Saturday, June 30, 2012

Why do we tolerate failure in the VC industry ?

An assortment of United States coins, includin...
I am an Angel investor ; and a member of the Mumbai Angel investors network. I attended a very interesting present day presentation today on “ Patterns of Success and Failure in High Potential Entrepreneurship” by Prof  Ramana Nanda from Harvard Business School .

He had an interesting take on how the US venture capital industry has evolved. He pointed out that historically the entire focus of the VC industry in the US was to aim for the “ home run”. VCs ( and PE fund managers) were paid big bucks so that they could find the one money company which would become extremely successful. This means that fund managers were willing to invest in a lot of very high-risk ventures , in the hope that they would get luck and hit the jackpot by finding the one company which would help them to become billionaires. However in order to find that one company which would become extremely successful, they had to live with the fact that they would have to back a number of failures. In fact, in the USA, it seems that failing has become a sexy thing to do . The US financial industry has marketed the concept of the iconoclastic entrepreneur very well ! It seems that the best path to success is littered with a number of failures – which means that it’s fine if the companies which these financial whiz kids invest your hard earned money in end up failing !

He pointed out that over the last 10 years, people who had invested in the venture capital industry have earned negative returns . VC fund managers have actually lost money for their investors ! I found this quite perplexing. People who invest in venture capital funds are supposed to be savvy , sophisticated financial investors , who were extremely knowledgeable and were willing to take risky bets, in order to earn higher returns ! They were smart and knew exactly what to do with their millions – hand it over to VC who would convert these to billions !

Even more importantly, VC fund managers are supposed to be the blue eye boys of the financial sector - it's only the very bright ones who get the privilege to become fund managers and invest other people’s money ! However, in spite of the fact that they are so smart and so rich, their real life performance has been pathetic.

This raises the  intriguing question - why do we tolerate such poor performance ? Why are we willing to accept such a high failure rate within the financial services industry ? This is not something we would be willing to tolerate in other professions ! For example , we would very unhappy if doctors started making lots of mistakes. We expect our doctors to be experts , and we trust them with our lives , so they can help us to get better. Similarly, we expect VC fund managers to be financial experts , and we trust them with our life savings , so that they can help us to become richer. When the doctor fails to provide us with the right medical care , we are happy to sue him for negligence. However, when the VC fund manager causes us to lose money , we are much more charitable and are willing to put it down to “ learning experiences” !

Doctors have a much harder time making right decision, because they deal with biological systems, which are often unpredictable and complex. Logically, we should be much more tolerant when they make mistakes ! However , our tolerance for doctor’s failure is very low and the knee jerk reflex for why this is so is “ Obviously! When a doctor messes up, it may cost me my life – and isn’t life and health worth much more than wealth ? “ However, if health is really so much more important than wealth, then why do VC fund managers get salaries which are ten times more than we pay our doctors ? Why do we have these double standards ?

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Friday, June 29, 2012

Why massage techniques to remove adhesions are all rubbish

Deep tissue massage therapy ( the Wurm  technique) to break soft tissue adhesions has been aggressively marketed under different names ( for example , clear passage therapy ). They claim  that as a result of applying deep pressure through the abdominal wall, it’s possible for the therapist to selectively remove the patient's adhesions , thus allowing  the pelvic organs to start functioning normally – and that this will reduce pain and restore fertility.

This is rubbish. And to  understand why, let’s look at some basic anatomy and physiology , as to why this can't possibly work. Adhesions are scar tissue , and are made of soft fibrous bands. Because of an insult to the tissues (for example , an infection), the walls of the fallopian tubes get stuck to adjoining structures ( such as bowel) Adhesions are made of soft tissue - which is exactly the same as tissue the fallopian tubes and bowels are made of . If someone tries to apply deep massage through the abdominal wall in order to remove these adhesions , simple common sense will tell you that there is no way that anyone could do it so selectively. It’s not possible to guide the massage in such a way that it would tear only the scar tissue, and not affect the normal tissue. ( Surgeons can do this, but only under vision, using a laser !)

If deep tissue massage was really effective in breaking and thus removing the adhesions, a lot of patients would end up with holes in their bowels ! Fortunately , the technique is completely ineffective , and no one can remove adhesions, no matter how deep the massage they apply.

Talk to any surgeon you know as to how he removes adhesions. In order to do so, he has to go through the abdominal wall, so he can see them. In the past, this was done by opening the belly; and today, this can be done by using a laparoscope. He then needs to use a laser or scissors to break the adhesions, in order to free the tissues and restore normal pelvic anatomy. This can be quite a challenging task , even for a skilled surgeon – and often takes a lot of time, skill and experience to do so safely ( without tearing the bowel), even though he is doing it under vision.

