Monday, March 29, 2010

Invest in patient engagement

Invest in patient engagement " This great website offers a comprehensive review of the best worldwide evidence, in English, of what works to engage patients and the public in healthcare.

This site will help healthcare providers to deliver higher quality, more efficient care and treatment, which:

* empowers patients with greater knowledge
* gives patients a better experience
* makes the best use of healthcare resources, and
* contributes to improved health behaviours and better health.

By analysing and making accessible 280 high quality research reviews, we answer the following questions:

* What can patient engagement and public involvement achieve?
* What works, when and for whom?
* What proof is there of effectiveness?
* What return on investment can be expected?
* What are the Best Buys?"

Friday, March 26, 2010

Physicians vs. Insurers -- An Uneven Fight

Physicians vs. Insurers -- An Uneven Fight: " Frustration with payors' changing reimbursement protocols and regulations is universal among physicians. They want to render service and care, not worry about third parties influencing decisions about who they can treat, how they treat, and, ultimately, the kinds of outcomes they can affect:

• 77% agree that time spent with payors and third parties inhibits their ability to spend time with patients (5% feel differently) .

• More than three-quarters believe payors inhibit the care physicians would like to provide their patients; just 7% feel the care they would like to provide is unaffected by payors."

Right now we have a doctor vs insurer scenario. This is tragic. After all, birth should be on the same side - that of the patient ! If health insurance companies can align their interests with doctors ( by helping them to be more productive and efficient), a lot of this tension will get resolved, and patients will benefit !

If I were the CEO of a health insurance company

The passage of the health reform bill ( Patient Protection and Affordable Care Act) in the US has attracted a lot of attention. Lots of this is positive, but some is critical as well.

I feel this bill is actually a big opportunity for health insurance companies to get their act together. At present, they are seen as money-hungry bureaucratic corporates which are out to squeeze doctors and patients by delaying the reimbursement process and making it needlessly complex and opaque. This is a valid criticism , but is actually a great entry point for a clever CEO who is willing to think "out of the box" and grab a large market share.

I feel health insurance companies should offer free PHRs to all their customers and free EMRs to all their doctors. This is a potentially disruptive innovation which will help everyone - doctors; patients and insurance companies as well ! This will enable online processing of claims; make finding a doctor much easier for patients; and cut out a lot of the paperwork and telephone tag doctors and patients need to play at present in order to get reimbursement. Insurance companies can actually encourage online consultations and preventive care; and help their clients to remain healthy, rather than just help them to pay their medical bills when they fall ill. They can be seen to be the “good guys” in healthcare who are using technology to heal a sick healthcare system !

But isn't there a reason why health insurance companies refuse to make their payment processes clear and transparent ? Don't they have a hidden agenda of deliberately complicating the payment due to the doctor, so that they can hang on to the "float"? Will they be willing to turn over a new leaf and help to make processing payments more efficient if this will result in a loss to them ?

My point is that a new company can create a new model which no longer relies upon inefficiencies to earn a profit. Instead, it will use efficient payment collections and processing to gain a larger market share. By making payment for medical care easy and painless, they will earn the loyalty of doctors - and patients !

One of the reasons insurance companies need to charge such huge fees is because a small proportion of doctors ( and patients) will game the system and will try to defraud them. By ensuring that patients store their medical data in EMRs and PHRs, insurance companies can prevent fraud and remain profitable without having to cheat and resort to underhanded techniques.

However, isn't there a danger if this is done that insurance companies will then start acting like Big Brother and refuse to cover patients at risk for serious medical problems ? What about the loss of privacy ? Yes, these are valid concerns, but it's possible to anonymize the data, so that the patient continues to own it, but will not be able to fudge it either !

The new bill encourages the clever use of technology to improve healthcare delivery ! Let’s make the most of it – we may not get another chance again !

