Monday, October 31, 2005

What doctors need to learn about service

Medicine is the ultimate service industry, but doctors often don't do a good job of providing this. I feel they can learn a lot from other businesses, and I found the book,
Delivering Knock Your Socks Off Service, very useful.

The authors define " Knock your socks off service " as:

Reliable - delivering on promises
Responsive - providing service in a timely fashion
Reassuring - building trust through competence and confidence
Empathetic - recognizing customers ( patients) emotional state and responding accordingly
Tangibles - taking pride in the quality of the materials ( services) that you produce

Most doctors love memorising lists - and this is a valuable list they can learn from !

Sunday, October 30, 2005

Sex ratios - muddying the waters

As a scientist, I find the deliberate confusion which "activists" in India have created over the sex ratio ( ratio of males to females ) infuriating. It amazes me why no one has objected to this, and why everyone has toed the wrong line !
Worldwide, the sex ratio is universally defined as the ratio of males to females . It's only in India that this has been deliberately distorted and inverted, so that in the Indian context, the ratio refers to the ratio of females to males ! Isn't this ridiculous ? It's like saying 1 kilo is 1000 gm in other parts of the world, but in India it's going to be 900 grams. You cannot change universally accepted scientific nomenclature like this - it's plainly ridiculous.
This brings us to the next question - Why was this done ?
The answer is simple - Because of a hidden agenda. Some activists are worried over the declining number of girls who are being born in India as a result of the preference for boys in Indian culture. If more boys than girls are born, then this means the sex ratio at birth ( when defined classically, as the number of boys to girls) will increase. Now, for most people, an increase is good. Therefore, to obscure the issue, some very clever manipulator of public opinion decided to reverse the very definition of the sex ratio, and decided that in India, the sex ratio would refer to the number of girls to boys ( rather than the other way around). This meant that he could then talk about the "declining sex ratio " in India - and since for most people a decrease is bad, he could get media support and attention ( and funds !) for making efforts to improve the "decreasing " sex ratio, and protect the girl child ! Very clever indeed !
While I must admire his brilliance in making a fool of the general public, what distresses me is how willingly other scientific researchers have agreed to toe this line. One cannot unilaterally change the definition of a scientific term just to suit one's convenience. Doing so just makes it impossible to intelligently discuss the issue, or compare ratios with other countries ! This stinks of manipulation which is being done with a vested interest !

"I was told the results were normal"

Sometimes, doing a consultation can be very frustrating. I saw a patient who had been infertile for many years, and had done 2 IVF cycles in other clinics. When I asked her for a copy of her test results, she said - "The doctor told me they were all normal. " This is not very helpful - after all, the eye only sees what the mind knows, and it's important that you have copies of the test results ( the actual values !) when you seek a second opinion - otherwise, how can your doctor help you intelligently ?
When I asked her for details of her IVF cycle, she said, " I don't have them - the clinic does not provide them. " Of course the clinic does not provide them - why should they ? They are quite happy to keep you in darkness, so you keep on coming back to them ! However, remember that your medical records are your property and that you have a legal right over them. No one can refuse to give you copies of your records. If you don't get your own records, the fault is yours, so there's no point in blaming the clinic or the doctor ! If the doctor or the clinic makes you feel guilty when you ask for a copy of the records, this is their shortcoming - not yours. A knowledgeable patient should know exactly what's happening to him !

Saturday, October 29, 2005

Should I do acupuncture while doing IVF ?

I had a patient who wanted to know if she could take acupuncture treatment while doing her IVF cycle. While I am not convinced that acupuncture will help to improve her pregnancy rates, I did encourage her to do this, for the following reasons.
1. By making decisions for herself, she is more in control of her life. When going through an IVF cycle, patients often feel helpless and lost. By deciding to take acupuncture treatment, she has regained control of at least part of her treatment - and this is important for her.
2. Acupuncture treatment is very "hands-on". This way, she will feel pampered and well looked after; and this can only help in reducing her stress levels. Happier patients are better off and have better outcomes - and if this also helps to improve her chances of getting pregnant, so much the better !

