can do in the clinic ! Doctors take a lot of the credit for the health of their patients, but we need to realise that we can have a much greater impact if we take a more holistic approach. Doctors are supposed to be the "health specialists", but a good engineer who can provide clean drinking water to a village ; or a clever marketing expert who can making smoking "uncool" for teens; or an entrepreneur who can provide white LEDs to illuminate rural homes instead of unsafe paraffin lamps can do far more good to improve the health of the community !

Phreesia - Changing the Patient Experience in the doctor's clinic

Phreesia - Changing the Patient Experience This is worth checking out ! " Phreesia installs Wireless enabled WebPads in the clinic's waiting areas. They provide everything the doctor needs, including the hardware and the wireless network. Their WebPads tie into their securely hosted Medical History application. Patients enter the cause of their visit and are prompted with a series of questions based on an elaborate decision tree. A report is then produced and sent to the physician with enough information to begin a focused patient interview, saving valuable physician time." Sounds cool - and instead of wasting their time being patient in the waiting room, patients can actually learn about their medical problems , since the computer can direct them to targetted websites ( based on their symptoms) which provide them with information which is relevant to their needs. And this is all free ! So what's the catch ? Read on...
All this is being sponsored by "Big Pharma" ! Thus, when patients input a description of their medical problem into the wireless laptop computer, based on their symptoms, the laptop displays a page with relevant health news items. The custom-built device not only allows drug companies to sponsor the health news offerings ( "Ask your doctor to prescribe this drug for you !") , it also sends a summary of the patient's complaint back to Phreesia's central server to be examined by its drug company clients ! Most people consider their medical records to be confidential, but Phreesia views them as market research. It hopes to sell the information to pharmaceutical firms looking to hone their drug rep sales calls and future ad campaigns.
What a shame that clever technology is being misused and manipulated for marketing purposes...

Tuesday, November 15, 2005

The Patient's Home: The New Healthcare Hub

The Patient's Home: The New Healthcare Hub" The Patient's Home: The New Healthcare Hub, a December 6, 2005 audio conference, will examine how healthcare organizations are using home monitoring technologies to improve care management and reduce healthcare costs.

Healthcare quality and access can be improved and healthcare costs reduced by moving care management functions away from provider offices and institutions and to the patient's home. Home monitoring technologies move care management processes away from costly centers of care. "

This will reduce costs - and also make medical care much more convenient for patients ! Medical care will truly become more patient-centric !

Leveraging technology to make doctors more productive

Everyone agrees that the healthcare industry in the US is a mess. This is a major multi-billion dollar opportunity and India can provide a solution , if we learn how to leverage technology intelligently to make our doctors more productive. Indian doctors are world- class; as is the Indian IT industry. If we marry these cleverly, we can significantly improve patient care all over the world. In the past, we helped to support healthcare in the US and the UK by exporting our doctors ( the "brain-drain"). We can now export our services instead.

Today, the major bottle neck for efficient healthcare delivery in the US are doctors. Doctors are few and far between, and are an expensive resource ( after all, it takes a lot of time and money to train a doctor) . How can we make better use of this scarce resource ?

Today, unfortunately, most of their time and energy is spent on paperwork (“documentation” ); and talking to insurance and HMO clerks for authorization. This creates a lose-lose situation. Doctors are unhappy and frustrated; and patients are angry because they perceive their doctors as being uncaring and rushed ; and are frustrated over the long waits for appointments. For example, it can take an infertile patient over 3 months to see a consultant in the UK today !

The solution I'd like to propose is the use of technology to leverage a doctor’s productivity. ( This would not apply for emergency situations, but for medical care for cold “elective” problems, such as fever, diarrhea, and chronic illnesses such as arthritis and asthma, which constitute about 90% of all medical care episodes.)

We need to change the model of the consultation – the entry point into the healthcare system. At present, a consultation is inefficient and time-consuming. Traditionally, this has been “ face to face “, but this is an archaic model. It’s time for a makeover ! After all, communication technology has changed everything else – why not this too ? Businessmen conduct conferences and meetings efficiently online – why can’t doctors and patients ?