The cervix and infertility

Monday, March 22, 2010

How to scare a patient into agreeing for surgery

Fibroids are very common in infertile women. Most are intramural fibroids , which are present in the wall of the uterus) , and these do not need to be removed prior to IVF, as they do not affect embryo implantation. You can read more about this at It is only submucous fibroids ( those which are in the uterine cavity) need to be removed. These can be best removed with an operative hysteroscopy.

Unfortunately, most doctors have itchy fingers and are happy to operate at the drop of a hat.

The following combination of facts adds up to a trigger-happy situation

1. Fibroids are very common in infertile women
2. Infertile women are desperately seeking a reason for their infertility, so the doctor can "fix" the problem and help them to have a baby
3. Modern ultrasound scan machines with their zoom functions are excellent at picking up small asymptomatic fibroids which are of no clinical importance
4. Sonographers are happy to report these findings as abnormalities. Usually, the fibroids are measured in mm rather than cm, so they seem to be even bigger than they really are
5. No one bothers to explain to patients that fibroids are very common in fertile women; that most of them do not affect fertility; and that surgery can actually reduce their fertility
6. Gynecologists are trained to operate - and are very happy to do so ! This is far more profitable than reassuring the patient or advising watchful waiting ! Many will justify their advise for surgery by saying - If I do not operate, then someone else will, so I might as well do the surgery myself !
7. The surgery involved is a " simple " laparoscopy. which does not need the doctor to ut open the belly. This is "minor surgery" , which is done on a day-care basis, so why not just fix the problem since the solution is so simple !

In fact, many gynecologists actually end up scaring patients into saying yes for surgery. They take advantage of the patient's ignorance, and trot out a large ( and very creative list !) of reasons for why surgery is the best solution for them.

This includes the following reasons, none of which are the unalloyed truth.

The fibroid needs to be removed now, because ( choose one or more of the following) :

It will grow during pregnancy and become even larger
It will compress the baby; prevent the baby from growing; and will cause growth retardation
It will cause a miscarriage
It will cause preterm labour

The advise seems to be - removing the fibroid may not help your fertility, but it's still a good idea to do so, because some fibroids can cause problems during pregnancy, so why take a chance ? Most infertile women are very emotionally vulnerable, and are happy to do everything they can to prevent problems during their much-awaited pregnancy. This is why many happily sign up for "preventive surgery" - without reaslising the risk they are running !
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Practice Notes: The Physicians Practice Blog

Practice Notes: The Physicians Practice Blog: "The Internet needs more docs. However you want, engage the Internet. We are the authorities on health. There is a paucity of good, credible health information on the Internet. Share your authority with the public. Use any format to get started, start slowly and proceed at your pace. Make the Internet credible. Patients should be learning from us, not TV."

Sunday, March 21, 2010

Why are doctors such hypocrites ?

After reading yet another article in a leading newspaper on how stem cells are helping paralysed patients to walk, I spoke to the journalist to ask him why they were continuing to misinform patients. The use of stem cells has been hyped so much, that most "clinical use" of stem cells in India now is an abuse. Private clinics have mushroomed all over the country, where cardiologists, neurologists and orthopedic surgeons have all jumped onto the stem cell bandwagon, claiming that these "miracle magic cells" cure everything from paraplegia to heart failure to arthritis. The sad truth is that while stem cells may hold a lot of promise, a lot of this is just that - promise. It takes a long time and a lot of effort to convert this promise into reality and both patients and doctors need to acknowledge this fact. By making such brazen , unsupported ( read false) claims, both doctors and journalists are doing a dis-service to patients, their profession, themselves and society.

Doctors are actually harming themsleves by over-promising and under-delivering. To grab their 15 minutes of attention, they concoct all kinds of rubbish - and it's still surprisingly easy to hoodwink unsophisticated reporters who are often medically naive. I can understand why doctors do this, however. Each media story gets them a fresh influx of new patients - and lots of moolah ! It's hard to say no to money and a newspaper story, so most doctors are quite happy to learn from the media stars; and since doctors are quite savvy, they employ PR agents to help get their name out in the press.

