Removing Financial Incentives May Reduce Performance - Researchers note decline in screening rates, performance when financial incentives are dropped - ModernMedicine

Removing Financial Incentives May Reduce Performance - Modern Medicine This is exactly what any person with common sense would expect. After all, doctors are rational human beings - they respond to financial incentives, like everyone else does !

As a Doctor I want to use technology to be able to ...

This is a guest post from Mr Aditya Patkar, Sales Director, Plus91, in which I am an angel investor.

As we improve our software products and work with more doctors, we are learning a lot about what doctors in India want from information technology . How do Indian Doctors view IT as an enabler ?

In theory, one would expect doctors to want to use IT for the following applications.
1. Computer Based Medical Records (EMR)
2. Clinical Information Sharing Networks
3. Clinical Decision Support
4. Administrative Functions – Accounts and Patient Profile Management
5. Computer Generated Prescriptions
6. Better Patient Communication and Care

However, what the practicing doctor wants in real life is quite different !

So what does the typical doctor’s list look like?

1. Accounts and (Mis)-Management

Indian Doctors give a lot of importance to accounting in their Clinic Software; they expect the package to bill as per their requirement. Unfortunately, because many of them do not always want to declare all their income , they want the software to provide “deductions” . We have to educate them that a good package will help them to improve their cash flow and collections by allowing them to track their patient inflow so that they know what business they are generating on a regular basis. Intelligent software will help to prevent embezzlement and will discourage the office staff from pocketing the doctor’s hard earned money ( which is easy to do , since this is still a predominantly a cash business today)

2. Referrals Management

Referring patients to specialists and other clinicians is a common practice the world over, but in India it has an additional financial angle. Doctors want to know how many patients they were referred and by whom, so that they can make the necessary payments back to the referring doctors.

3. Medical History

Doctors want easy access to their patient’s information to help them make better medical decisions. While they are happy about the fact that the software gives them instant access to the patient’s medical records, they are still reluctant to use clinical decision support tools, as they would rather depend upon their clinical ability, than use a computer .

4. MIS ( Management Information System( Reports and Patient Registers)

MIS reports and registers are a commonly requested feature . Sadly the uninitiated ones forget that data first needs to be entered properly , so that it can be intelligently extracted. The reasons for the MIS reports are both noble (research purposes) and mundane (for filing income tax returns) .The biggest challenge here is designing forms and data capture mechanisms which give useful reports. Often , there is a big disconnect, when doctors design incomplete templates , and still expect to be able to generate relevant data ! . Garbage In = Garbage Out !

5. Custom Designed Templates

Plus91’s software has designed so that doctors can customize their own templates , to suit their personal preferences.. Doctors love this feature, as each one wants to design something as per their own workflow.

What of the future ? We hope that as the Indian doctor matures and becomes more comfortable with using IT, he will want the following features as well.
a. Clinical Decision Support
b. Computerized Prescriptions
c. SMS/Email alerts and reminders
d. Online EMRs
e. Insurance Claims Management

Plus91 software is already built to provide these enhancements, which will give a definite boost to the quality and efficiency of their practice , and also help them to improve their profitability.

How to reach out to your patients using technology

This is a guest post from Mr Aditya Patkar, Sales Director, Plus91, in which I am an angel investor.

A doctor today has many opportunities to reach out and touch his patients. Clever technology can help him do so very easily and inexpensively – but many doctors do not take advantage of these simple tools ! Why should you bother ? For one , it makes you popular amongst patients – and will help you become even busier ! Patients will rave about doctors who take the time and trouble to contact them – and this will help you to stand out ! Doing so will also help to educate other patients, who will be happy to offer you their blessings because you have shared your wisdom with them. Finally, contributing to the knowledgebase of the community improves the community you are a part of – and help you become a respected leader in your community !

So what do you need to do?

1. Reach out to many people as possible. The internet lets you update and express your views, either as 160 character bursts on twitter, or as a long thoughtful post on your blog , detailing your experience.