The buck stops with me

A patient I saw today had just flown in from the UK. She had endometriosis, and had been advised IVF. She had an endometriotic cyst ( chocolate cyst) in her right ovary, and her IVF doctor refused to start her IVF treatment until the cyst was removed. He referred her to her gynecologist, for removal of the cyst. She got so fed up while waiting for the IVF specialist, the GP and her gynecologist to get their act together ( 6 month in exchanging correspondence and 6 months just to get the needed appointments) that she got fed up and flew down to India to start her IVF treatment cycle with us. We promptly aspirated her cyst and have started her treatment. This is what doctors need to learn - patients want a one-stop-shop, where all their needs can be met, rather than being bounced back and forth from specialist to consultant to the referring doctor. Medical practise needs to be patient-centric; and the doctor who can do this properly will always do well.

Tuesday, October 25, 2005

Why I feel educating doctors about ethics is futile

I recently read that the Bombay University is planning to start a course on teaching ethics to medical students. I feel this is an exercise in futility. Ethical conduct is a very personal matter, and depends largely upon how you've been brought up. It's hard to teach anyone "ethical behaviour after they join medical college - it's much too
late, in my opinion !

I feel good doctors don't need to be taught; and bad doctors will never improve, no matter how much you teach them !

This is why I feel the focus should be on patients, and not doctors ! Well informed patients will not allow doctors to take them for a ride; and are the best safeguard against unethical doctors.

Dr Jekyll and Mr Hyde

I was talking to a patient and she was recounting her unhappy experiences at an IVF clinic. She was complaining that the procedures were opaque; information was not provided; and she had to endure needless long waits. These are common complaints, so when I asked her why she didn't leave and find a better clinic, she explained that she was "locked in" because she had paid in advance. She was therefore committed to going through with the entire treatment cycle with them, even though she was very unhappy.

We have found this is surprisingly common. Doctors are very charming and courteous at the first visit; but when you've parted with your money, they reveal their true colours.

Patients are emotionally very vulnerable, and perceive themselves as being helpless and powerless. When a doctor with a good reputation then turns on his charm and subjects you to a high powered sales pitch, it's very hard to resist. However, once you are lured in, it's impossible to get out !

There is a simple strategy you can use for finding the best doctor. Make a short list of at least 3 doctors ( remember that on one has a monopoly - there are always options !); and then interview all of them. Tell them upfront that you are seeking a second opinion, and ask them to explain why they feel they are better than the others. This way, you'll learn a lot, including , what the strong and weak points of each doctor are, and what questions to ask ( after all, who can educate you better about a doctor's shortcomings than another doctor ? )

Also, the fact that you have options will empower you, so you no longer think of yourself as being helpless. Of course, you may still end up making the wrong choice , but at least you'll have peace of mind you did your best !

Actually, this is simple common sense - we routinely do it before buying a TV or a car, so why don't we do it for choosing a doctor ?

Monday, October 24, 2005

Surrogacy - right or wrong ?

It always amazes me how people can have such strong opinions about some areas, without their having thought through the issues clearly. Surrogacy raises a lot of emotional issues, because it hits lots of "hot buttons", as a result of which a debate on surrogacy often sheds more heat and less light. I was watching a program on NDTV about surrogacy, and I heard this upper middle class woman pompously opine that surrogacy should be outlawed, because it allows commercial exploitation of poor women; and is a form of "reproductive prostitution" because no sane woman would ever "hire out" her uterus to another woman. I was shocked ! This woman was a self-righteous do-gooder , who felt that she was protecting her "poor sisters" by asking for a ban on surrogacy. However, by not allowing them to offer surrogacy services, wasn't she actually encroaching on their autonomy ? She didn't even respect them enough to allow them the freedom to choose for themselves - because she felt poor and stupid are synonymous; and that poor women are stupid women who are easy to exploit, because they cannot think for themselves, which is why they need protection which their richer ( and smarter) sisters could offer them. I feel it's much better to respect every woman's intelligence, and allow her the freedom to choose for herself. Suppose a poor woman with 2 children does decide to act as a surrogate for an infertile couple, so she can earn some money which will allow her to provide better food and education for her existing children, then what's wrong with this ? Why take away her freedom to do so under the garb of "protecting her rights" ? Unfortunately, exploitation is a fact of life, as Karl Marx so eloquently pointed out. As long as it's between mutually consenting adults, I feel the rest of us should mind our own business, and allow individuals the freedom to choose for themselves !