But why do journalists, who are supposed to be sophisticated professionals, whose expertise lies in reporting the truth, fall for this ?

Reporters have to live with deadlines and they are under constant pressure to report "news". Their editors pressurise them to dig up positive stories about Indian doctors, to offer a "feel-good" flavour to the reader. Stories about the cutting edge" of medical techology are always well-read - and will usually secure a by-line for the reporter. These are human interest stories, and are often featured prominently in the paper. Also, there is lots of competition amongst journalists for stories, and many of them are afraid to displease these media-savvy doctors, as some competitor may get the next scoop !

However, it's not just the journalists who are to blame ! They are not gullible, but they are not medical specialists either ! This reporter told me that when he asks other doctors for their opinion, so they can provide a balanced article as well as an alternative point of view ( something which is basic to all fair reporting), many doctors flatly refuse to criticise another doctor in the media. While they are extremely happy to bad mouth these doctors and backbite about them ( the amount of medical politics which goes on is mind-boggling !) , they do not have the courage of their convictions to say so aloud ! They refuse to "go on record" and refuse to stick their neck out in public. This is a shame. By refusing to criticise bad doctors, they are abdicating their responsibility and actually encouraging bad doctors to flourish. They are scared to be critical of other doctors because they do not want to break the bonds of professional collegiality. I think this is ridiculous. Ethical doctors - or those who think they are ethical - have a responsibility to be honest and to prevent medical malpractise. They need to acknowledge that the media has a very important role to play in educating the public - and that good doctors need to partner with the media, to ensure that medical stories and honest and factual. By keeping quiet, they are actually being cowardly ,unethical and dishonest. The fact that full-time professors in medical colleges refuse to be quoted is especially disheartening. These are academic professionals, to whom journalists should be able to turn to for an honest unbaised free and frank opinion , because they do not have an axe to grind. Unfortunately, even these leaders of the profession prefer to criticise journalists for carrying poor quality stories, instead of actively contributing to ensure that the stories are reliable and accurate ! They need to have the courage of their convictions , rather than just behave as docile impotent back-benchers.

If leading doctors will not accept responsibility for policing the medical profession and for keeping doctors honest , then they really should not complain about these poor quality stories ! If you are not part of the solution, this means you are part of the problem !

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Saturday, March 20, 2010 - GE Launches Handheld Ultrasound Tool - GE Launches Handheld Ultrasound Tool: " Touted as the 'stethoscope for the 21st century,' GE's smartphone-sized ultrasound scanner is now commercially available worldwide, GE announced this week.

Dubbed the Vscan, the handheld device, which resembles a flip-up cell phone, can be purchased by physicians in the United States, Europe, Canada and India. GE hopes the tool will become part of routine care, as physicians slip it in their pocket on the way to see patients."

This is like a Star-Trek doctor's dream come true ! It will be especially helpful for cardiologist's who need to check the function of the heart at the bedside; and obstetricians who need to monitor the wellbeing of the fetus during pregnancy.

However, I think they will have major problems selling this in India. Because of the PNDT Act which closely regulates the sale of ultrasound scanners in India, it's very unlikely they will be able to get the permissions needed , because it is so small and portable !

Tuesday, March 16, 2010

The UID and a personal medical record for every Indian

This is a guest post from Aditya Patkar, Marketing Director of Plus91.

A unique medical record for each person is considered to be the Holy Grail in the world of healthcare IT – especially when applied to a country like India. When is this going to happen? To begin with a unique medical record would not have to be electronic, but logically speaking it needs to be. A physical record has constraints of sharing and updating, so let’s accept that this unique medical record needs technology to create it. This is a challenge – and a unique opportunity as well, as we do not have any legacy issues; and can piggy back onto the UID initiative started by the Govt of India and spearheaded by Nandan Nilekani.

What will this unique medical record contain? Simple - every piece of your medical history. From your birth, all your medical reports, your changing demographic biological profile, your health information, details about your insurance and your doctors, allergies and medications. It is a time-map of your health, created over time by a range of different people, and owned by you. It will be a combination of your EMR and PHR.