We need to replace the consultation with a better alternative ! I agree this may cause a certain degree of discomfort , because the visit to the doctor is still the “holy cow” of medicine, because medicine is based on “doctor patient contact “. However, is this really needed ? Isn’t there a better alternative ?

Telephone diagnosis is now routine for many specialties , and has been proven to be safe and effective. This confirms that options to the traditional real world consultation are viable alternatives we need to actively explore.

I am going to offer my solution based on my personal experience. As an infertility specialist, I am a resource in scare supply. It takes me about 60 min to do a consultation, and I can manage to do about 4 consultations a day . I am in private practice, and have a wait list of 2 weeks. It also takes the patient a total of 3 hours of their time ( to commute to the clinic and to wait for their turn) to come for a consultation. How can we make this more efficient ?

What do I do in a consult ? Primarily, like most specialists, I take a history; review the records; and then formulate a treatment plan. I don’t need to do a physical examination for the vast majority of patients. ( Many studies have shown that over 80% of medical diagnoses can be made based on the history !)

I have therefore designed a structured questionnaire on our website ,which anyone anywhere in the world can fill up online and email to me . I can review it and reply by email and it takes me an average of about 5 minutes to reply to each query. I know what the key points on the form are; so that I can quickly look for these; and then guide them accordingly. Most problems are ones I have encountered before ( after all, I am an expert !); and most questions are ones I have answered before, which means I can reply much more efficiently

This is actually a better model than a face to face consultation ! In fact, a personal consultation may not be the most effective or efficient way of providing the doctor with medical information ! I know this may be iconoclastic, but patients are often confused, disorganized, or embarrassed. By subjecting them to the discipline of filling up a structured form when they have the time to do so , they can provide the key bits of information the doctor needs much more intelligently !

I can also provide reasons for my recommendations , and additional references if needed. Patients are much less stressed out ( studies have shown patients forget half of what their doctor tells them during a consultation) when they email me, which means they remember and retain a lot more of what I tell them, because it’s all in writing. Moreover, this can be an iterative process, because they can ask more pointed queries , which I can reply to.

It’s much easier for me too, because I can reply in my pajamas; and for complex problems, I can refer to my medial journals ! I can also “refer “ patients to online information resources, so they become better informed about their problems.

It’s also much easier for my patients because they can ask me queries at their convenience; and they have a written record of what their options are . Patients can also think about their queries; discuss their options with family members; organize their medical records; and structure their thoughts. I now “see” 25 patients in the virtual world ! I find these patients are much better informed and have more realistic expectations, which makes treating them in the real world much easier. This model would work well for all chronic illnesses, such as diabetes , arthritis, hypertension.

One of the limitations of this model is that no personal physical examination is possible, but this is not essential for solving problems in many specialties today. Not only can a history provide a lot of useful information; the record of the primary doctor’s physical examination notes; as well as the results of imaging studies can be very valuable, which often means that a personal physical examination is not even required in the first place.

Medical experts in world class hospitals have been providing second opinions to patients from halfway across the world ( without examining or seeing them) for many years. Doctors are also used to providing useful medical advise on the telephone. Why can’t we use these models to improve the doctor’s efficiency ?

US doctors have become so petrified by the possibility of being sued anytime they write anything down, that they have got paralysed into inactivity ! They can no longer think of innovative ways of providing medical care, because they are so worried about possible medicolegal liabilities . There’s no reason why Indian doctors should allow this irrational and misplaced fear to immobilize them ! We need to capitalise on this opportunity !

We can use this model intelligently and “extend” it using physician extenders. Using a “ learned intermediary” ( who could be a nurse , community social worker , family member or caregiver) can help to extend the utility of this model. Maybe a “targeted “ physical exam can be done by a trained physician assistant or nurse, who can make house calls and video conference with the doctor ? This could also be done by “expert patients” or peers, for example. I agree that the “human touch” is important; and that an online consultation can be impersonal, but this is no reason to throw out the baby with the bath water.

