Tuesday, January 31, 2012

The Health 2.0 conference in India

I've just come back from attending the Health 2.0 India Conference held in Delhi. The conference was a lot of fun and I enjoyed myself thoroughly. The format is extremely interesting , because they compress a lot of information in a small amount of time without ever letting it get boring . For example , the demonstrations are just four minutes ; and the panels last for about 1 hour, so attention does not flag.

The themes are intriguing ; and I was very impressed with the ability of the Health 2.0 conference organisers to get such a diverse group of people with such different interests all together on one platform . These are people who come from various different backgrounds - designers; software geeks - and even some doctors ! ( The pharmaceutical companies were notable by their absence - it seems that they do not think they are in the business of providing healthcare ! )

They all share one passion - How can we use our skills to be able to provide better health care - whether the healthcare is for someone who is a multimillionaire living in Bombay ; or someone who works in a small village in Rajasthan. The common denominator seems to be the clever use of technology and it was quite interesting to listen to these presentations . I enjoyed the chance to meet people from all across the world, all of whom work in the same area - this bolsters your confidence that this is work which is well worth doing !

The star of the show was Mr Anil Swarup an Indian government bureaucrat who's actually completely revolutionized how health insurance can be delivered . Thanks to his innovative scheme, the Indian government actually provides health insurance for over 90 million poor illiterate people . They need to pay less than 50 rupees to sign up; and do not have to fill up even a single form ! This is something I will blog about more later, but what I really liked about him was his can-do attitude and his positive infectious enthusiasm !
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Why doctors should let patients decide for themselves

I recently saw a patient who came to me for a second opinion . She was advised IVF treatment and a workup showed that she had an endometrial polyp which was about five millimeters in size . She'd gone to another doctor , who advised her to get the polyp removed before doing the IVF treatment . This is one of those gray zone areas of medicine where it's always very hard to make a definite decision because different doctors have different opinions as to what needs to be done. Most doctors would take the approach that anything inside the uterine cavity needs to be removed before putting an embryo inside the uterus ; and they would automatically and reflexively suggest an operative hysteroscopy to remove the polyp before doing the IVF cycle. This is standard medical advice and is perfectly reasonable. However, there are other doctors who feel this is unnecessarily aggressive , because there is no proof that a small polyp can affect embryo implantation. This is a vexed issue which is very controversial because there aren’t enough studies to be able to come to a definitive conclusion. This is hardly surprising. Most IVF specialists will see only infertile women , so any time they see someone with a polyp , they will assume that the polyp is the cause for the infertility and will advise removal. However, the fact remains that lots of fertile women will also have endometrial polyps , which neither they nor the doctor will ever find out about , because they have enough sense not to go to a doctor to get this diagnosis !

So what is the doctor to do ? and what about the poor patient ? She gets conflicting advice from different experts, one of whom advises surgery and the other one advices you don’t need to do anything at all about it. This is the kind of situation where information therapy is extremely potent . We need to empower the patient with information so the patient can decide for themselves.

What I usually do is explain both options to the patient along with their pros and cons. While this works well with educated, intelligent patients who are capable of making a decision for themselves , there are lots of patients who don't like this approach. For one , they think I’m wishy -washy ; and for another they conclude that I don't know what to do myself , which is why I'm asking them for their advice ! In reality , I’m not asking them what to do - what I'm helping them to do is to come to a decision which they feel will be right for them.

At the end of the day , outcomes are always uncertain. It's not that removing the polyp will guarantee IVF success ; while keeping the polyp will not mean that the IVF cycle will fail. However, there are some patients who are petrified of surgery and will do anything to avoid it. On the other hand , there are patients who are very sure that they want to maximize their chances of success by removing all possible obstacles and hurdles ( no matter how speculative) which may come in the way of their IVF cycle succeeding.

The trouble is a doctor can’t read a patient's mind which is why we need to ask patients to provide their inputs ; and we need to factor these inputs in when we make a decision. I always tell patients the buck stops with me. After all , I am the professional and since I am the doctor , I guarantee that I will never let them make a wrong decision . On the other hand, when there are choices , I encourage them to apply their own mind and to provide their personal inputs , so that we can jointly make a decision which is right for them.

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Monday, January 30, 2012

Why patients need to become experts !

I saw a very interesting patient today. She’d been referred to me by a gynecological oncologist who had made a diagnosis of early endometrial adenocarcinoma and had sent her to me because she wanted to find out what her reproductive options were. This was a young 24-year-old woman with polycystic ovarian disease who had just got married six months ago. She had gone to a doctor for an evaluation because she had heavy menstrual periods and the doctor found she had a uterine polyp , which is why she performed a hysteroscopy . Much to her dismay , when the histopathology report came back , it showed she had complex hyperplasia with atypia with early endometrial adenocarcinoma .

Further evaluation showed this was a localized cancer with no invasion , and she wanted to know whether it was possible for her to conserve her uterus because she wanted to complete her family. Now the standard advice in this situation is to go ahead and do a hysterectomy. This is what most doctors would advise because it is actually much safer for them. For one , it's standard medical advice. After all , when you have cancer , you remove it - who can argue with that ? For another, it actually helps to protect the doctor ! In case the doctor does not advice surgery and then the cancer spreads , the patient may come back and sue the doctor for not advising surgery in the first place. This is why many doctors are quite reluctant to advise nonstandard approaches - because of the fear of being sued.

My approach was simple. I told the patient you are going to have to become an expert on your problem. Not only will you have to learn a lot about endometrial adenocarcinoma and its treatment options , you are going to have to learn about polycystic ovarian disease and fertility and infertility and IVF as well. The trouble is that I'm an IVF specialist and don't know much about endometrial cancer - whereas your gynecological oncologist knows a lot about the endometrial cancer , but may not know much about IVF , which is why you need to inform and educate yourself. Not only do you need to understand the alternatives and options , you also need to provide your own personal preferences and inputs so that you make a decision you’re comfortable with.