How will this help ? Any doctor you give permission to will be able to see your entire history, thus helping him to make better medical decisions. Today hiring companies and insurance companies are two corporate entities which constantly ask for health check-ups, which means a huge amount of time and money will be saved by giving them permission based access to the required part of the record. For the patients, a continuous record gives them the tool to manage their health better; having a constant record of the test gives a clear indication of what is stable and what is not. Many of us here in India rarely have more than even two previous reports stored properly ! On a much more global scale, statistical and empirical studies on medical data gleaned from these reports provides fodder for research. Predicting disease outbreaks, health hazards, improving living conditions - all require solid data to make proper decisions, all coming from the same source, your medical record. After all – all this data should benefit you !

The challenges to getting a unique medical record are plenty:
a. Lack of technology infrastructure. As PCs get smaller and cheaper (not to mention the entry of ubiquitous smart phones which can compute) and internet penetration scales progressively, this will slowly cease to matter.
b. Lack of cohesiveness in IT solutions . A hundred providers provide a multitude of solutions that look, act and store things differently, so how does one make a unique record, forget about integrating the paper records ? The technology itself is providing an answer , using clever new methods to interface and exchange information.
c. Lack of initiative. Patients and doctors have survived for many years without a unique medical record, and unless appropriate incentives are provided, the situation will remain as it is. Educating the public, providing low cost effective solutions; and providing competitive benefits to those that embrace this technology as early adopters it are a few things that can be done to fast track the change in mindset.

The challenges are vast, but the rewards are too big to not give it a good shot. I think we should also be realistic in what we can achieve. Even once the pieces are in place, entering data for even 10% of the population is going to be a massive task. Also the focus should at first solely be on getting people into the system and capturing all that happens after this point, rather than worrying about the past. The past information can be slowly entered later on. I think we need to move forward, rather than waste time thinking about how to get all the past records of a patient on board.

The ambitious UID scheme only provides the identification mechanism. Now it will be up to healthcare IT firms like Plus91 to integrate this UID mechanism into the software they sell and portals they start, using the UID system to tag each record to a unique person. Over time all providers can then either pool the information or provide access across their databases using this UID. I think a cloud like structure where your record is spread across multiple databases of various providers , but with the same unique tag , is a definite short term possibility. So for you accessing your record using a unique interface will feel like it’s a unique record, but in reality it is but 100 pieces of a jig-saw spread all over the Internet.

This is a challenge – and a huge opportunity !

Sunday, March 14, 2010

The older woman - balancing career and fertility

What are the Common Questions patients ask the embryologist in the IVF Lab ?

What are the common questions patients ask the embryologist in the IVF Lab ? This is a guest blog post by Dr. Sai, Senior Embryologist , Malpani Infertility Clinic Pvt. Ltd.

While most infertile patients know quite a lot about their scans and medications, most are very poorly informed about what happens in the IVF lab ! At Malpani Infertility Clinic, we show all our IVF patients their embryos before transferring them. There are lots of questions patients ask me.

Here are some of the common questions, and their answers.

Sunday, March 07, 2010

What I learned from my failed ICSI cycle

This is a guest post from a patient, who is now a good friend !

My first ICSI attempt failed. The first day after hearing this I was very disappointed and down. But the next day, I felt this strange sense of peace and happiness. I realized that I have learned so much from this experience, I am very grateful for that. Firstly, I am really proud of myself, I never in my wildest dreams imagined that I could be so emotionally and physically resilient. Secondly, I feel a deep sense of gratitude for everything I have, my family, my health and so many other blessings that I tend to take for granted. Life is fragile and it is important to be aware and thankful for all our blessings, every minute, every single day. Thirdly, I am much more compassionate than before and feel a strong inner desire to become a better person and do more charity. I have felt pain and want to help others in their pain in whatever capacity I can. Fourthly, I have learned to be less of a control freak, I always plan, have spreadsheets & timelines for pretty much everything in my life and I have learned to not plan and obsesses this much. This has made me so much calmer now. All I can do is work hard (try my best a couple more times at ICSI), be a good person and have faith that God will take care of good people.