Doctors have a lot of expertise –we need to tap this intelligently. Many attempts were made in the past which attempted to use “artificial intelligence” to help the doctor to make the right diagnosis. Most of these failed, because I feel their goal was misplaced. Rather than try to use technology to replace human expertise, it would make more sense to use it so that to multiply its efficiency. Amazon’s Mechanical Turk was developed to help solve specific internal data processing problems that required human judgment and intelligence.

It's a clever marriage of information technology and human intelligence. India has lots of medical intelligence, and we can leverage this...

The key would be structured questionnaires designed for each specialty which the patient would need to fill up. The concept could easily be extended to allow family doctors to seek a medical opinion from specialists.

Every specialist need a core of critical information on the patient, based on which he formulates a treatment plan using his expertise and experience. While it may not be possible to capture his experience, reasoning skills or experience, by providing him with the core information he needs efficiently, his expertise can be used much more productively !

This business model would allow expert doctors ( even those who have retired and are no longer in active practice ) to generate more revenue; and also allow patients easier access to medical expertise inexpensively ( because they would no longer be compelled by geographic constraints to going to expensive doctors in the US; or to wait for months and months on a NHS waiting list). This may even galvanize doctors in the US to reduce their expenses; and force them to become more efficient and patient-responsive ! The benefits for insurance companies are also enormous, because these consultant doctors would provide objective evidence based advise, with no vested interests ( since they are not going to be actually treating the patient).

Sunday, November 13, 2005

Questions to ask and things to take with you when you go to the hospital.

Here's a useful list from the BBC website.

Questions to ask when you go to the hospital.


What's the name of the ward/ room number?

What's the name of the nurse looking after you?

What's the name of my consultant?

What are the names of the other doctors, therapists etc. looking after me?

When are visiting times?

Where's the toilet?

When are meals served and how do I choose what I'd like?

Can I leave the ward to go for a walk, go to the shop/chapel etc?

Is there a phone I can use?

When do the doctors do their rounds?

Things to take with you when you go to the hospital.

* Contact details of your next of kin
* Contact details of family and friends
* Regular medicines
* Night clothing
* Toiletries
* Books, magazines, puzzles
* Pen and paper
* Food snacks
* Personal radio/stereo (if allowed)

Saturday, November 12, 2005

Doctors leam how to say sorry - in the US !

In Colorado, the state’s largest malpractice insurer, COPIC, has enrolled 1,800 physicians since 2000 in a disclosure program called the “3Rs” for “Recognize, Respond, and Resolve” . Under the program, physicians immediately express remorse, apologize to patients, and describe in detail what went wrong in the wake of an error.
Traditionally, lawyers have advised doctors never to "say sorry". Medical errors were covered up, leaving patients in the dark, because of the fear of litigation. ( For most lawyers , "Just Say No !" is the commonest defense they propose !)
If doctors re-learn the 3 Rs, this will be much healthier - for them, and for their patients ! ( The lawyers are going to cry all the way to the poorhouse if this works out well !) Honesty is always the best policy, and telling the patients the truth is much better for everyone involved.

Friday, November 11, 2005

Why is medical care so disproportionately expensive in the US ?

The US is considered to be a model of capitalism; and most other countries strive to emulate the prosperity of the US. However, why is the healthcre system in the US such a mess ? Why is the care so disproportionately expensive ? Why does an IUI treatment cycle which costs about US $ 100 in India cost about US $ 2000 in the US ? Using purchasing power parity, one would expect it to be about US $ 500. What can account for the nearly 200%-400% markup in medical treatment costs ? Is it greed ? inefficiency ? pharmaceutical clout ?

Thursday, November 10, 2005

WSJ Examines Increased Use of Telemedicine To Reduce Costs

WSJ Examines Increased Use of Telemedicine To Reduce Costs
The Wall Street Journal on Thursday examined how telemedicine has begun to move 'into the policy mainstream' as governments and technology companies are 'investing heavily to tap its potential for sharply reducing health care costs for a growing elderly population.' "
If Mohammed will not go the mountain, then the mountain needs to go to Mohammed ! Are we seeing the return of the "home-visit" ( with the only difference that it will be a "virtual" visit, so it'll cost much less !