Twitter: On twitter you can start putting up bursts of interesting cases you see, new techniques you hear about, and information about your local medical network which may help people in your area! Go onto www.twitter.com, register yourself and type away.

Blogging: If you are doing research which you think people should hear about, blog about it ! Many people will find it online as they search for information about their problem , and they will be happy to treat you as a trusted authority if you provide this information on your blog. Go to www.blogger.com and start your own blog !

2. Allow people to contact you: Step one is to get a website. It helps you disseminate information about your services for patients looking for the same. This is not advertising, it’s offering a service to patients who need information and education about their medical problems and treatment options. Patients face many choices and are hampered by a lack of reliable information. On your website, please don’t only talk about yourself ! Rather, tell patients more about what diseases and disabilities you treat, what are the latest treatments, and maybe even offer them a second opinion to help them get the best possible treatment ( even if they do not come to you !)

One of Plus91's missions is that every Indian doctor should have their own website ! Check out what we offer at www.websitefordoctors.in. We will hold your hand and guide you through the entire process to maximize the impact on your patients .

3. Using Software: Modern EMR ( electronic medical software) comes with integrated communications tools which allow you to painlessly and seamlessly contact your patients, either through email or SMSes !

Plus91’s EMR packages allow you to send SMSes to sendalerts, appointment reminders and prescription reminders to your patients !This is a new level of service, and patients will be thrilled to know that you provided automated intelligent alerts to help them get the best medical care ! You can see our products on www.plus91online.com


These are just some pointers on how technology can help you to to interact with your patients – without spending much time or money ! Leverage your time and expertise using modern technology – Plus91 will be happy to help you to do so, so you can delight your patients !

The Infertility maze

This is a clever little game you can play to learn more about
infertility !

Download it free at drop.io/infertilitymaze !

The Journal of Participatory Medicine

The Journal of Participatory Medicine " Here are some of the principal requirements for the coming-of-age of the e-patient: we need evidence to prove whether and how PM improves health and lowers costs; education to spread the word; exhortation to persuade people to act; enabling efforts to ensure that health care supports individuals' involvement; emolument to persuade institutions as well as individuals; and occasionally edicts, or laws and policy when enticements fail. " Esther Dyson.

This is such a great idea. Patients participate in their medical care, whether they like it or not ( in fact, they should be the key actors , since the purpose of medical care is to help them to get better). Unfortunately, the degree of participation leaves a lot to be desired today. Patients are rarely active players - and most of the time, are passive recipients of medical care. This could be because patients don't know enough ( or care enough) to be intelligent participants; or because their doctors do not encourage them to participate. Hopefully this will change soon !

How infertility can drive you crazy !

This is a guest post from a patient who is worried that infertility is driving her around the bend.

" I failed my second ICSI. Both times I had 2 excellent embryos put in and I am 33, makes my chances of success high but I failed. I have dealt with failures before but always believed that if you work hard enough, you get what you want. I am not sure of that anymore and that bothers me. It’s unfair, it’s tough. This process can put your life on hold and consume you, you feel empty and in pain all the time and its terrible because in theory you know that you have so much to be grateful for, so many blessings but it gets harder to live in the moment and enjoy what you have. That’s the problem with being driven, you can’t help but live in the future, keep stressing, analyzing and planning what you can do better next time. It’s tough to accept that there isn’t much you can do differently. This process can make you so irrational. I am a highly educated, rational person but I am seriously considering crazy thoughts like going to an astrologer to pick the next ICSI month, give up sweets and other things I like so God feels sorry for me and gives me what I want, these are just 2 thoughts, I go through a 100 such irrational thoughts every day. It has impacted my self esteem. I have read so much about meditation, spiritualism but at times like these, it’s all out the window, know it all in my head but so difficult to implement. I can’t deal with free time, too many thoughts I hate thinking so whenever I am free, I watch tons of TV and movies just to numb my brain ! Gone are the days I would love sitting around staring at the ceiling, doing nothing. They say time is the best healer. At some point, I hope one of 2 things happens to me. Either I will succeed and experience true happiness after a long time or I will stop trying and learn to accept and live with the pain, maybe with time the pain won’t consume me as much and I will be able to focus on the blessings I have. Will have to wait and watch till my next and last ICSI and trust me I hate waiting…it seems never ending."