Sunday, October 23, 2005

Motherly Love and Determination A Recipe for a CURE

Motherly Love and Determination A Recipe for a CURE : This is so inspiring ! I wish more patients would get together and help themselves, rather than feel they are victims and get paraysed into inactivity and depression.

The Wisdom of Our Decisions :A peek into a thoughtful doctor's heart and brain

The Wisdom of Our Decisions : "His parents had educated themselves about epilepsy and its treatments to a degree unusual even for parents of severely challenged children, who often know more about epilepsy than their doctors do." Here are some touching stories about wise neurologists who take care of patients with epilepsy.


THE MERCK MANUAL--SECOND HOME EDITIONThis is an indispensable reference guide for any medical problem - and if you read this, you are likely to be as well informed as the average family physician ! By providing it free online, Merck has shown that they have a generous heart - make use of this valuable resource !

Superb free online book to help you look after yourself !

Understanding healthcare
Understanding healthcare, by Richard Wurman, is a brilliant book which you must bookmark ! It has 3 sections - Understanding yourself; Understanding them ( doctors and hospitals); and making it happen. He uses a clever analogy, and says that just like you use your car's dashboard to make sure your car is working fine, humans too need to check their own dashboard ( using blood tests and scans) to confirm they are in the pink of health. This is one of the cleverest and most imaginative layouts I have seen for an online book - not only is it packed with information, it's a work of art as well !

Dealing with medical futility - a guide for doctors

Medical Futility What happens when the patient ( or her family) ask for treatment which the physician feels is futile ? This is a complex issue, laden with ethical pitfalls. Here's a useful guide for doctors - and will help patients to understand some of the difficulties they have to deal with.

Can 40 Seconds of Compassion Reduce Patient Anxiety? Journal of Clinical Oncology

Can 40 Seconds of Compassion Reduce Patient Anxiety? : Here's a scholarly study from the Journal of Clinical Oncology which shows what a tremendous impact the doctor's behaviour can have on the patient. I wish more doctors were aware of the power they wield over their patients !

The Art of Oncology

The Art of Oncology - stepping inside a doctor's brainHere's a touching article written by an oncologist, which allows us to see that doctors are humans too !

Improving Doctor-Caregiver Communication

Improving Doctor-Caregiver Communication Here's some useful stuff doctors and caregivers can learn from each other !

Doctor's clinic visit checklist

Office visit checklist Here's a simple list of things to do before, during and after visiting your doctor !

10 tips for caregivers

10 tips for caregivers Taking care of a loved one can be taxing. Learn how to take care of yourself, so you can take better care of them !

Free tools for managing a chronic illness

Welcome to ParkinsonsHealth.comManaging any chronic illness can be challenging, but the right tools will make it a little easier for you. These free tools help you learn more about Parkinson's disease, track your symptoms and progress, and improve communication with your health care team, so that you receive the best care possible. You can easily modify them for any chronic illness !

Saturday, October 22, 2005

Why don't patients ask questions ?

I just saw a very intelligent patient, who works as an analyst for a leading multinational bank. He is an MBA, and routinely makes decisions regarding buying and selling millions of dollars worth of shares daily in the international markets. He had been to a doctor and had surgery done, which I felt was unnecessary and uncalled for.

I asked him why he had agreed to have the surgery done, and he said, " Because the doctor told me to do it" . I was amazed at his naivete - I would have expected intelligent patients to take a more proactive approach towards their own medical care ! He did not so any reading about his problem, or get a second opinion - he just signed on the dotted line and went ahead with the surgery - something which he would never do in any other area of his life !

This got me thinking - " Why don't patients ask their doctor questions ?"

I feel there are two possible answers - one of which has to do with patients; and the other to do with doctors.