Wednesday, November 09, 2005

The DigitalTransformations of Healthcare in the 21st Century

The Digital Transformation of Healthcare in the 21st Century: "Digitized healthcare".
The complete digitization of healthcare (both clinical and administrative) will lead to a number of profound changes.

* Hundreds of millions of medical records (shorn of personal identifiers) combine into a massive n-dimensional, queriable, retrospective database, allowing, for the first time, the emergence of true evidence-based medicine.
* “Just In Time Knowledge” systems bring the physician clinical and diagnostic information that she does not yet know that she needs — based on the patterns of information that she is putting into the system
* These systems, and other fail-safe mechanisms built into software, occasion a large-scale drop in medical mistakes and malpractice litigation.
* CEOs and other chief officers can access financial information in real-time in a “virtual close” accounting system
* Procurement “bots,” as well as real-time online market-making in supplies, financing, and drugs replace most of the procurement mechanisms we use today."

Reinventing healthcare - the very "big" picture

Reinventing healthcare - dream big ! " In this system, every individual has a lifetime health care account. Into this account and through it, money flows electronically from a variety of sources: insurance companies, government, employers, personal earnings and charitable institutions. Funds are fully invested, yet they are accessible for health care at times or for purposes determined by the account holder.

The funds are accessed by an electronic transaction device acceptable at any qualified provider of health care service or products. Each transaction is instantly authorized prior to performance of services, and payment is made electronically when the service is rendered--at a cost of less than two pennies per transaction. The system provides insurers and funders an immense variety of data, allowing them to custom-design authorization procedures to balance costs, losses and the level of service they wish to provide in competition with other providers.

The same system simultaneously carries an immense amount of individual, institutional and community health data. Each provider of health care services has electronic equipment custom-designed for its practice compatible with the overall information structure. Thus, 95 percent of the system is incrementally owned and operated by tens of thousands of health care providers and vendors in free and open competition with one another, yet it functions as a unified whole through common standards, along with a few, central, cooperatively owned elements, such as a central switch everyone has access to. The few paper documents required are now produced automatically and instantly at any point in the system.

The system has complete data on the costs, performance and capabilities of every health care provider, and this is readily available to every consumer. Each consumer has complete freedom to select the provider of his or her health care. An ever increasing amount of health information and care is provided through inexpensive, interactive voice-data-video equipment in the home and at countless community locations open to the public.

The medical history of each individual is encoded in machine-readable format in a health care transaction device, encrypted so that it is not available without consent. However, emergency vehicles and facilities are equipped to override the encryption in the event an individual is incapacitated. With consent, the card can be electronically read to produce all necessary medical history or to create patient records in any format desired by the health-care provider.

Government retains the authority to tax and redistribute income or otherwise set public policy to ensure a minimum level of care to each person, but it is not involved as a direct provider, owner or controller of the system.

Individuals control their own health and health care, as well as the money for it. They initiate all transactions. It is a customer-driven system. Perhaps the most interesting feature is that if individuals can maintain excellent health, a portion of the funds in their accounts eventually reverts to them as capital--so they have great incentive to avoid health risks and obtain the best, moderately priced service."

This is a truly "disruptive innovation". Can we make it happen ? Why not ?

Designing a better hospital

What If: The Experience Economy: "'Think of patients as guests,' says founder Dr. Alan Pierrot. 'If you make that leap, you provide a significantly different service, and you view the people differently. The typical hospital room, by its very design, says, 'We don't care about you. We value something else more, whether it's JCAHO technical indicators, or state regulations, or our own rules, not your spiritual and human comfort. We want a correct diagnosis and a good outcome. How much you enjoyed the ride is not particularly an issue for us.'"

Improving healthcare by listening to the patient

What If: The Experience Economy: "This philosophy - 'Give people what they want and the patients will come' - has its roots in Griffin's 1987 experience designing a new child-birth center." So why is this so hard for doctors to do ?