The outcome for any treatment is always going to be uncertain , and you don't want to beat up on yourself later on that you made a decision without having all the right inputs. Patients need to make a decision matrix of what their options are and then think through their personal preferences, so they can come to a conclusion which they comfortable with. It’s very helpful to document this in writing , so that patients can systematically walk their way through all the steps . Their doctor also is protected , because he can document that he’s explained the pros and cons ; and the patient has provided informed consent before making a decision which may have outcomes , some of which are likely to be unfavorable to the patient.

Unfortunately, few doctors in India take this approach. Most of them prefer being paternalistic – their approach is that patients come to us with their problems because we are the experts ; and it's our job to provide solutions ! They will often provide just one simple solution with a black-and-white approach and then tell the patient - You can either accept this solution if you want to come to me ; and if not, you can find another doctor and go somewhere else. While this is a straightforward approach and something which works well for some doctors , it is not one which I'm comfortable with myself because it doesn't allow the patient to play any role at all in such a complex decision-making process which will affect the rest of her life !

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Saturday, January 28, 2012

Science, IVF and God

An online patient asked me a very intriguing question recently.

"Do you think a superhuman power plays a bigger part in deciding whether the embryo should implant or not? From your experience as an IVF doctor for several years whats your conclusion after seeing so many IVF cases - or do you think its just science, probability and luck? Have your ever noticed any difference in a successful patient's mentality and an unsuccessful one?"

Read more at http://www.drmalpani.com/science-ivf-god.htm
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Friday, January 27, 2012

Why do so many women stop treatment after failing their first IVF cycle ?

Most infertile women know that IVF represents their best chance of having a baby, which is why they sign up for the first IVF cycle. Those who have realistic expectations understand that the failure rate in one cycle will always be more than the success rate, which is why they should be prepared for the fact that they may need to do a second or third cycle before they achieve their goal of having a baby.

Read more at http://www.drmalpani.com/why-stop-treatment-after-failing-first-ivf-cycle.htm

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Wednesday, January 25, 2012

Why bed rest after embryo transfer is a bad idea

Many doctors advise bed rest after ET. Ironically, even if doctors don't , many patients ( and their family members) will impose this on themselves . Many patients are worried that their embryos will fall out if they walk around, which is why they remain flat in bed after their embryo transfer.

This is completely illogical ! Your embryos are safe in your uterus. Nothing you do can harm them , so please do not worry about this. However, it's hard to change preconceived notions - especially when they are so deeply embedded.

I first try to use logic. I ask them - Do people rest in bed after having sex in their bedroom ? If they don't need to take precautions in their bedroom, why should you take any ?

The reply usually is - But isn't IVF artificial ?

This is illogical. IVF is not artificial or unnatural. All that we are doing in an IVF cycle is mimicking what would normally happen in the bedroom, but is not happening naturally, because of a medical problem. The test tube acts as a fallopian tube for helping the embryo to grow in vitro for a few days, that's all !

Once it reaches the uterus, it really does not matter that the embryo has spent a few days in the IVF incubator ! It behaves exactly the same way as an embryo created after well-timed sex in the bedroom. Whether the embryo was formed in vitro or in vivo does not matter as far as implantation is concerned.

If logic fails, I try appealing to emotions. I remind them that God has designed the body with enough sense, so that the embryo cannot fall out , so there's no reason why they should worry !

In fact, bed rest can actually be harmful and counter-productive and I believe it reduces the chances of success. For one thing, it increases stress levels and makes the long 2ww even worse. It demoralises patients, who sit and brood about their chances of success all day long, thus helping to drive them ( and their spouses) crazy ! It causes constipation; and increases the risk of deep vein thrombosis. Prolonged physical inactivity is medical harmful !

Even worse, it encourages a subtle form of blaming the victim if the cycle fails. It's physically impossible for a healthy young woman to sleep all day long in bed , so they are not likely to do so. Now, if the cycle fails, she is quite likely to blame herself for the failure ! ( " I got up to have a shower, which is why my embryos fell out " ). Even if she does not blame herself, family members may do so - or her doctor will , because he needs to provide an explanation why the cycle failed even though he provided such good quality treatment.

Please do remember that implantation is a normal biological process , whether your embryos were created in vivo or in vitro ! This is not influenced by diet or activity - and is completely
out of our control. Please don't let your mind play games with you.

Keeping physically active; and keeping yourself gainfully occupied and your mind engaged will help you cope with the stress of an IVF cycle much better, so there's no reason why you should not go back to work after your embryo transfer.

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Monday, January 23, 2012

Why do IVF patients drop out of treatment ?

One of the biggest problems IVF doctors face is the fact that patients will often drop out of IVF treatment, when they fail their first or second cycle. This is a tragedy because the fact is that repeating the IVF cycle is often their best chance of success . It’s disappointing that no one has researched what makes women who continue doing IVF treatment even after a failure different from women who choose to drop out.

Read more at http://www.drmalpani.com/why-do-ivf-patients-drop-out-of-treatment.htm

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Friday, January 20, 2012

Making babies without making love

When most couples get married, they expect to have sex and get pregnant , when they are ready to start their family. However, some find to their dismay that they are not able to have sex. This could happen because of many reasons.

Some men have ED ( erectile dysfunction), as a result of which they cannot achieve intravaginal penetration. At the other end of the spectrum are men with such severe premature ejaculation that they end up ejaculating before they can penetrate - the end result being the same - an inability to consummate the marriage .