I always remind my patients not to beat up on themselves ! It's not the stress which causes the infertility - it's the infertility which causes the stress ! Normal woman find themselves behaving completely irrationally when they are taking IVF treatment - but I feel this is a normal response of a normal woman trapped in an abnormal situation.

I tell my patients to remember the Serenity Prayer -

God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

The four wisest words are - " This too will pass !"

Why do doctors "treat" men with normal sperm counts ?

I see many men with completely normal sperm reports who have been prescribed all sorts of medicines, presumably to "boost their fertility" . These include a wide variety of pills ( depending upon which part of the world they come from) , ranging from Proxeed to Speman to Manix to CoQ and antioxidants.

Why are doctors so keen to treat normal men who do not need any treatment
whatsoever ?

I feel there are multiple reasons.

First is ignorance. Many sperm testing labs and doctors still do not even know what a normal sperm count is. I still see labs which print the normal sperm count range as being from 60 - 150 million per ml ! This means that even men with normal counts of 40 million are " diagnosed " as having a low sperm
count !

Second is pressure from patients. Many men are petrified that they cannot get their wife pregnant because their sperm count is not good enough. They want medicines to "boost " their sperm count and enhance their fertility ( along the same lines of their eternal desire to increase the size of their penis and increase the volume of their ejaculate ! I wonder why men have this obsession with size and numbers ? Is this a result of the exposure to the trick photography they use in pornography films, which distorts their sense of what is normal and average ? )

This means that there is a lot of pressure on the doctor to treat ! Let's do something - anything ! They do not want to lose the patient and are quite happy to pander to their desire to consume medicines ! And it's easier to write a medicine ( even if it is useless) rather than sit and spend 10 minutes with the patient and explain that there is no need to prescribe anything !)

It's very easy to justify this prescription. Many doctors say - Yes, these medicines may not help, but at least they do no harm ! And doctors often fall prey to the " post hoc ergo propter hoc fallacy" . They remember their anecdotal successes - the men with completely normal sperm counts who got their wife pregnant after taking the tablet prescribed by the doctor ( it's quite likely that they would have achieved a pregnancy even without taking the tablet, but the doctor is always happy to take the credit !)

Will IVF cause me to run out of eggs ?

I just got this email from one of my patients." How many unsuccessful IVF attempts does a person like me go through before AMH levels get impacted and early menopause sets in?

This is a very common concern many IVF patients have. They feel that pumping their body full of hormones in each IVF cycle is bound to have a deleterious effect on their body - no matter what the medical studies show. This is a very real fear , which is often not articulated.

" IVF will never cause you to have an early menopause. Let's look at some basic reproductive biology to understand why this is true. Every month , about 40 ovarian follicles start growing. This is called follicular recruitment, and occurs as a result of the production of FSH ( follicle stimulating hormone) . Of these, only one matures . This is why most women normally have just one baby at one time ( unlike rabbits, who have a litter, because many of their eggs mature simultaneously every month). What happens to the others ? They naturally undergo a process of atresia every month. What this means is that about 39 follicles "die" every month, whether or not you do ICSI. In each IVF cycle, we are only rescuing the follicles which would have died anyway, so you will not run out of eggs any sooner as a result of doing IVF ! This is why the risk of ovarian cancer is also not increased as a result of using these drugs. All these superovulation drugs are natural hormones - we are just mimicking the natural process, but improving its efficiency by growing many eggs at one time ! Now it is true that some infertile women have poor ovarian reserve. These women will have an early menopause because of their impaired ovarian reserve. Now, many of them will blame their IVF cycles for this - but the fact is that they would have had an early menopause, whether or not they had done IVF ! "

Understanding your Medicines - what every infertile patient needs to know !

Open publication - Free publishing - More infertility

The Health Care Blog: Gimme My Damn Data!

The Health Care Blog: Gimme My Damn Data!The stage is being set for a kind of disruption that’s in no healthcare book: patient-driven disruptive innovation.