I guess patients feel scared and vulnerable when they are ill. It's very comforting to be able to put all your affairs in the hands of your doctor, and trust that he will do what is right. It's good to have faith in your doctor - but blind faith can be dangerous ! You need to verify what our doctor is saying, before taking such a big step ! Other patients may feel intimidated by the doctor; or feel they will look like fools if they ask questions; while others don't want to take up the doctor's "valuable " time with questions.

And the other side of the coin is doctors who are very happy treating "compliant" patients, who don't ask questions and do what they are told. This allows them to maximise their "throughput", so many doctors are quite happy to "put patients in their place" and remind them who is in charge, when they get too uppity by taking up their valuable time by asking questions !

This is the mindset which we need to change - for both doctors, and for patients ! I believe it's easier to work on patients, and once they change, and start demanding answers from their doctors, I feel doctor will fall into line, and start answering questions more readily !

Friday, October 21, 2005

Information to Knowledge to Wisdom

Many patients are confused about the difference between data, information, knowledge and wisdom - and so are many doctors ! Thus, your doctor may have more information than you do, but this does not necessarily mean that he is more knowledgeable - leave alone wiser than you. Moreover, he may have more information about the disease, but you know much more about yourself, which means you are the expert on your personal illness. How wise you are about dealing with your problem depends upon you ! While it's easy to acquire information, and even knowledge, wisdom is a different cup of tea !

Data itself is not very useful. Think of it as the “Know-nothing” stage.
We must understand what the data is ( for example, your blood sugar levels) and how to acquire it, which is where the medical expertise is valuable.

Data to Information
Once we can apply this data to our disease, the data becomes information. This is the “Know-what” stage. This is when the doctor makes a diagnosis, for example, by pattern recognition - by matching your symptoms with those described in a text book.

Information to Knowledge
Next, the information must be converted into knowledge by finding patterns within the information. Thus, charting your blood sugar levels in relation to time , meals and exercise makes it knowledge. This is the “Know-how” stage and helps you to gain insights into your illness and how it affects you. The knowledge can be generic and can be applied to most patients with a particular disease.

Knowledge to Wisdom
Wisdom arises when the knowledge is transformed into insight or principles. Once you understand the source of the patterns of your personal illness, you can learn to manage your own illness, with your doctor's help. This is the “Know-why” stage, and when you reach this stage, you become the true expert on your illness ! You can now share your wisdom with other patients - and your doctor, if he is wise enough to be willing to listen to you !

Thursday, October 20, 2005

Why hospital charts should have a section for patients' notes

A hospital chart is meant to be a record of the patient's stay in the hospital. Ironically, there is no space in present hospital charts for recording the patient's views at all. I feel this is a major lacuna, which can easily be corrected. All hospital should have a separate chart for patient's notes, where patients ( and their relatives, visitors and friends) can be invited to enter their comments. Not only would this help to ensure that the chart is a much more accurate record of the central player in the hospital - the patient; but it would also help to minimise errors because of poor communication between the medical team and the patient; empower patients, so they feel more in control of their hospital stay; and serve as a very useful patient-feedback tool which can allow hospitals to improve their services.

Keeping your own medical notes

I just saw a patient from the UK, who was complaining bitterly about the NHS. She had been referred to a consultant, who spent 15 minutes talking to her; and then dictated a note about his medical recommendations to her GP. When she met her GP 6 months later, the GP showed her the note - and there was absolutely no resemblance between what the consultant had told her verbally; and what he had written in the note. Unfortunately, the only record available of the consultation was the consultant's note, so she was forced to just fume silently. This is why it's a good idea to make a note of the your version of the consultation and the doctor's recommendations, and keep this as part of your medical record. If you want, you can send a copy of this to your consultant, so he can amend it if he feels the need to. This is the best way of making medical records more accurate - and more patient friendly !
What I do in my own practise , at the end of the consultation, is to read out what I have written ( my writing can be quite illegible !) to the patient. This allows me to to confirm that my recording of their medical history is correct; and that they have understood the plan of action.