Read more at http://www.drmalpani.com/making-babies-without-making-love.htm

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Thursday, January 19, 2012

What to do when a patient complains - a guide from Dr Malpani

Doctors try to do their best to take care of their patients. They work hard and will often put in long hours to make sure their patients do well. However, some patients are sometimes unhappy with the care they receive. Often , this may not be because of any fault on the doctor's part. The patient may be upset about having had to wait too long; or be angry because the receptionist was rude. Some patients have unrealistic expectations - while others want VIP care 24/7 , and expect the doctor to see them first, even when there are other patients who are waiting .

When patients are unhappy, they get upset and complain. Sadly, doctors often do not know how to handle these complaints from patients. However, do remember that medicine is a service profession; and whenever there is a complaint, this is actually an opportunity for service recovery.

Please don't lose your cool or brush the patient off. Try to put yourself in your patients' shoes - patients don't like coming to doctors; and it's easy for them to get upset because they are worried and emotionally fragile.

Please don't make a bad situation worse by refusing to see the patient or pooh-poohing his concerns - this can can quickly snowball and allow a minor issue to escalate until things get ugly.

Try to take the approach that patients are rational; and that most will not complain to you unless they have a very good reason to do so. Every complaint is a gift - and if you spend time and energy on fixing the problem, patients who complain can often become your most ardent advocate.

It's worth spending the time investigating all complaints and fixing the problem. For every patient who complains, there are likely to be ten who keep quiet - but who will walk away and go to another doctor.

It's not possible for a doctor to be present in his clinic and supervise all his staff all the time - and if a particular complaint keeps cropping up ( for example, about a receptionist who is rude), this is a chance to fix this problem before it gets out of hand and creates more damage.

Often , all you need to do is to give the patient a patient hearing. Sometimes the chance to vent; and to hear a simple sorry is all that patients want. Of course, not all problems are so simple, but unless you take all of them seriously, you won't know which ones are serious and which ones are not !
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Wednesday, January 18, 2012

The golden rule as applied to Medicine

The golden rule is timeless - Do unto others as you would have them do unto you.

However, it's very difficult to to apply this in medical practise, simple because it's impossible for a doctor to read a patient's mind and understand what his personal priorities are. This is why most doctors just blindly apply "evidence based guidelines" when treating patients. However, these have been developed by mindless committees - and it's a truism in medicine that one size cannot fit all.

This leads to a lot of unhappiness -
for doctors ( who are frustrated that their patients do not provide more articulate inputs) ;
for patients ( who don't want to be treated as a number) ; and their
family members ( because they feel that the doctor impersonal and does not care).

A feel a better option would be for all doctors to treat all their patients as if they were doctors.
This would solve a lot of problems !

Thanks to professional courtesy , most doctors are on their best behaviour when treating other doctors. It's a good idea to treat all patients with the same degree of respect !

When talking to doctors, doctors are very careful with their explanations, because they know that the doctor is well-informed as well ! They don't talk down to them; and will treat them as equals.

Most importantly, doctors will allow other doctors to make their own decisions. They treat doctors as empowered patients; and will handle them as being partners in the treatment process.

Does this mean that doctors abdicate all their responsibility and just do what their patients want ? Of course not ! Even when treating another doctor, the doctor is still a professional; whose job it is to ensure that the patient does not make a wrong decision. This combination allows patients a mix of both freedom and safety ; they are secure that they have the doctor's professional expertise backing up their decision, so that they know they are not doing something stupid; while at the same time they are happy that the doctor is willing to listen to them and to respect their personal preferences.
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Tuesday, January 17, 2012

Why do doctors make patients wait?

It’s quite common to see patients waiting for hours on end to see senior doctors in India today. The very busy doctors are extremely busy and their waiting rooms are packed full of patients and worried relatives. The irony is that patients are extremely unhappy about having to wait so long in order to see a doctor for just a few minutes of his attention.

However, if patients are so unhappy , why do they continue to put up with this ? And how do doctors get away with such terrible behavior? The only reason doctors can afford to make patients wait is because patients are willing to wait - so the key question is - why do patients wait so long in order to see a famous brand-name doctor ?

It's not as if there is a shortage of doctors in India. There are lots of extremely well qualified experienced expert doctors , many of whom have started practice after training overseas for many years and are therefore well qualified. However, they don't have many patients at all. So why don't patients go to see these technically competent doctors , rather than wait for hours on end to see the “ famous “ doctors.

Let’s start by accepting that patients are rational , and that there is a good reason that they do this. It's a question of managing their perceived risk. Patients are worried when they are sick , and they want to make sure that they get the best possible medical care. According to them , the best way of getting this care is by going to the right doctor - the one who has the most experience and who can help them to fix the problem. The only way they know of finding the right doctor is by asking around , and since there are very few doctors who have this reputation of being the very best , these are the doctors whom all patients then seek out !

Because there are so many patients waiting to meet such few doctors , and the doctor has only a few hours in a day when he can be productive , patients need to wait for hours on end to see him. The question then arises – What can the young expert doctor do in order to attract some of these patients from the older more senior doctors ?

What they need to do is to reduce the risk in the patient's perception by being able to convince the patient that they are experts ; and know what they're talking about. Now this can be extremely hard to do , because there's so much at stake here . It maybe a question of the patient's life, which is why patients are very reluctant in order to go to new doctors who don't have a brand-name & would rather stick with the senior brand name doctors , simply because of their reputation.

One thing which young doctors can do is set up websites , where they can inform patients and their relatives about their experience and expertise , so that it becomes easier for patients to be able to find out who the available experts are ; and what kind of expertise they have. Of course just putting up a website is not enough. I think the one important thing doctors need to offer is a free second opinion online , so that patients can actually test and try out the doctors medical expertise by judging the quality and timeliness of his answers, without experiencing any risk.