Here’s what we see when we step back and look anew from the consumer’s view:

1. We’ve been disrupting on the wrong channel.
2. It’s about the consumer’s appetite.
3. Patient as platform:
* Doc Searls was right
* Lean says data should travel with the “job.”
* “Nothing about me without me.”
4. Raw Data Now: Give us the information and the game changes.
5. HITECH begins to enable patient-driven disruptive innovation.
6. Let’s see patient-driven disruption. Our data will be the fuel.

The new HITECH rules require the doctor to share the patient's medical record with the patient ! One of the Physician Objectives is * Provide patients with an electronic copy of their health information (within 48 hours)

This is great news for patients - and for doctors who believe in patient empowerment and information therapy !

The Internet Lifts All Clinical Boats

The Internet Lifts All Clinical Boats Dr. Pion oversees the Pion Group, where he serves as a health care consultant on issues related to improving clinical outcomes and patient care. Dr. Pion believes the Internet, and its telecommunications applications, will improve patient care and outcomes, virtually link physicians with each other, and virtually bond physicians more closely with patients.


“Q: The focus of this interview is how to help doctors in solo or small group practice succeed through the use of the Internet and telecommunications. How can doctors become more efficient and effective through the use of new telecommunications media?”

“A: Doctors have to begin to talk in terms of computers, smart phones, and IPods just as easily as they talk of stethoscopes, otoscopes, and proctoscopes. We must talk of telecommunication tools currently available to physicians in any specialty and to any primary care doctor, now becoming known as realtors who own medical homes. “

The internet allows doctors to reach out to patients directly - and gives young doctors and doctors in solo practise a chance to compete with senior doctors and corporate hospitals !

Listen to your patients. They will tell you what is wrong with them.

I just saw a very distressed young man . He had been married for 3 years, but had still not been able to get his wife pregnant. His wife had got all her tests done, and her gynecologist had confirmed she was fine . She then asked him to get his semen analysis done, and this is where he was stuck . The problem was that while his libido was fine, and he had an active sexual life, he had been unable to get his semen analysis done. Every time he went to the lab for a semen analysis, they told him that they were unable to do it, because there was nothing in the container that they could analyse !

His gynecologist dutifully referred him to a surgeon, who examined him and confirmed he was normal. He asked him to go to another lab for his semen analysis - with exactly the same results !

The doctor told him blankly - If you cannot get your semen analysis done, I cannot help you, sorry ! He then changed another two doctors. One suggested he visit a psychiatrist, to help with his "erectile dysfunction"; while another suggested that they could do a testis biopsy to see if sperm were being produced in his testis or not.

He was completely fed up. " Doctor, I know I do not have impotence or erectile dysfunction ! I get a perfectly adequate erection - it's just that I have not been able to get my semen sample tested so far , because when I get an orgasm, nothing comes out of my penis ! I am not an idiot ! Why don't my doctors believe me ? And why can't they help me ? Am I a freak ? "

The problem is that the eye only sees what the mind knows, and many doctors are not comfortable dealing with the infertile man because they do not have much experience in handling these patients. While they learn now how to manage common problems such as erectile dysfunction or azoospermia ,they are surprisingly clueless when dealing with uncommon problems ! And if the patient does not fit into their pre-existing notion of the correct diagnosis, they are quite happy to adopt Procrustean techniques until the square peg fits into the round hole !

The first thing I did was sit down and take a detailed history, probing systematically into the following steps :

sexual desire;
erection;
ejaculation and
orgasam.

He had no problems with libido; his erection was satisfactory; he got an orgasm; but there was no ejaculation even after he got an orgasm. This meant his problem was orgasmic anejaculation , also known as aspermia.

The commonest reason for this is that the man ejaculates his semen backwards into the urinary bladder. This is called retrograde ejaculation. I told his to get his urine tested after his next orgasm - and just as I suspected, there were lots of sperm in his post-orgasm voided urine sample ! When I showed him these under the microscope and told him we could use these for ICSI , I was gratified to see a big smile on his face. " Thanks so much, doc ! It's such a relief to know I am not a crackpot and am not going crazy. None of the other doctors would believe me !"