Conversations In Care -Web-book for doctors

Conversations In Care Web-book " The issues surrounding physician/patient communications are many. Anxiety, fear and embarrassment can all impact the way a patient communicates with his/her doctor, and make it difficult to articulate concerns and participate effectively in their treatment. A physician is no less likely to feel anxiety from trying to meet both the psychosocial as well as the medical needs of a patient, or fear at having to break traumatic news." Here's a very wise book which teaches physicians how to communicate with their patients. It should be compulsory reading for all medical students, residents and doctors ! Just learning how to operate is not enough - this book teacces the basis of how to develop a better bedside manner.

S-P-I-K-E-S Makes Breaking Bad News Easier

When you have to break bad news, think S-P-I-K-E-S!

Set the scene by ensuring the privacy of your conversation. Select a quiet and private place in which to break the bad news. Greet your patients warmly, with a smile and make eye contact. Ensure there are no physical barriers between you and your patients.

Assess patients' perceptions of their illnesses by asking open-ended questions. Remember the vocabulary that the patient uses and repeat their choice of words when you break the news.

Invitation to impart medical information should come from your patients. The vast majority of your patients will want to know the details of their illness, but to respect those who don't, be sure to ask their preference.

Knowledge should be shared with your patients by replicating their vocabulary. Give your patients small chunks of information, making sure that they understand the content after each chunk.

Empathic and exploratory responses should be used when responding to your patients' emotions on hearing the bad news. Validate their feelings.

Strategizing and summarizing will give you a chance to reiterate what has just been discussed, and provides the opportunity to raise important issues that should be covered immediately. Create a strategy so the patient knows what will happen next. "

I love clever acronyms - they help mentally overloaded physicians to remember key information better !

Tuesday, November 08, 2005

Will Disruptive Innovations Cure Health Care?

Will Disruptive Innovations Cure Health Care?
" It's no secret that health care delivery is convoluted, expensive, and often deeply dissatisfying to consumers. But what is less obvious is that a way out of this crisis exists. Just as the PC replaced the mainframe and the telephone replaced the telegraph operator, disruptive innovations are changing the landscape of health care. Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions are fighting these innovations tooth and nail. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seeds of its own destruction. The history of disruptive innovations tells us that incumbent institutions will be replaced with ones whose business models are appropriate to the new technologies and markets. Instead of working to preserve the existing systems, regulators, physicians, and pharmaceutical companies need to ask how they can enable more disruptive innovations to emerge. If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone. " So true ! The trouble is that by the time you become a doctor, all the initiative and enthusiasm has been drained out of you !

Monday, November 07, 2005

Who is the lowest paid worker in the doctor's clinic ?

" You already know that the physician is a practice’s most expensive worker, but can you identify your lowest paid workers? Don’t bother looking in the file room or reception. Your least expensive workers are your patients ! Without compromising excellent service, your patients can help reduce your busy staffers’ administrative hassles by completing the registration information in advance, and online. Many physicians mail registration forms to new patients to fill them out before coming into the office. Now a few have started offering online registration for new patients—either as a form they can print right off the Web page, or a true on-screen registration form. Of course, your front-office staff must still review and approve any completed form. That’s because inaccurate form-fillers cause more problems at registration than do inadequate forms. "

This nugget was adapted from Improve Your Productivity, from Advisory Publications, a division of HCPro, Inc.

Now I would not have put it this way, but I am glad someone realises that patients can be a very useful healthcare resource , if they are tapped intelligently - and respectfully !

Sunday, November 06, 2005

Where There is No Doctor

Where there is No Doctor This is one of the most useful books I have ever read. The title suggests that it's useful only for people living in remote areas, but the impact of this book is far greater. For one thing, it's an excellent model of clear wiriting and teaching - I wish all books were written so well ! Secondly, it can empower all of us to learn to take care of our own medical problems ( most of which are minor and self-limited), rather than run to the doctor for every cough, cold and fever. This book can teach all of us the basics of medical self-care - please bookmark it !