The patient can ask questions by submitting his medical documents and records online, which the doctor can then review and provide a second opinion on . Since this doesn't involve traveling on the part of the patient and he doesn't actually have to physically hunt for a doctor or travel many hours in order to find the doctor , it's quite easy for him to be able to get many second opinions. Once he has more than one opinion , he's then in a better position to judge the experience and the expertise of the Doctor.

Doctors who are helpful and are willing to explain and answer questions will obviously start standing out , and will be able to build trust and confidence in patients that they are the right doctor for them – that they are professionals who know what they're talking about. This actually makes a lot of sense for the new doctors as well. They are not very busy , which means they have enough time on their hands; and they can invest this time in order to reach out to patients and try to help them . It’s something which they can do quite easily , because they are doing it online , so it doesn't consume much of their time either .

In the long run , it will be possible for them to attract patients from the senior more experienced brand-name doctors to their own clinics ; and this is a simple way of allowing the services of doctors to be more uniformly distributed amongst patients , so that patients don't have to wait extremely long hours in order to just see the “ top names “ doctors.

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Monday, January 16, 2012

How to distribute patients more fairly amongst doctors

One of the problems with private medical practice today is that the busy doctors are very very busy; while other doctors ( who are equally competent but don’t have a “brand name” ) don't have enough patients to see , which is why they waste their time twiddling their thumbs. This kind of mismatch and inequitable distribution of demand for medical services creates a lot of unhappiness for doctors and patients as well.

The busy doctors act as prima donnas. They are extremely rushed and don't have enough time to do justice to their patients. Ironically, their patients are unhappy too , because they often have to wait for hours on end to see their doctor. Even worse , society loses on the expertise and the ability of the young doctors who may actually be even better technically than the more senior ones , but because they don't have the brand-name , are not being able to attract any patients.

This is actually a great opportunity for clever entrepreneurs to create a platform in order to solve this inequitable distribution problem. Part of the problem arises because of the perception of risk on the part of the patient. When you fall sick , you want to make sure you go to the best possible doctor available . This is usually the guy with the best brand-name - the one with the top reputation ( which may often not be deserved; and is often bought by using clever PR services and huge marketing budgets).

Patients are reluctant to find out if there are other doctors who could provide equally high quality services. It is very difficult to discover how good your doctor really is ; and what his skill and experience and expertise are , which is why you use his “ reputation “ as a surrogate marker for your doctors capabilities .

Here’s a solution. It’s possible to create a platform where patients could upload their medical records and ask specific questions about their medical problems on this platform . Doctors who have spare time and are anxious to see more patients could then offer to provide second opinions , preferably free of cost, to these patients. This way you’re setting up a competition amongst doctors for the patient's services - and the patient then gets a chance sitting at home to evaluate the doctor’s replies . Amongst the replies which he gets , he can then pick and choose which particular doctor he wants to go to ( based on the timeliness and quality of the doctor’s reply !) .

This is a system which is likely to be extremely helpful for patients because it allows them to get multiple second opinions that inform and educate them about all their treatment options. It’s also good for doctors because the non-busy doctors will have enough time and energy to devote to crafting high-quality answers to questions which will allow them to attract more patients. The extremely busy doctors would not be affected anyway because they're very busy seeing real life patients , so that they really couldn't care much about some of the patients going off to another doctor.

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Thursday, January 12, 2012

How reframing a problem can help to fix healthcare

Most patients feel that the biggest problem with health care today is that there are just not enough good doctors. They feel that the few good doctors in their town are extremely busy and don't have enough time for them. Most good doctors offer appointments after 2 to 3 weeks - and then when they finally do see you , they usually make you wait for 2 to 3 hours and usually talk to for just about 5 to 6 minutes. This lack of communication creates a lot of angst and disharmony amongst patients who feel that they are not getting the best possible medical care.

Patients feel trapped and helpless because they feel that it's the doctor who has all the specialised medical knowledge and skills and tools in order to help them to get better ; and that if there just aren't enough good doctors, what can they as poor patients do? This is why they will often use contacts in order to get an appointment with the person who is considered to be the best doctor in town, so that they can have access to his special skills.

Part of the problem with this approach of course is that there's very little which doctors themselves can do to fix the problem. Busy doctors just keep on getting busier and busier and since they have a limited amount of time and energy in a day there’s no way they can spend more time with each patient even if they would like to be able to do so. Even worse the tragedy gets compounded because equally efficient doctors don't have enough patients to see, as a result of which their skills get underutilized and wasted , causing a lot of frustration and unhappiness for everyone within the system.

The government & medical authorities also seem to be equally helpless because the standard response is “If there aren't enough doctors , what we need to do is open new medical colleges and creates new doctors , in order to improve the doctor-patient ratio. “ Unfortunately, this is not likely to help because most patients will flock to just the top one or two percent of doctors , as a result of which the problem just continues to perpetuate itself.

I think the key lies in reframing the problem. It's not a shortage of doctors which is the problem – it’s the fact that patients feel powerless and helpless and do not realize how much they can do to help themselves, which is the real problem. We'll never be able to create enough doctors - we all know that. However, what we can do is create lots of expert patients ! Patients can learn to take better care of themselves , so that they are no longer passively dependent on their doctors. This is a very effective solution which will help to make sure that medical care gets more evenly distributed . Patients empowered with information can better make use of whatever medical resources are available to them .

It’s not the large number of patients which is the problem , but rather the fact that patients feel that they cannot do anything for themselves without the help of medical assistance from their doctors . We need to remember that patients are the largest untapped healthcare resource and we need to reinforce their ability to take care of themselves. Lots of health problems are self-limited and get better on their own ; while others are chronic problems for which the patient needs to institute lifestyle changes for himself . Very few problems are dramatic or urgent , which require emergency attention from a doctor. This approach will not make doctors obsolete or redundant – it’ll just ensure that we will be able to make better use of the limited resources we have available.