My heartfelt gratitude to Dr Malpani who took such wonderful care of us and went way beyond his call of duty. Thank you for being a kind and patient friend and for always reminding me that this experience should make me a better and not a bitter person.

A failed IVF cycle is a personal crisis and it requires a lot of resilience to bounce back ! The word crisis in Chinese has two meanings - danger and opportunity. I like the fact that this patient is mature enough to learn from adversity and has converted this problem into an opportunity for growth ! We can't choose our problems - but we can choose the way we choose to respond to them !

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Friday, March 05, 2010

From the bench to the bedside - and the bedside to the bench !

In most medical research, scientists develop molecules at the lab bench which doctors can use for treating patients at the bedside.

Interestingly, in IVF it is exactly the opposite ! Instead of moving from the bench to the bedside, we move from the bed to the benchside, as we try to perform in the IVF lab what is not happening in the bed !

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Thursday, March 04, 2010

Institutionalising corruption and malpractise in medical practise

A thoracic surgeon performs a mitral valve rep...Image via Wikipedia

Most senior doctors are quite cynical and pessimistic about our efforts to try to improve the standards of ethical practise in India. They feel that the cancer has become so deeply embedded that trying to remove it will require such heroic surgery that the patient may die in the process !

Tragically, even large corporate hospitals have started giving kickbacks to referring doctors. They have "marketing departments" which pay doctors a "referral fee" which is euphemistically called a "patient management fee". The only management the referring doctor does is to refer the patient to the hospital - and he gets 10% of the hospital bill ! With so much easy money so easily available, is it surprising that doctors are tempted ?

The fact that pharmaceutical companies do this all over the world has been very well documented. Even worse, the scourge has now spread to specialists as well. Cardiologists expect cardiac surgeons to given them a 20% cut for referring patients to them for bypass surgery !

I was talking to a hospital administrator, who was telling me that the reason their superbly equipped operation theater is empty most of the time is that they insist that their doctors collect their patient fees by cheque only. Since the doctors are not allowed to collect cash under the table, they prefer taking their patients to other hospitals !

The fact that the corruption in the medical profession is so widespread is sad. What's even worse is how blithely we all ignore it. We have assumed that this problem is insoluble - and have even given up trying to fix it ! Medical associations do not even discuss the issue because they are scared of offending their own members - after all, who will bell the cat ? Even investigative journalists are not willing to dig deeper and probe the problem !

How will we ever find a solution if we turn a blind eye ? The medical profession needs to heal itself and the best way of doing so is to acknowledge that we have a crisis on our hands which needs to be resolved. Since this is primarily an economic issue, we need to think of ethical ways in which doctors can charge their patients, without having to worry about giving cuts and kickbacks in order to make their ends meet. Based on my personal experience, I feel the best way of doing this is to reach out to patients directly - and the best medium to do this is the internet !

This is why HELP is offering grants to provide free websites for doctors . Millions of patients are already online, looking for good doctors – and we need to ensure that good doctors have an online presence, so it’s easy for patients to find them. We hope these websites will help good doctors to showcase their talent, and will allow them to grow their practice ethically.

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Wednesday, March 03, 2010

How the internet can promote ethical medical practise

Many good doctors are wary of putting up their own website. They feel that this will be seen to be advertising their practise - something which is unethical and demeaning to their dignity. Doctors are professionals and advertising to solicit patients is unethical and frowned upon . It is also true that many quacks have put up websites which are full of garbage and tall claims , as a result of which many responsible doctors have shunned the internet so far.

However, it is my argument that it is unethical in this day and age for a doctor not to have a website !