Monday, October 17, 2005

askMEDLINE- making medline searches easier

askMEDLINE: When doctors are stumped by a complex problem, they search the medical literature to find the answers. The standard database all doctors all over the world use is called Medline, and is maintained by the National Library of Medicine, USA. When the National Library of Medicine first threw open Medline searches to the public, this was a huge step forward in demystifying medicine, and allowing patients access to the same depth of information their doctors had. However, searching Medline was always a little tricky, and often patients would get confused or put off by the intimidating search interface. By sharp contrast, google searches were a breeze, because users no longer had to worry about correct syntax or using operators such as AND and OR ! Taking a leaf from google's success, Medline now allows natural language searching of its database, and this is great news for patients ! Check this out !

Sunday, October 16, 2005

My favourite authors

I am a voracious reader - reading is one of the few pleasures in life which is not immoral, illegal or fattening ! My current favourites are Isaac Asimov and Richard Feynman. They are my heroes, and I'd love to emulate them. They were both clear thinkers; unorthodox, with the ability to think out of the box; had a sense of humour; were willing to explain their ideas; called a spade a spade; and they both wrote so well !

Why do patients put up with obnoxious doctors ?

I often hear horror tales about how rude some doctors are; and how unfeelingly and uncaringly they treat their patients. I have little sympathy with patients who go to such doctors, because I could never understand why they had to go a doctor who they felt was rude or uncaring, just because he was the "top guy in the field" . Couldn't they just go to someone else instead , who would treat them more compassionately ? It's only when I started reading Dr Robert Caldin's book, Influence - The Psychology of Persuasion, that I understood why patients continue to flock to certain doctors, no matter how bad their bedside manner was. Caldin talks about the six weapons of influence - reciprocity; consistency; social proof; liking; authority and scarcity. The reason why some "top" doctors are so busy that they simply cannot take good care of their patients, is because of the influence of "social proof" - our tendency to assume that an action is more correct if others are doing it. The logic is, " If he's such a busy doctor that there are so many patients who are waiting for so many hours to see him, he must be good !" Once I asked a patient why she was willing to wait for so many hours in a certain IVF specialist's waiting room, and her answer was an eye-opener - " Doctor, there are patients who come up in a Mercedes who wait for hours on end , so who I am to object ? " This is why some doctors prefer having full waiting rooms - so that they appear to be busy and popular - and presumably, competent as well, by extrapolation !

Saturday, October 15, 2005

Management of health disasters and emergencies

The Kashmir earthquake relief efforts have once again highlighted the need for information on how to manage disasters when they occur. The WHO and PAHO have produced excellent educational materials on health disaster management.
Unfortunately, these printed materials are hard to find ; and since emergencies occur without warning, this information is usually not available when it can do the most good - at the time of the emergency !

The Humanity Development Library distributes this valuable content
on CD-ROMs, so that it can reach out to many more people all over the world, much more inexpensively.However, this also provides only a limited distribution network.

We have uploaded the full-text of five of these books on our website, at so that it is immediately available to any health worker anywhere in the world. This is a free service; and we do hope this will allow many more healthcare workers and doctors to access this invaluable information when they need it ! The internet is the ultimate repository of information, and we need to use it intelligently so that we can reach out to many more people in their time of need !

Biased reporting - please take off your blinkers !

" In Asia, at least 60 million girls are "missing", according to the State of World Population 2005 report." What's the explanation ? The media have once again trotted out the old - " Strong preference for boys in some countries has led to the elimination of millions of girls through prenatal sex selection". Unfortunately, no one has ever bothered to even consider that it would be nearly physically impossible to terminate so many fetuses ! This explanation is off by at least one order of magnitude ! While it is possible that the sex ratio is changing because of female feticide, this needs to be proven with raw hard data.

If this hypothesis ( that the decline in females born is due to female feticide) is true, then the only explanation for the missing girls is that they have all been aborted. Now, the only inexpensive commonly available method of fetal gender determination uses ultrasound. Since this can be used to determine gender accurately only after 14 weeks ( since the fetal external genitals are visible only after 12 weeks) , this means that if selective female feticide needs to be performed, the doctor would need to do a second trimester abortion. This is a fairly complex medical procedure, which is usually performed only by gynecologists.