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Wednesday, January 11, 2012

The older newly married couple

We are now seeing a new kind of patient in our clinic these days. These are couples who are older and have got married recently , so typically the wife is more than 35 & the husband is more than 40. They are usually professionals who have had very busy lives and fulfilling careers . They are doing very well for themselves ; and chose not to get married for many years because they couldn't find the right person. Now that they have finally found the right person ( often online , thanks to sites like shaadi.com; or through friends, neighbors, relatives), when they finally hook up with someone they then need to decide whether they should start a family or not.

This is when they come to grips with the fact that their biological system no longer functions as optimally as it would for a younger woman ; and this can be a bit of a rude wake-up call for lots of these older women. These are typically very successful professionals who are used to doing everything for themselves and succeeding in life . They have high-profile lives and high-profile careers and most of them have been able to climb the rungs of their profession to get to whatever stage they wanted to.

They also automatically ( and naively) assume that once they have found Mister Right , they’ll be able to have a baby when they want to, because they have always been able to get what they want in life , as a result of their hard work and determination. However, when they find out that their eggs maybe too old for them to be able to get pregnant , this comes as a bit of a rude surprise and shock , because no one ever prepared them for this eventuality.

What can be very disconcerting for some of these women is how strong their craving to have a baby can be – baby lust can be a very powerful force indeed ! These are the kind of women who would have never thought of the possibility of becoming moms or thinking of themselves as taking care of babies or toddlers when they were 30, who now find that at the age of 36 that this has become the major obsession in their life.

These are very interesting patients to work with because they're well read and well informed and have done their homework . They are mature and have seen quite a bit of life , as a result of which they are very capable of making their own decisions for themselves .

Many of these women come with many regrets and a lot of emotional baggage. ( I wish I had decided to have a baby earlier ! I wish I hadn’t put it off for so many years. I wish someone had told me about the biology of ovarian aging !) It’s quite challenging to explain to them that even though IVF technology has advanced significantly , there are still limits as to what we can do when we deal with women with poor ovarian reserve.

Many of them are worried that they are now too old to be good parents and are concerned that they will not have enough energy to be able to bring up a toddler. I remind them that while their parenting style will be different from a 25 year old mother’s, in some respects it will be much better. They are likely to be much more laid back and mature; and since they have more money, they are in a better position to provide their child with a lot of life’s luxuries. Also, since they are spending so much time, money and energy on getting pregnant, they are likely to do a stellar job with bringing up their baby, who will not lack love and attention.

Fortunately, not all older women will have poor ovarian reserve ; and some of them will very happily get pregnant in the first IVF attempt itself , so that it makes all the efforts we put on their behalf very worthwhile.

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Tuesday, January 10, 2012

How to keep your doctor happy

There are lots of books and articles on practice management for doctors, which teach them how to keep their patients happy. This is obviously important for doctors because if they have happy patients their practice is likely to do well. However, let's not forget that doctors have lots of patients and an occasional unhappy patient is not likely to affect him too much. However, most patients have just one doctor and therefore learning how to keep your doctor happy should be far more important for patients as compared to doctors learning how to keep patients happy.

It's actually not very difficult to keep your doctor happy because most doctors are fairly simple creatures who take pleasure and pride in their professional work and making sure that their patients get well. The tragedy is that patients are so used to complaining when they go to their doctor that they often forget to say simple things like – Thank you for helping me to get better.

The irony is that this is such a simple thing to do – and the patient who does remember to be complimentary to the doctor and say thank you is actually likely to have a much happier doctor as compared to patients who treat their doctors purely as technicians. Investing some time and energy in thinking about your doctor and remembering to thank him when you do get better can make a world of difference in the quality of care which you get from the doctor.

It’s equally important to say thank you to the staff as well. After all , his staff are the gatekeepers - the ones who are responsible for controlling access to the doctor . If his staff knows you by name & remembers you as a person who smiles and is thoughtful about their needs and requirements, you’re likely to have a much happier and kinder doctor. Patients who are smart & learn to keep their doctors happy are much likelier to be happy patients !
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Monday, January 09, 2012

Why is surrogacy so overused ?

After a failed IVF cycle, many patients feel that surrogacy would be their best option. It's true that this does seem to be a logical solution. If beautiful embryos fail to implant after IVF, doesn't this clearly means that there's a problem with the uterus ? So let's change the uterus and use a surrogate the next time !

This sounds logical - and is a solution which is promoted by doctors as well , because it's much more profitable to do surrogacy than to repeat the IVF cycle ! Also, many patients are just plain fed up of going through the IVF grind. Surrogacy seems like a very convenient shortcut to success !

Sadly, this is flawed reasoning. The commonest reason for the failure of implantation of beautiful embryos is not the uterus - it's usually genetic problems with the embryos. 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 cannot be screened for.

Let's not forget that human reproduction is not an efficient enterprise - and that even normal fertile couples take time to make a baby in their bedroom ! It's only in Hindi films that everyone gets pregnant the first night they try !

The truth is that not all genetic problems in the embryo can be diagnosed, even with modern sophisticated techniques using PGD/CGH ( preimplantation genetic diagnosis using comparative genomic hybridisation). This technology is still very crude - and while it's good for identifying embryos with gross chromosomal problems, it cannot rule out all lethal genetic defects.

Even worse, patients have unrealistic expectations from surrogacy - please do remember that IVF surrogacy success rates are not 100 % either ! It's quite likely that if the patient had been patient and transferred her embryos into her own uterus, she would have had a healthy baby without having to waste so much money on doing surrogacy !