The word doctor is derived from the word, "docere", which means to teach. An integral part of a doctor's responsibility, both to his patients and to society, is to teach patients about their medical problems and help them to remain healthy . A website is one of the best tools to do so . It is quite inexpensive to publish a website and as internet penetration and smartphones become ubiquitous , it will be possible to reach practicalyl everyone through the web. Websites are accessible 24/7; can be easily updated; and the information can be provided in various languages , using rich audiovisual media formats. Doctors who do not share their hard-earned wisdom using the web are actually doing a disservice to their patients by being selfish and hoarding their knowledge!

Websites promotes transparency because everything is written down. They promote empathy, as doctors learn to be patient-centric and to provide information in language which patients can understand. It helps doctors to remain uptodate, as they need to publish current information; and helps to improve the doctor patient relationship because doctors need to polish their communication skills when writing articles for their website. Websites facilitate direct doctor - patient contact, and cutting out the middleman will also enhance the doctor patient relationship.

One of the reasons many patients get poor medical care is because of misleading articles in the media which often hype the "latest medical advance" without providing any context or information about the problems and limitations associated with these so called advances. A good example is the use of stem cells to cure everything from Parkinson's disease to Alzheimer's. Responsible doctors can use their websites to educate patients and explain the ground reality , so that patients do not get taken for a ride by unethical doctors.

It is true that there is a lot of rubbish on the internet. Good doctors can provide reliable trustworthy information on their sites which can serve as a powerful antidote to this problem - information which can help to dispel myths and misconceptions. Information therapy is powerful medicine and doctors need to learn to prescribe and dispense this !

If doctors take the time and trouble to educate their patients using the internet, patients will become empowered. Expert patients can form online patient communities, to guide other patients ; inform and educate them; and provide them with emotional support. They will provide first hand accounts of what the treatment entails - and will also be able to identify good doctors and bad doctors.

I think the formation of online patient communities will make a big difference towards improving medical practise. It's very hard for patients to differentiate between good doctors and bad doctors - and bad doctors can literally get away with murder. Expert , trusted , respected patients can rate doctors and provide an objective unbaised opinion as to the doctor's skills and competence. Word of mouth has always been one of the most effective techniques in rating doctors . So far, this was done informally and patchily. The net allows much better dissemination of information regarding a doctor's expertise and reputation.

Patient feedback will help to improve the medical services provided by doctors. Doctors who ask for cash under the table or those who order too many tests will be red-flagged in online discussions, so that patients can stay away from them. Doctors will also have to be on their best behaviour and treat all their patients as a VIP , because even one vocal unhappy patient can damage their digital reputation.

Online doctors will be able to learn from patient comments and feedback. They will be able to use other clinics as their benchmark, so that they can incorporate the best practises of doctors from around the world. This kind of online interaction can help good doctors to attract and treat patients from all over the world.

It takes a lot of work to establish a good online reputation and ethical doctors who spend the time and energy on doing so ( rather than in making the rounds of family physician to keep referring doctors happy) will find that this hard work pays off extremely well by providing them with a regular stream of satisfied patients !

HELP is offering grants to provide free websites for doctors . Millions of patients are already online, looking for good doctors – and we need to ensure that good doctors have an online presence, so it’s easy for patients to find them. We hope these websites will help good doctors to showcase their talent, and will allow them to grow their practice ethically. This will help patients as well , who will become aware of what services ethical doctors provide ,and what medical facilities are available in India.

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Tuesday, March 02, 2010

How to be ethical - inspite of being a doctor !

I attended a very interesting conference on Medical Ethics over the weekend where I was invited to give a presentation on the ethical aspects of IVF. My talk was on IVF - the good, the bad and the ugly , and I will be uploading this soon.

What I found very interesting was a talk by one of the organisers, Dr Sunil Pandya. He posed a very provocative question - Are conferences on medical ethics of any use ? He was lamenting the fact that inspite of organising many such conferences , the standard of medical ethics seemed to be going progressively downhill in India. Medicine is perceived to be a money making business rather than a profession ; and doctors are seen to be greedy individuals, out to maximise their income, rather than act as healers.