He was grateful, not just because I had made the right diagnosis and could offer him an effective solution to his problem, but because I had treated him and his complaint with respect. I had used the oldest therapeutic tool of a healer's armamentarium - a patient hearing !

All I had done was listen to him; and translated his complaint into medical terms, which I could then analyse intelligently. The other doctors had just tried to lump with all the other common problems which they see daily - and when he did not fit, they labelled him a crock !

The truth is that not all patients will have garden variety problems - and the most important tool for solving rare problems is a detailed history ! This is very low-tech and inexpensive, and rarely inspires awe, but is the differentiating factor between a good doctor and a run of the mill physician. An expert doctor knows how to take a history; which questions to ask - and which to probe further !

" Listen to your patients. They will tell you what is wrong with them." This is an aphorism which is often attributed to Dr William Osler. This is as true today as it was centuries ago !

Is is possible to improve ovarian reserve ?

Image via Wikipedia

I had just advised a young woman who had oopause ( poor ovarian reserve) to try empirical therapy, with DHEA, wheat germ , yoga and acupuncture , before we started her IVF treatment.

She wanted to know the rationale behind my advise. " Doctor, on one hand you are saying that I have poor ovarian reserve, which means that I only have few eggs left in my ovaries. Women are born with all the eggs they will ever have and I cannot make any new eggs any more. In that case, how will taking all these medicines help me to grow more eggs during my IVF cycle ? "

This was my reply.

" Yes, it is true that we cannot make you grow new eggs. Your ovary contains all the eggs you will ever have. These eggs are in a resting phase, and are contained in primordial follicles. Each month some of these these follicles are selected and start growing. This group is called a cohort, and this is a response to the high FSH levels during the follicular phase. Of these follicles , only one will mature, while the others will die ( a process called atresia). It is our hypothesis that yoga and acupuncture will help us to recruit more of your follicles , so that if the cohort is larger, hopefully more follicles will mature when we superovulate you during your IVF treatment."

I enjoy being a doctor because my patients keep me on my toes !

Good news, bad news

I saw a 30 year old woman today who wanted a second opinion. She had failed multiple IVF cycles in other clinics and had been advised surrogacy. When I reviewed her medical records, I found out that her ovarian reserve had never been properly tested. I checked her AMH levels, and found to my dismay that they were very low. She had very poor ovarian reserve and would need donor eggs if she wanted a baby. I was afraid she would be upset when I broke this news to her, and did so as gently as I could .

I answered all her queries :

Why didn't the other doctors do this test for me ?
How come I am still growing eggs if my AMH is so low ?
Can't we treat the AMH level ?

and then asked her - Are you angry with me for giving you this bad news ?

She looked at my crestfallen face , and then gave me an answer which proved she was wise beyond her years ! She reassured me - Please don't worry doc, actually, this is good news. At least we know now what our problem is, and rather than continuing to grope in the dark, we can explore options which will maximise our chances of success !

Truly I am blessed that I have the opportunity to learn so much wisdom from my patients daily !

IVF and alternative medicine - best of both worlds ?

Many IVF patients these days use acupuncture and will often ask me whether it's fine to do so or not . I advise patients to explore additional alternative medicines options such as yoga as well. Some of my patients think that the fact I am advising this stuff means I must be a quack. Others are happy that I have an open mind and am willing to explore alternatives with them.

I never want my patients to feel they have left any stone unturned. The truth is that many patients will explore alternative medicine without telling their doctor. I prefer taking a proactive approach, so they know I am on their side, and that they do not need to hide anything from me !

I am quite happy with this approach if the intervention is simple , harmless and inexpensive. I then feel that it's worth trying, even if there is no "evidence" that it works, provided the patient understands that this is not evidence based medicine and is willing to use themselves as a clinical trial, where n=1 ! I believe in Integrative Medicine and do not feel that Western medicine has all the answers. This is especially true when dealing with problems such as poor ovarian reserve, when we have very little which is useful to offer to the patient.