A simple rule in medicine is that common things occur commonly, so if you hear hooves, you should think of zebras, not horses. If you have failed multiple IVF cycles, and want to change something, it's a much better option to change your doctor; or to change your embryos by using donor eggs, rather than change the uterus !

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Saturday, January 07, 2012

Primary healthcare in India gets a corporate lift

Primary healthcare, dominated by the state system and family physicians, is increasingly drawing the attention of India’s corporate sector, which has thus far directed most of its investment towards the specialities.


All these clinics will invest in IT in a big way ( EMRs and PHRs) to be able to provide more efficient and cost effective care for their patients !

Is the bedroom better than the clinic for making babies ?

I see lots of young married couples who come to me for counselling. They are not technically infertile, but are very anxious to conceive. Many of them have very busy stressful jobs, which means the often just don't have enough time to have baby making sex ! Others are being pressurised by parents to start a family quickly - while some hear their biologiocal clock ticking away, because they got married after the age of 30 !

The now want a baby as a priority - and expect this to happen on demand. When this doesn't, they get upset and ask me for help.

My advise is that it's much more fun making babies in the bedroom than coming to me. I try to discourage them from using my services; and encourage them to try on their own more actively.

However, I had an interesting conversation today , which is making me re-think my approach.

This was a young man, who is the CEO of a company. He was complaining that timed baby making sex was ruining their relationship. " Doctor, we've stopped having sex for fun ! My wife
forces me to perform only on demand, when her ovulation test kit tells her she is maximally fertile. I sometimes find that I cannot get an erection at these times, and this has started to affect my self-esteem. I feel my wife is treating me purely as a stud - and I am starting to resent this. This has now set up a negative vicious cycle, as she feels that I do not care about her ; and do not love her anymore when I cannot even get an erection !

Small fights are becoming major sore issues - especially when she has just got her period. Her PMS has become much worse, and I actually dread the days when her period is due. The major issue is always - Will this be the month ? And if not, then what do we do next ?

When a friend who got married after us gets pregnant, our inability to have a baby becomes a major sore point and she refuses to talk to me. She thinks I am not taking this issue of having babies seriously enough; and feels that I don't care at all. I love babies and would love to be a Dad, but I really don't know how to handle her mood swings.

I am quite patient and am happy to let nature take its own course, but my wife is not happy about this. She thinks that I am refusing to cooperate because I am being selfish and do not love her.

Why can't we just expedite the baby making process ? Why wait for Mother Nature ? Can't we just go ahead and do an IVF cycle so we can move on with our lives ?

I had to agree that his argument made a lot of sense. After all, IVF is safe and effective, with a very high success rate; and no risks. Did it make sense for me to refuse to treat them just because they did not have a well defined medical diagnosis ?

After all, if the stress of coming to me is less than the stress making a baby in the bedroom, then doesn't it make sense for them to use modern IVF technology to fulfill their personal reproductive goals as quickly as possible, so that they can move on with their lives ?

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Friday, January 06, 2012

Why global health insurance brokers should promote medical tourism

The world is shrinking; and many companies have become large multinationals , with over 10000 employees and a presence in countries all across the globe. Providing employee benefits is one of their key responsibilities, and since this has become such a challenging task, they outsource this to companies which specialise in administering and harmonising these benefits. Typically, they use a single health insurance broker to provide life insurance and health insurance coverage to all their employees across the globe.

Since there such a huge price differential between elective high ticket surgical procedures performed in India and the US ( for example, for knee replacement), I was wondering why health insurance brokers do not take advantage of this and offer medical tourism packages as part of their service offerings.

Let's take the example of a GE employee in Washington DC who needs hip replacement. If the cost for this in a Washington hospital is US $ 50000; and a hospital in India can do the exact same surgery using the same artificial hip manufactured by Johnson and Johnson, for US $ 10000, wouldn't it make sense to fly the employee down to India for this surgery ?

Health insurance brokers are very well positioned to be able to identify hospitals all across the world which meet JCAHO standards, thus ensuring safety, while saving money as well. In fact, the quality of care at some of these "focussed factories" would be far better than what would be available in the "local" US hospital !

Smart patients are already taking advantage of the superb cost effective care medical tourism service packages offer them on an individual basis. Why don't corporates learn from them, and make good use of these lessons ?
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Can stress cause an IVF cycle to fail ?

There are more myths about stress and IVF than about any other area of reproductive medicine. It's become fashionable to blame stress for every failed IVF cycle - which is why "mind-body" programs which teach patients how to manage their stress have become so popular.

When an IVF cycle has gone well ( good embryos; a good uterine lining; and an easy embryo transfer) , patients expect to get pregnant. Doctors are also usually quite optimistic at the time of embryo transfer , because they want to cheer up the patient !

When a perfect IVF cycle fails, the doctor ( and the mother in law and the husband) will often blame the patient - You took too much stress, which is why your body rejected the embryos.
You need to relax, otherwise all your IVF cycles will fail. You are too uptight and highly wound , which is why all your cycles have failed so far.

Sadly, most patients also buy into this argument - after all, it's impossible to disprove ! Since they already suffer from low self esteem, many believe that it's their fault that the beautiful embryos did not implant.

I think this is a cruel form of victim blaming. Every IVF patient is stressed out - after all, no one looks forward to doing IVF . If stress caused IVF cycles to fail, then no IVF patient would ever get pregnant !

We need to remember that embryo implantation is a biological process , which is not affected by stress levels. Let's not forget that a woman who gets raped can also get pregnant - and we all know how sky high her stress levels must be !

I believe that stress does not affect the outcome of the IVF cycle. Everyone has different ways of coping with the stress in their life; and with the stress of the IVF cycle. Some people take this in their stride, while others go to pieces. However, this does not correlate with the outcome of the IVF cycle.