Is this a sign of the changing times we are living in ? Are we fighting a losing battle ? Can we do anything to improve the situation ? Can ethics be taught ? And are doctors willing to learn ?

Most medical students become doctors because they are idealistic. They want to become healers because they like helping patients and want to help them to get better. Unfortunately, medical college seems to kill their ideals and dreams. They often become cynical and uncaring. There are few good role models they can emulate , and in fact they often end up learning bad habits from their seniors – for example, how to be rude to patients so they can complete their duties and find time to catch up on their sleep.

Things are even worse when they start practice. Sadly, no one encourages a young doctor to be ethical. In fact, there is a lot of pressure on the doctor who has just hung out his shingle to be unethical , because the only way a new doctor seems to be able to get patients today is by providing cuts and kickbacks to the referring family physician. Woe betide the junior doctor who does not toe the line – he is likely to be forced to sit in an empty clinic, twiddling his
thumbs ! Please remember that young doctors just starting practice are very vulnerable. They are under a lot of financial pressure, as they have loans to payback and families to feed , so they find it quite easy to justify these payments to their own conscience. They are easily tempted to take shortcuts - after all, everyone does it – so why shouldn’t I ? And I’ll only do it in the beginning – I’ll stop once I am well off. Unfortunately, this is a steep slippery slope and once doctors start going downhill, it’s practically impossible to stop and get off ! In order to pay the cuts, they are forced to accept part of their fees in cash, and then the next easy step is to under-report their income and cheat on their taxes.

The presence of pharmaceutical companies with their billion dollar marketing budgets is another potent force in causing doctors to lose their ideals. These companies are easily able to seduce doctor s into prescribing their expensive drugs , even when they are not in the patient’s best interests , and it’s hard to resist the temptation. Diagnostic centers and laboratories which provide a “referral fee” just add to the vicious cycle, which means that it’s becoming easier day by day to count the number of ethical doctors on your fingertips.

No one likes being unethical. I believe that most people are upright, and would rather earn an honest living, so they can sleep well at night. Most doctors who are well off would rather earn a comfortable income ethically, rather than sell their soul for a few extra rupees. If a doctor has an adequate income, most will refuse to be unethical for an additional measly 20%. However, if he stands to lose over 50% of his income by sticking to his high moral principles , then most doctors, like most ordinary citizens, will crumble. It’s not fair to subject doctors’ morals to such an unfair stress test ! The present system practically forces young doctors to become unethical !

Unfortunately, self-regulation by the medical profession has failed miserably. Similarly, policing by the government is a very ineffective solution, which actually creates even more unethical behaviour, as doctors learn to game the system.

We need to change the ecosystem in which doctors practice. I feel the major reason for the sad state of affairs today is the presence of middlemen between the doctor and patient. This middleman could be the family physician who refers patients to specialists; or the HMO , who decides which doctors are going to be on their panel. If we can cut out the middleman who demands his cut, and ensure that the doctor-patient relationship becomes a simple and direct one, I think doctors will have much more incentive to remain ethical and practice honestly. Under these conditions, I believe most doctors will prefer to practice ethically !

Is this a pipedream ? No ! I’d like to offer a simple practical solution which I feel can help to improve the situation and we are trying out the following experiment, to see if it works . HELP is offering grants to provide free websites for doctors . Millions of patients are already online, looking for good doctors – and we need to ensure that good doctors have an online presence, so it’s easy for patients to find them. We hope these websites will help good doctors to showcase their talent, and will allow them to grow their practice ethically. This will help patients as well , who will become aware of what services ethical doctors provide ,and what medical facilities are available in India.

The transparency which the web imposes will:

help to reduce costs, by promoting competition;
encourage honesty from doctors ( it’s easy to tell a lie and make tall claims in the four walls of the clinic, but doctors cannot get away with falsehoods online !) ;
and ensure patients have realistic expectations from their doctor.