The 2001 Census figures for Punjab show that there are 1.7 million boys between the age of 0-6 years. If the sex ratio were normal (0.95) , we would expect to have 1.6 million girls. Since the census shows there are only 1.35 million girls, that means 250000 girls are “ missing “. If the newborn girls are missing because of abortions done after fetal sex determination as claimed, this means that 250000 mid-trimester abortions would have had to be carried out in Punjab in the past 5 years – a virtual epidemic of abortions , because this would mean 50000 mid-trimester abortions a year ! Mid-trimester abortions are like mini-deliveries, and are fairly complicated to carry out. They can be done safely only by a skilled gynecologist. It would be a simple matter to verify the number of abortions carried out in Punjab because most abortions are carried out in Govt recognized centers.( Since abortions are legal, there is no need for doctors to perform these on the sly , so one would expect all the abortions performed to be documented, even though the reason given for terminating the pregnancy may be false.) If the study shows that the number of abortions is not so high, this means that the hypothesis is not true, no matter how appealing and logical it may be. We then need to search for an alternative explanation for the declining sex ratio, rather than blame illegal sex determination procedures for this ! Such a study is important because it is the only way of proving the proposition that female feticide is altering the sex ratio, and will lend valuable support to the demand that the laws which ban female feticide be more strictly implemented.

Should we be looking for alternative explantations ? Yes, we do need to keep an open mind !

Here's an interesting alternative hypothesis which the Indian mainstream media refuses to publish ! I wonder why ?

" The Case Of Asia's "Missing Women" - The culprit may not be government policy, but hepatitis B virus

In 1990 my Harvard colleague Amartya Sen caused a stir by observing in The New York Review of Books that excess female mortality in China, India, and other Asian countries meant that there were 100 million women fewer in the world than there should be. The presumption was that the excess mortality came from discrimination against women by men and governments. Although the estimate was lowered to 60 million by demographer Ansley Coale's more detailed analysis in the 1991 Population & Development Review, this still shockingly large number became a symbol of discrimination against women in developing countries. Many people think the reason is abortion and the killing of newborn girls. But new research suggests another reason. Harvard economist Emily Oster, in her PhD thesis "Hepatitis B and the Case of the Missing Women," suggests that biology explains a good deal of the missing-women puzzle.

In Western countries, such as the U.S., the ratio of male to female births is around 1.05. Higher male mortality leads to decreasing male-female sex ratios as the population segment gets older. In the whole population, the two forces roughly cancel each other out, leading to an overall male-female ratio close to 1. In contrast, since at least 1980, male-female ratios are around 1.08 in China, India, and Pakistan. This demographic phenomenon is limited to Asia and does not relate to economic development. The male-female ratios are not high in sub-Saharan Africa and Latin America.

The Sen-Coale assumption was that the high ratios in Asia reflected high female mortality rates. They calculated how many women would have existed if female mortality rates had been normal, which Coale computed in relation to a country's overall life expectancy. The difference between this hypothetical number of women and the actual number equaled the missing women.

Oster argues that this calculation overlooked something crucial -- unusually high male-female birth ratios in Asia years before abortion became widespread. Given mortality rates by gender, a rise in the male-female birth ratio leads to an increase in the male-female population ratio. Motivated by Baruch Blumberg's book, Hepatitis B: The Hunt for a Killer Virus, Oster sees the high incidence of the hepatitis B virus (HBV) as a major culprit.

There is much evidence that parents infected by HBV are more likely to have male children. Places with substantial HBV -- Asia, Alaska, and parts of the the former Soviet Union -- tend to have high male-female birth ratios. Studies in Greece and France show that HBV-positive parents had male-female ratios for offsprings of 1.7 to 1.8, vs. 1.1 to 1.2 for those who are HBV-negative. This pattern also shows up among immigrants, with those from high HBV areas, such as China, having high male-female offspring ratios in the U.S.

The biological explanation for the HBV effect is unclear, though it may involve more frequent spontaneous abortion of female fetuses. But the effect is large, concentrated in certain regions, and susceptible to elimination via the HBV vaccine. In Alaska, the use of the HBV vaccine in 1982 led to a sharp decline in high male-female birth ratios.