Yes, it's true that your ability to cope with stress does affect the IVF treatment process. It's much easier for you ( and your spouse !) to deal with the emotional roller coaster ride if you learn how to manage your stress. This is why programs such as Inner Engineering and the Art of Living can be so helpful - they teach you how to still your mind and deal with failures and uncertainty.

However, please don't blame your stress levels if the cycle fails - and don't let anyone else blame these either !

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Thursday, January 05, 2012

Coleman's Laws of Medicine

Dr Vernon Coleman qualified as a medical doctor in the UK many years ago ; and has published an excellent series of books on health and wellness. They are packed with wise insights and commonsense - and many of these are as true today as when they were first published !

Here are his 12 Laws of Medicine - something which all doctors should put up on their clinics, so patients keep them in mind when going to a doctor !

If you are receiving treatment for an existing disease and you develop new symptoms then, until proved otherwise, you should assume that the new symptoms are caused by the treatment you are receiving.
There is no point in having tests done unless the results will affect your treatment.
If the treatment doesn’t work then you should consider the possibility that the diagnosis might be wrong. This is particularly true when several treatments have been tried.
Screening examinations and check-ups are more profitable for doctors than for patients.
It is doctors, not patients, who need annual check-ups.
Hospitals are not suitable places for sick people. If you must go onto one, you should get out as quickly as you can.
There are fashions in medicines just as much as there are fashions in clothes. The difference is that whereas badly conceived fashions in clothes are only likely to embarrass you, ill-conceived fashions in medicine may kill you. The fashions in medicine have, by and large, as much scientific validity as the fashions in the clothes industry.
The medical establishment will always take decisions on health matters which benefit industry, government and the medical profession, rather than patients. And the government will always take decisions on health matters which benefit the State rather than individual patients. What you read, hear or see about medicine and health matters will have more to do with the requirements of the pharmaceutical industry and the government, than the genuine needs of patients.
Doctors and nurses know little or nothing about staying healthy. In particular, doctors and nurses know nothing about food, diet and healthy eating. (Sadly, the same is true of nutritionists and dieticians).
There are no holistic healers. There are only holistic patients.
There is no such thing as minor surgery.
Same patients will always be treated more equally than others.

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How too much testing can reduce your fertility

One of the first things medical students learn to do is to order tests . Medicine is supposed to be scientific, and test results are supposed to provide doctors with objective data which they can use to treat their patients.

It's easy ( and profitable !) to order tests - but few doctors learn how to interpret them properly. They just blindly follow what the medical text book suggests. Wise doctors know that the patient's body does not always read the text book - and good doctors know which test results to ignore - and how to make sense of the outliers !

The danger is that we are becoming overdependent on tests and this causes us to practise bad clinical medicine. Many tests are untested and unreliable and give results which are difficult to interpret. An excellent example of this is the sperm DNA fragmentation tests.

Explaining this fact to patients can take too long, which is why most doctors don't bother to educate patients that most test results rarely provide answers in black or white - they are usually shades of grey ! Interpreting them in the context of the individual patient's clinical presentation requires skill and clinical judgment and experience - something which all doctors do not possess in equal measure.

The trouble with overtesting is that this fools patients. Many naively believe that a doctor who orders many tests is more thorough; better informed and more knowledgeable - after all, he has ordered tests which the earlier doctors did not have the sense to ask for ! Doesn't this prove that he is a better expert ?

Sadly, more is not better - and newer tests are often more harmful ( and more expensive) than older tests, because they are still untested themselves ! Doctors like to play with new toys - but patients need to remember that tests are not benign ! They can be harmful and cause anxiety and worry. Even worse, they can lead to overtreatment and wrong treatment.

This situation is unlikely to change, given today's reality. Doctors find it easier ( and more lucrative) to order tests rather than to sit down and explain to patients why they don't need the tests in the first place!

Too many physicians still do not understand test interpretation. The patient's clinical presentation provides the context for any diagnostic test interpretation, not the other way around. Today, it is testing which often defines the problem , rather than serving its appropriate function as a diagnostic aid.

Thus, rather than treat the patient's infertility, many doctors end up treating the chocolate cyst diagnosed on the ultrasound scan. They advise surgery, which is beautifully performed technically - but this just ends up reducing the patient's ovarian reserve , so she now needs donor eggs ! The tests and the treatment did not help the patient at all ! Doctors need to treat patients - not just test results - and patients need to remind their doctors this basic fact !

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Wednesday, January 04, 2012

Dos and Donts during the IVF 2 ww

For most IVF patients, the worst part of the IVF treatment is the dreaded 2 week wait. While there's a lot of action ( injections, scans) and handholding ( frequent visits to the clinic for monitoring) by the medical staff during the superovulation, egg collection and embryo transfer portion of IVF , after the embryos have been transferred, patients often feel they are left in limbo for 2 weeks. The IVF clinic pretty much leaves them on their own ; and except for the advise that they have to take meds for luteal phase support, there's not much support they
offer . Each hour takes a day to pass - and the mind plays all kinds of games during this wait.

Even worse, patients are often very confused as to what they are allowed to do; and what they are not, during this period.

For example, if they get a cough, is it safe to take antibiotics for this ? Can they ask their family physician to prescribe this ? Or do they need to talk to their IVF doctor ? Can they take symptomatic relief for their constipation ? Which meds are safe for headaches ? fever ?

Patients often feel abandoned during this time. The family physician is very reluctant to prescribe tests or treatment during this time, because they do not understand much about the IVF treatment, and don't want to do anything to reduce the patient's chances of success. Their usual advise is - please ask your IVF doctor . Most IVF doctors aren't very interested in treating coughs and colds. Their advise is - we've done everything we can - please ask your family physician ! Patients feel lost - and don't know whom to turn to.