These websites will also improve the doctor-patient relationship, by allowing much more open communication between doctor and patient, by cutting out the middleman. Interacting with patients online will also help doctors to become more patient-centric and empathetic. Information Therapy - the right information at the right time for the right person - can be powerful medicine and can help to heal a sick healthcare system ! Ideally, every doctor and clinic should have an online patient education resource center – and it’s becoming extremely easy and inexpensive to make sure that they do.

Why were most doctors ethical in the "good old days" ? I don’t think they were more principled or had higher moral standards ! I feel this was simply because there used to be only one or two doctors in a community and patients quickly learned through word of mouth, who was good and who was bad. This ensured that doctors treated all their patients well, because they were completely dependent upon their patient’s goodwill. Rude doctors or incompetent doctors were soon booted out because patients refused to go to them !

Why do bad doctors flourish today ? This is primarily because patients are clueless. It’s hard for them to get reliable feedback about a doctor from other patients. They cannot differentiate between a good doctor and a bad one because they have limited medical knowledge. However, once good doctors start educating their patients online, the balance of power will change quickly . Patients will be able to learn about their medical problems and treatment options ; and will be able to quickly screen through multiple doctors online, from the convenience of their homes ,so they can select the one they feel is best for them. Once patients have this knowledge and power, doctors will have to improve their bedside manners, if they want to continue to attract patients !

I feel there is no point in complaining about declining ethical standards or waxing lyrical about the good old days. Good doctors do not need to be taught ethics and bad doctors will never learn ! Will my solution solve all problems ? Sadly, no . There will always be greedy doctors who would rather eat cake , and it is true that many bad doctors will also have their own websites. However, over time, thanks to the negative feedback which expert well-informed empowered patients will provide online about these bad doctors, they will be forced to improve ! Meanwhile, good doctors will flourish, thanks to the positive feedback their patients will provide about them. We hope that once all doctors have an online presence, this will create a win-win situation for patients and doctors, and will allow doctors to practice medicine ethically once again !

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Monday, March 01, 2010

Why doctors avoid patients when the IVF cycle fails !

I see lots of patients who have failed IVF cycles in other clinics. It often depresses me when I see how little patients understand about why their IVF cycle failed. Patients are understandably frustrated when the cycle fails and this is aggravated when they do not get a clear answer from their doctor as to why the cycle failed. They feel forsaken and believe the doctor has abandoned them after extracting a huge amount of money. Others may suspect that the failure was because the doctor did something "wrong" - and when the doctor does not provide answers, this suspicion gets reinforced ! While everyone knows that the IVF success rate is not 100%, patients need to learn from each cycle, so they can optimise their chances of success in their next cycle.

Unfortunately, many doctors will avoid patients when the cycle fails. They'd rather not answer difficult questions. Many refuse to meet the patient when the cycle fails because they don't like giving bad news. Others will talk about "fate" or " luck", so the patient remains in the dark. Often, the only suggestion is - Let's repeat the cycle again. Other doctors will fob off patients by providing meaningless reasons for the IVF failure, such as - Your eggs are weak; or your uterus is hostile. The worst are the doctors who will run additional tests ( for example, for checking sperm DNA fragmentation; or immunological tests for NK cells) , and then trot out abnormalities in these as being "scientific explanations" for why the embryos did not implant !

A good doctor will provide a honest answer as to how limited our understanding of embryo implantation is; and then provide the rationale for what advise he gives to the patient regarding their future course of action. Sadly, this is often missing. Patients are rarely given even a basic treatment summary , forget about details such as the embryo quality and morphology.

Even worse, many doctors will " blame " the patient for the IVF failure ! Some will claim that the cycle failed because the patient did not take bed-rest; or was too "stressed out". Others will blame the egg quality and suggest alternative options such as donor eggs or surrogacy, at the drop of a hat !

While the final outcome of an IVF cycle is not in either the doctor's hands or the patient's, a good clinic will provide high quality medical documentation of the treatment cycle and will take the time to educate and counsel patients as to what happened, so they can then decide what to do next. This is a decision the patient needs to make, but it should be a well-informed decision !

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