There are many intangible benefits to doing this. Most importantly, the patient feels that they have done everything humanly possible , and the peace of mind this can give them is invaluable ! It helps me to keep an open mind, and I learn from my patient's experiences. I am happy to share their successes and failures with other patients - and I feel Julia Indichova's book , Inconceiveable , is a great example of what the determined and motivated patient can achieve, even when the odds are against her. In fact, it is based on these "anecdotal successes" that we can learn newer techniques for treating our patients !

However, I do draw a line , especially when the treatments are expensive. Good examples of such useless treatments are Clear Passage Therapy and Proxeed. Patients need to be protected from quacks, and a good doctor will help them to do so.

What Doctors Want You to Know About the Web Practitioner Schools

What Doctors Want You to Know About the Web What's the first thing you do when you start feel a cold or illness coming on? If you're like many Americans, you probably don't pick up the phone and make a doctor's appointment. Instead, you're probably more likely to go online and Google your symptoms. But no matter how much you rely on the Internet for school or work, you shouldn't trust the Internet quite as much when it comes to your health. Why? Keep reading for the risks and benefits of using the web, according to doctors.

Embryo transfer versus embryo implantation

Many patients do not understand the difference between embryo transfer and implantation and will often confuse these terms.

Embryo transfer is a simple mechanical process in which the doctor inserts the embryos into the uterus, using a catheter ( a plastic hollow tube).

This is usually an easy procedure which takes about 10 minutes to do. It is done by the doctor, and is usually performed using clinical touch ( where the doctor guides the catheter through the cervix into the uterine cavity with his sense of touch: or with ultrasound guidance).

In some patients ( for example, those with cervical stenosis ( a narrow cervix) or with an angulated cervix, the procedure may be technically challenging, and the catheter may not pass through the cervix easily. There are many ways of solving this problem , based on the difficulty and the doctor's experience and expertise. The doctor may use dilators or special catheter sets, which are designed to help him negotiate the cervical canal; or do the procedure under general anesthesia; or
do a ZIFT, thus bypassing the cervix altogether and transferring the embryos directly into the fallopian tubes.

Implantation, on the other hand, is a biological process , and involves three phases - apposition, adhesion and invasion. This is not in a doctor's control, and while most doctors are very good at making embryos in the IVF lab and then transferring them into the uterus, whether these embryos will finally implant or not is not in anyone's control.

Unfortunately, implantation is not an efficient process, whether done in the bedroom or in the clinic , and only about 30% of apparently perfect embryos will finally become babies. The commonest reason why embryos do not implant is that they have a genetic abnormality , and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which we still cannot screen for efficiently. However, as PGD technology improves, our ability to do so will also improve !

So if your doctors makes good quality embryos and transfer them into your uterus, this means he has done a good job. Now whether these embryos will become babies or not you will find out only after the dreaded 2 week wait !

Empty Arms - The Lonely Trauma of Miscarriage

Between a rock and a hard place

I just finished doing the Day 12 IVF cycle scan of a patient with poor ovarian reserve ( also known as diminished ovarian reserve, or oopause) from the UK. She had already failed 3 IVF cycle in the UK, and had come to us for IVF. We used the aggressive superovulation ( letrozole antagon ) protocol, to help her grow more eggs

The aggressive superovulation worked, and the Day 10 scan showed she had 4 mature follicles . However, this scan also showed she had a small 0.5 cm size polyp in the uterus. This was an unexpected finding, as the Day 3 check scan we had done for her before we started her superovulation showed her uterine lining was normal.

Polyps are benign finger-like growths found in the uterine lining. They occur because of a localised growth of endometrial tissue; and since they are estrogen dependent , they grow in size as the estrogen levels rise.

How polyps affect fertility is still unclear because it is quite common to find polyps in healthy young fertile women as well . However, a concern is that large polyps may prevent embryo implantation, because they may act as a foreign body.

The truth is that we still do not understand the natural history of polyps. It is quite possible that lots of fertile women have small polyps ; and because these do not interfere with pregnancy , they are never detected.