Most patients are understandably very reluctant to take any meds at all during their 2 week wait. Since their embryos have been transferred into their uterus, they are petrified that any medicine they take will have an adverse effect of their embryos. After all, aren't there lots of medicines which are unsafe during pregnancy, because they can harm the fetus ? Won't these meds also harm the their embryo ?

Actually , the truth is that they do not need to worry at all. All the prohibitions against medicines during pregnancy only apply after the pregnancy test ( HSG) is positive . Till then, there really are no special dos and don'ts at all. This maybe counter - intuitive, but the reason is simple. Until the embryo has implanted and established a significant blood supply from the mother, no medicines you take are able to have a harmful effect on the embryos.

This is why when fertile couples have sex in their bedroom, no special precautions ( regrading antibiotics or medications or X-rays) apply to them, until they miss a period ! It's exactly the same after the embryo transfer. The proscriptions against certain prescriptions apply only after HCG is positive !
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Tuesday, January 03, 2012

Should IVF doctors refuse to treat patients who have a low chance of success ?

Sometimes patients come to me with unrealistic expectations of success , and my initial knee-jerk reflex and first response is to simply say no , because their chances are so poor .

This is what happened recently when a patient with a high FSH level asked me to do IVF treatment for her. I suggested that she’d be better off using donor eggs, but she then countered by asking me an interesting question. She said , “ Doctor , why are you refusing to treat me ? This is my money which I am choosing to spend . I'm not asking anyone for any help or any assistance - I'm not placing a burden on anyone else. I understand fully well that my chances are extremely poor. I'm not asking you to raise false hopes or do anything unethical or do anything wrong. All I’m asking you to do is help cooperate with me so that I can achieve my goal, which is that I have peace of mind that I tried whatever options were available to me. I'm an intelligent woman . I understand exactly what I'm capable of doing and equally what you're capable of doing. I understand that I have ovarian failure and that my chances of success are poor but I don't want to kick myself later on that I did not give myself the best shot possible and therefore I would be grateful if you would accept my request and take me on as the patient. “

I think this was a reasonable request from a perfectly intelligent patient. She was autonomous , and was making a decision for herself. She was intelligent. She had realistic expectations. This was a treatment which didn't carry any harm. It wouldn't hurt anyone else in the process , because she wasn't using anyone else's money or consuming scarce resources to go through with her treatment . Equally , it would help her. Perhaps it would not give her baby , but would still benefit her from her perspective because it would help her to achieve emotional closure that she had tried whatever treatment options were available to her , given today’s technological limitations that we cannot create artificial eggs in the lab.

Since she needed assistance from an IVF specialist to do this treatment , I actually felt it would be unfair on my part to refuse such a reasonable request. I was pretty certain that she wouldn't grow any eggs - or that even if she did , the chances of success were practically zero. But as long as I was honest with her and explained the facts to her; and she understood this , and in spite of that chose to go on with the treatment, I concluded that I would not be fair in my part to refuse her.

One of my colleagues was quite critical of my decision. He said as a medical professional, it’s important that you decide what patient’s requests are reasonable and what requests are unreasonable. This is not the kind of patient whom I think you should treat because your ability to be able to help her to have a baby are extremely slim. You know that and it's your job as a Doctor to tell her that so she doesn't pursue this foolhardy course.

I agreed with him that from a purely medical perspective , his stance was correct and that my ability as a medical professional to help her have a baby was very slim , given her high FSH level and her poor ovarian reserve. However, my ability to help her as a professional , not just in the limited perspective of giving her a baby , but of helping her to achieve her heart’s desire and emotional closure that she'd given it her best shot were something which I felt I could not in all fairness refuse.

I think it is my job as a doctor to counsel patients and offer them advice and my personal perspective. However, I also think it's perfectly acceptable for them to override my decisions and come to their own conclusions. As long as these will not harm them, I'm quite comfortable with allowing them to follow their hearts desires. After all I can never walk in her shoes ! Going through the IVF cycle would help her to come to terms with the fact that she would never be able to have a baby with her own eggs and that technology could not help her. Even if the cycle failed, she will still be better off than if she never tried at all.

In fact, going through the cycle would change her as a person hopefully for the better a) because she'd given it her best shot and b) because it might help her to then consider alternative options for carrying on with her life, which could perhaps include either being contented living a child free life ; or considering adoption, or even donor eggs.

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Monday, January 02, 2012

Why second IVF cycles are much easier than the first

Many women go to pieces when their first IVF cycle fails; and some will just give up trying to have a baby after this failure.

This is a tragedy, because second IVF cycles are often much easier than your first cycle.

For one, you know what to expect. The fear of the unknown has gone away; and you have
learned that there is no pain or surgery during the IVF treatment . Also, you have an additional comfort factor, because you have now established a relationship with your doctor and the nurses.

More importantly, you now have much more realistic expectations. In the first IVF cycle hopes are always very high. You expect this to work finally - after all, you've spent so much time, money and energy to get to this stage ! Surely God will not be so unkind and allow this cycle to
fail. Isn't IVF technology much better these days ? And wasn't your doctor very hopeful ? And weren't your embryos of Grade A quality ? How can the cycle fail when you've done everything right ?

The sad truth is that most cycles do fail, unfortunately, for reasons which are beyond our control. Human reproduction is an inefficient enterprise, whether it's in the bedroom or in the clinic.

Patients who have dealt with IVF failure are much more emotionally resilient. They can deal better with the IVF emotional roller coaster ride, and are much less stressed out.

Second cycles are much easier for IVF doctors as well ! We know how your body responds to the meds and can fine tune and tweak the protocol to optimise your ovarian response.

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