Among Asian countries, the HBV influence is greatest in China, explaining 75% of Coale's missing women. In India, the adjustment is less important, explaining only 17%. For Asian countries in general, Oster locates 46% of the absent women, ending up with 33 million missing, rather than Coale's 60 million or Sen's 107 million.

Looking ahead, broader use of the HBV vaccine should lower male-female ratios. But another force -- sex-selective abortion -- which wasn't critical before the 1980s, is growing in importance because of the spread of ultrasound technology and, in China, the one-child policy. In Chinese censuses, the male-female birth ratio rose from 1.09 in '82 to 1.13 in '89 and 1.18 in 2000. The 1982 ratio likely reflected HBV prevalence but the subsequent increases probably reflected sex-selection. An obvious countermeasure: Eliminate the one-child policy.

The Oster research features interactions between biology and family behavior and government policy in the sensitive area of gender studies. This is the kind of research that Harvard President Larry Summers recently advocated in widely criticized remarks. Fortunately, the typical approach in economics is to take on almost any topic that can be usefully tackled with economic tools and let the data speak for themselves.

Robert J. Barro is a professor of economics at Harvard University and a senior fellow of the Hoover Institution ([email protected]). "

Confused ? Confusing ?

The UN Population Fund (UNFPA) presented the State of World population report 2005, and highlighted the fact that as a result of India’s high fertility rates ( at 2.92 in 2005 , we have one of the youngest populations in the world ) we are at a cusp of a demographic bonus because we have a higher proportion of working age people than ever before.

A few years ago, the same population experts were issuing dire warnings about the dangers of unbridled fertility, and how having too many children would cause India to become overpopulated, and how this overpopulation would perpetuate poverty. The mantra in those years was - Family planning and ZPG - zero population growth. ( Fortunately, most Indians had the sense to ignore their words of advise !)

In a few years, everyone is now singing a completely different tune ! People are now seen to be assets, and they can be capitalised upon to promote economic growth ! I feel the take home lesson is simple - The experts are often wrong - though few of them have the courage to accept this. I wish they would at least learn from their mistakes !

Tuesday, October 11, 2005

When did you last give your doctor feedback ?

Patients enjoy complaining about doctors - but they usually do this behind his back, where it does little good. If you are unhappy with your doctor, please let him know !

How else will we improve ?

Trust me, you have nothing to lose ! If your doctor get supset, this means he is not a good doctor, and you should be happy to change him. If he is good, he will appreciate your input - and provide better service the next time around !

Monday, October 10, 2005

Two types of doctors

I believe there are two types of doctors. The first, who is comfortably ensconsed on his pedestal, enjoys crushing you into submission . He is the expert who spouts jargon, quotes statistics, makes you feel inferior and inadequate; and rushes you into treatment. The other ( a much rarer breed !) empowers you to make your own decisions . " This is the difference between an idol and God. An idol tells people exactly what to believe, God presents them with choices they have to make for themselves. Before the idol, men remain dependent children; before God, they are burdened and at the same time liberated to participate in the decisions of endless creation." ( Arthur Miller, Timebends). A good doctor burdens and at the same time liberates his patients ! What a delicious paradox - and only very good doctors know how to maintain this balance. He allows patients to make their decisions for themselves - and this can be a heavy burden, which not all patients are willing to carry ! A good doctor will help lighten this burden, so that the load is bearable - and even liberating ! As I tell all my patients - "You need to make the decision for yourself. It's your life - no one else can make it for you. You cannot abdicate the responsibility of decision making - but I promise you I will not let you make a wrong decision. " Patients who actively participate in making medical decisions have much better outcomes - and much happier doctors too !

Patients get the doctors they deserve

Many patients enjoy complaining about their doctors and how rude they are, or how they make them wait for ever. It's easy to blame the other person, but I feel patients need to learn to take more responsibility . While you cannot control your doctor's behaviour, you can control the doctor you select. If you persist in going to a doctor who is rude, uncommunicative or unhelpful, then aren't you as much to blame for his behaviour, because you put up with it ? Rather than think of yourself as a helpless victim, learn to be more assertive - this will help your doctor to improve as well !
After all, doctors also get the patients they deserve ! Doctors who invite questions from their patients , take pride in answering them , and encourage patient participation have a much better class of patients, and a much more satsifying practise, because challenging patients are what makes a doctor's life worthwhile !