Healing the Healer

Healing the HealerHere's a very useful guide which teaches medical students how to take care of their own health. Patients can learn from what their future doctors are learning now ! "Mark Twain once said, "The physician who knows only medicine, knows not even medicine." In order to be skillful in the art of health and healing we need to start with ourselves. Your first patient is you. If you continuously explore how you define your own health, you will be more present and successful in helping your patients do the same. And more importantly, you will be more happy and fulfilled in your life's work."

Health Hint: Using Journaling to Aid Health

Keeping a journal or diary provides an avenue for expressing stressful emotions and thoughts that may have a tendency to worsen physical symptoms.

Studies have found that if we express feelings about a time in our lives that was very traumatic or stressful, our immune function strengthens, we become more relaxed and our health may improve. Writing about these processes helps us organize our thoughts and create closure to an event that our minds have a tendency to want to suppress or hide. This can be done in the privacy of the home and requires only pen and paper. No one but the individual needs to read what is written. The most benefit comes from writing the document and the words can even be destroyed if so desired.

This process can bring back into conscious some frightening events that would best be handled with the help of a licensed therapist. These services should be sought out if needed.
How to Journal

* Write about an upsetting or troubling experience in your life. Something that has affected you deeply and that you have not discussed at length with others.
* First describe the event in detail. Write about the situation, surroundings and sensations that you remember.
* Then describe your deepest feeling regarding the event. Let go and allow the emotions to run freely in your writing. Describe how you felt about the event then and now.
* Write continuously. Do not worry about grammar, spelling or sentence structure. If you come to a block, simply repeat what you have already written.
* Before finishing, write about what you may have learned or how you may have grown from the event.
* Write for 20 minutes for at least four days. You can write about different traumas or reflect on the same one each day.
* Consider keeping a regular journal if the process proves helpful.

Rakel, DP. Shapiro D, Mind Body Medicine, Textbook of Family Practice. 6th ed. Saunders.

An excellent resource for more information on this subject can be found in a book titled, Opening up: The healing power of expressing emotions by James Pennebaker, PhD. Guilford Press, 1997.

How to motivate yourself to change

Need to improve your behaviour ? Get rid of a bad habit ?
Motivational interviewing can help - and you can do it yourself !
Directions for the Motivational Interviewing Worsksheet:

* Download the Motivational Interviewing Worksheet (PDF)
* Choose a behavior or habit that you have that you would like to change.
* Write down the positive things about this behavior.
* Write down the not so positive things about the behavior.
* After making the two lists above, take some time and look at what you have written in each section. Contemplate on how each of these may influence your decision to continue this behavior.
* Then list one or more goals that you would like to work for in the future. These goals should match those things in your life that fill your cup and support your sense of meaning and purpose.
* Take time and review what you have written and then ask yourself how this behavior may help or hinder your ability to reach these goals.
* Is this a behavior that you want to continue? It is your decision!

Saturday, November 05, 2005

Medical Seminars In Ancient India

Medical Seminars In Ancient India Medical seminars and symposia are not a new phenomena ! They existed in ancient India where indeed there were codified rules of debate and discussion. Dr B S Mehta illustratively discusses a few important medical seminars that were held in ancient India. Given the scholarly tenor of the debates, he writes, these deserve to be included in medical encyclopaedias. Indian medicine has a long tradition and a history we can be proud of. Unfortunately, most of it is very poorly documented. This series of articles on the history of Indian medicine from the magazine, HouseCalls, is a treasure trove of valuable detail , based on painstaking research, which deserves a wider audience. I hope someone publishes these articles in a book, which all Indians can be proud of ! "“There weren’t that many drugs then, and often treatment would involve just talking nicely to the patient,” says Dr Nilima Kshirsagar, head of the pharmacology department at Seth GS Medical College & KEM Hospital, Mumbai, who is incidentally also its current dean. She takes time off to talk to Nilufer Fernandes on pharmacology, the drug trials her department is involved in, and the ethics of such human trials that are sometimes conducted on unknowing patients in India". If you'd like to find out more about medicine in India, this is a great site to go to ! It's an extremely well-produced magazine, and packed with information you will never find anywhere else !

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