IVF specialists tend to treat every abnormality we see. Since we see only infertile patients, we often assume that every problem we see must be contributing to the infertility - which is why it must be "corrected".

Sometimes these "abnormalities" are just incidental findings of no clinical importance; and we may sometimes end up overtreating our patients, in our enthusiasm to diagnose and treat abnormalities.

I discussed her options with her.

If she had had lots of eggs, one option would have been to go ahead with the egg collection; to freeze all her embryos; and then , in the next cycle, do a hysteroscopy with polyp removal , and then transfer the frozen embryos after thawing them.

However, this was not a very good option for her since she had only a few eggs and there was a risk that we may not have many embryos to freeze , which meant that there was a possibility that her frozen embryos would not survive the thaw.

The other option was to cancel the cycle. She was understandably reluctant to do this. These were hard earned , expensive eggs , and she did not want to waste them

We finally decided to go ahead with the egg retrieval and the embryo transfer ; and keep our fingers crossed and hope for the best.

Of course, if she gets pregnant, we'll all be very pleased we made the right decision ! If she does not get pregnant, we may kick ourself for not removing the polyp ( even though this may not have any impact at all on her chances of success). Life can be hard when we do not have enough evidence to make the right decision - but medicine is a messy biological science, and sometimes we just need to make the best of a bad deal !

Adoption in India: More Americans Plan Surrogacy Abroad - ABC News

Adoption in India: More Americans Plan Surrogacy Abroad - ABC News: "Reproductive tourism is now a $500 million business with hundreds of clinics across the country offering surrogacy. There is concern, though, that with no legislation governing the industry and so much money on the table, commercial surrogacy has also become a breeding ground for unethical practices. There are reports of couples being swindled and of dermatologists masking as fertility doctors to cash in.

'What happens is infertile couples are very easy to exploit,' said Dr. Aniruddha Malpani, an infertility specialist in Mumbai, India. 'A very common racket is to say, we will take the payment and then at 14 weeks, 'Oh, I'm very sorry to tell you that the woman miscarried.''

But for many couples, the benefits of a successful surrogacy far outweigh any risks.

Mary and Victor Hui-Wee's Indian journey ended blissfully with a beautiful baby boy.'It just was a dream come true to actually see him,' said Mary Hui-Wee. 'And he's ours. He's beautiful.'"

In order to make sure all surrogacy arrangements have a happy ending, it's important to find a reputed clinic to help you have a baby !

IVF doctors and oneupmanship

There is no question about the fact that IVF is a competitive business. IVF clinics are usually run by doctors in private practise, who do their best to attract lots of patients to maximise their revenue.

This competition can be good for patients because it enforces doctors to keep their prices competitive; and they also need to ensure that their technology is updated, so that they do not fall behind.

However, this can be a mixed blessing. One effective way of getting patients is to get an interview published in the press. This is why many doctors now employ PR agents, to ensure that they get a lot of press coverage. While this has its pros ( it creates a lot of awareness about the newer medical options which are available for treating infertility) , some of the downsides are that health journalists are often not sophisticated enough to differentiate between hype and reality - and they may end up misleading patints by providing inaccurate information supplied by the IVF doctor who wants to promote his clinic as being the best.

Along with competing with other IVF clinics for press coverage, many IVF doctors also play a more subtle game of oneupmanship within the clinic !

When a patient comes to you for a consultation, how do you show her that you are better than all the other IVF doctors ? What makes you their best choice ?

Let's take the case of the patient who has failed one IVF cycle, and is now looking for a second opinion. This patient has already lost confidence in IVF doctors and is now "looking for the best" !

There are many subtle ( and not so subtle) techniques doctors use to influence the way the patient perceives them.

1. Give appointments after many weeks , to show how busy they are !

2. Give the patient an appointment, and then make them wait for ever and ever, in order to see the doctor. ( It's easy to do this if you have poor time management skills, and overbook lots of patients for the same slot ) Patients are very impressed by how busy the doctor is ! As Prof Cialdini's book, Influence showed, social proof is a powerful way of influencing others !