Sunday, October 09, 2005

Why doctors need to read more !

Doctors usually do read quite a bit - but it's mostly medical literature, to help them keep abreast of newer advances. I wish, on the other hand, that they would read books written by patients, which describe the patient's experience with doctors, hospitals and the healthcare system. Many of these books are written by writers, which means that they are a pleasure to read - and they provide an amazing insight into what goes on in the patient's mind. I am reading one right now called "Living Proof" - and I am sure it will help me to become a better doctor !

Why I prefer patients who ask questions

I just received a thoughtful email from a patient, who said - " I drive my current doctor crazy. I question everything and I just can’t follow orders until I actually agree to follow them. " Many doctors still prefer passive patients who agree to do what they are told to. Unfortunately, what they don't realise is that these quiet passive patients are often the ones who don't "follow orders" - they are the ones who are non-compliant. While it is true that it does take longer to talk to active, questioning patients, they are the ones who are much more co-operative and compliant, once they agree with the treatment plan, because they have played an active part in its formulation !

NB I wonder why we feel that patients need to "follow doctor's orders". This is a hangover from our paternalistic medical model of the past, when patients were treated as children and were expected to do what the doctor told them to ! Today, even children don't listen to their parent's "orders" , so why can't we think of a better term to describe the doctor's advise ?

Free Online Medical Diagnosis by Symptoms

Free Online Medical Diagnosis by Symptoms
" The important thing to remember, is that understanding the underlying cause of your symptoms may be crucial. Education of patients about their symptoms improves the chance of obtaining the right diagnosis and obtaining prompt and correct treatment." This site allows you to make a short list of the possible diagnoses based on your symptoms. This can help you to help your doctor !

Thursday, October 06, 2005

Should You Change Doctors?

Should You Change Doctors?: "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. " Here are 6 Cs to help you confirm your doctor is right for you !

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." A doctor shows you how you can organise yourself better for your visit to the clinic !

Patient Education - Can You Know Too Much?

How to use patient education in positive ways

To be a partner in your own health care and be able to use patient education in a positive way:

# Always give full details of the symptoms you are experiencing when you consult with your doctor.

# Learn about your disease or medical condition. Patient education will help you understand the decisions and direction your doctor offers.

# Learn about treatment options and medications. Patient education regarding treatments and medications will inform you about the expected benefits, and help you recognize possible side effects and adverse events.

# Discuss all issues and concerns openly with your doctor. Your doctor is most effective if all pertinent information is disclosed. Your medical history is as valuable a diagnostic tool as a newly ordered test.

# Present your doctor with all of your questions. Don't make the mistake of thinking you know an answer before discussing a specific concern with your doctor. Don't leave your doctor's office with unanswered questions.

# Be a compliant patient. Recognize that you and your doctor are indeed a team working towards the same goal - managing your medical condition.

# Be honest. Your doctor can only work with the facts. If you didn't take your prescribed medication as directed, don't pretend you did."

Sunday, October 02, 2005

Gamasutra - "Games for Health 2005"

Gamasutra - "Games for Health 2005": "Serious Games Initiative, which organizes the Games for Health conference, says there are two sides to games for health: personal treatment and professional practice. The former includes treatment, disease management, physical therapy, exer-gaming (or gaming that promotes exercise), mental health treatment (VR/psychotherapy), cognitive learning (Brain Training for the Nintendo DS is an example), and other applications that people personally purchase. The latter includes health messaging, modeling, simulation, and training. The future of games for health includes virtual reality medicine, commercial games, and technology." What fun - play games and improve your health at the same time !

Games For Health: Games for Health Conference Release

Games for Health " Games for Health demonstrates how we can tap into an emerging medium, like video games, to explore creative new approaches to addressing complex health and health care challenges". I am very pleased when people make such clever use of technology for constructive purposes.

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