3. Order lots of tests - and the more expensive and esoteric they are, the better ! This long list of tests shows how thorough this doctor is ( in comparison with the earlier doctor, who missed out on doing all these basic tests - another testimony to his incompetence !)

4. Use new ( unproven and untested) tests and treatments ( such as IMSI)

5. Use lots of jargon to confound the patient. Any one who uses so many polysyllabic words must truly be an expert !

6. Criticise the earlier doctor, for not doing a good job ! ( for example, if the doctor did a Day 3 transfer, even if this is standard medial treatment, say they should have done a Day 5 transfer). It's very easy to be wise in hindsight, but you do not improve your standing by pulling someone else down !

The truth is that you can fool some of the people some of the time - and it's especially easy to fool infertile patients , most of whom are very vulnerable and desperate. However, this approach can also often backfire. Badmouthing other doctors can end up hurting all doctors ! You cannot build up a patient's confidence in your medical skills by undermining her confidence in other doctors ! Also, what goes around comes around - and the other doctor will be happy to badmouth you when your failures go to him ! Doctors need to take a more mature approach - if you are good, you are good , and you don't need to be any better than anyone else !

Why do doctors treat patients as idiots ?

Image via Wikipedia

Many doctors underestimate their patient's intelligence. The truth is that most patients ( most of the time):
1. want to know as much as possible about their illness and their treatment options
and
2. are smart enough to understand their options

Patients want to be treated with respect. They look up to their doctor - and trust he will do a good job treating them. So why don't all doctors treat their patients as intelligent adults - someone who is capable of understanding what has gone wrong and what the doctor needs to do to fix the problem ?

Do doctors feel threatened by patients who ask questions ? Or is it that they do not have the time or energy to answer these questions ?

Some well-meaning doctors are worried that patients will not be able to understand the niceties of their medical problems. The nuances of medicine can be subtle, and few answers are black or white. Most are shades of gray, and these doctors are worried that providing additional information will just end up confusing the patient.

Others are not happy about sharing the uncertainty which is inherent in medicine with their patients. They want to be perceived by their patients as being the expert, and this is why they need to provide unequivocal answers. Others are concerned that discussing unclear issues with patients may cause them to lose confidence in the doctor. They believe that patients expect clear-cut answers - and that it's the doctor's job to provide these. Why add to the patient's confusion by talking about ifs and buts and maybes ? Doing so also runs the risk that the patient may end up selecting an option the doctor does not personally like - and this will just add to the tension.

I believe that if the patient cannot understand what the doctor is saying, the fault is the doctor's - he is not doing a good job explaining ! Most patients are quite sophisticated, and are used to handling uncertainty in their daily life. They want a doctor who will discuss their options with them, and provide guidance when asked for, rather than tell them what to do and expect them to blindly follow instructions.

I have found that sharing medical journal articles with patients will often them to come to terms with their disease, and help them to make the right decision for themselves.

Good doctors have a deep understanding of the technical minutiae of their specialty - and while they are capable of doing advanced research and publishing in medical journals, they are also capable of simplifying and explaining all the nitty gritty of their specialty to their patients !

Patients who are treated as idiots tend to behave like idiots !( Of course, sometimes patients do behave like idiots on their own as well , but thankfully this is a small minority !) Patients who are treated with respect will , in turn, respect the doctor and look upto him as a trusted professional , for guidance and wise counsel.

I treat many patients who are CEOs . They are very smart and teach me all the time ( if not about medicine , then about how to run my practise, for example !) If they are bright to run a company, I am sure they are smart enough to understand everything about IVF. Clever doctors will acknowledge the patient's expertise and make use of this !

Doctors need to take a proactive approach and understand that teaching their patients and treating them with respect is a great way of differentiating themselves from the competition.
The web is a great tool for patient education - and the nice thing about developing patient educational modules on the web is that once they have been developed, they can be used many times !

I have found this very rewarding, and you can see some of the patient educational modules we have developed at www.ivfindia.com. This is a "proof of concept" - and we hope that other doctors will use this as a model they can emulate !