The trouble is that most people are so reluctant to undergo surgery today , that they are quite happy to clutch at straws which offer nonsurgical alternatives. Unfortunately , a lot of these techniques prey on the patient’s ignorance . Simply because patients don't know any better, it’s very easy to take them for a ride. they are marketed very clever.  These are often  very expensive techniques ( someone has to pay for the slick marketing !) which are completely ineffective.

So, why do some patients believe they have improved as a result of this therapy ? Making an accurate diagnosis of adhesions is extremely difficult – and it’s not possible to do this on an x-ray or an ultrasound scan - you need to either open the abdomen or do a laparoscopy to make a reliable diagnosis, Now, since most of the patients do not have a visual proven diagnosis , it’s very convenient to label everyone with chronic pelvic pain as having adhesions – and blaming the adhesions for their pain, without ever
proving or disproving the diagnosis . Now, since pain is perceived in the brain , any intervention - sometimes , just a kind word ! - can help to relieve this pain. This is why a lot of patients who believe ( or have been fooled into doing so) that they have pain because of adhesions, will improve , thanks to the therapy, not because the treatment itself works ! They feel better, not because their adhesions have melted, but simply because someone has been nice and kind to them , and actually laid their hands on them ! The placebo effect can be very powerful, and  this is something which patients need to understand !

What about those infertile couples who claim  they conceive after taking Clear Passage Therapy ? Usually, their correct diagnosis is unexplained infertility – and many patients with this diagnosis do get pregnant , even when nothing is done for them ! If it really were so simple to remove adhesions nonsurgically, most surgeons would be very happy to stop cutting up patients to open their abdomens,  and start doing this deep tissue massage themselves !

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Thursday, June 28, 2012

How much wealth do entrepreneurs destroy ?

Entrepreneurs have always attracted a lot of positive attention. We admire these young people, who create a company from scratch – who are able to start from zero, and become heroes. They are the role models of the new generation, who want to follow in the footsteps of these stars, so they can convert their dreams to reality.

These success stories are highlighted by the press – and thanks to the internet, everyone has heard of these resourceful young people , who have become millionaires in a few years. These entrepreneurs are a typically American phenomenon , because American society has always put the individual on a pedestal. Americans like rooting for the underdog ! They admire individuality and creativity – and would always back David over Goliath !

These are very inspiring success stories – and these men ( and women) are the heroes of the new generation – after all, if they can create wealth, so can I  !

I am an angel investor, and have had first hand experience with supporting entrepreneurs. Entrepreneurs are typically energetic and driven, so it’s fun interacting with them, but that being an angel investor in a startup is not an unmixed blessing ! While it’s very exciting to talk about entrepreneurship and success, outsiders often underestimate the hard work and the grind which is involved in growing a company.  While an entrepreneur maybe passionate and committed, this is not enough to become successful.
For every one company which succeeds, ten fail.  What worries me is how little has been written about the failures. Most of these failures are undocumented and never come to public attention, simply because they fail at a very early stage. However, we need to track these failures as carefully as we laud the successes , so that we can learn from them. Otherwise, every new entrepreneur will end up making the same avoidable mistakes his predecessors did.

The general perception is that we need to support entrepreneurs and small enterprises, because these are our future. These are the companies which are young, nimble and daring, and which will actually create the future. We need to nurture and support them, because they create jobs and drive the economy.
What about the flip side ? How much wealth do they destroy ? How many dreams go down the tube when a startup fails ? What’s the cost of experimentation ?

It seems to have become cool to fail, but what’s the price which employees pay when the entrepreneur fails to grow the company and raise money ? Will investors continue to fund new ventures when they lose money left , right and center ? How much of the failure is because the entrepreneur was immature ? Or didn’t have access to enough resources ? Would the deep pockets and managerial support which a large company be able to provide have transmuted failure into success ? How do we go about answering these questions, so that the quality of our mistakes improves, and we do not repeat the same errors ?

How do we share the stories of the failures, so that we don’t end up presenting a skewed view of the impact of entreprenurship? Tom-tomming only the successes distorts reality, which hurts everyone in the long run.

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Wednesday, June 27, 2012

Population policies, the government and the individual

CHICAGO, IL - OCTOBER 31:  Commuters fill the ...

All governments formulate population policies for their citizens, as they want to improve their productivity and happiness. Unfortunately , they end  up focusing primarily  on numbers . In the past , the holy grail was zero population growth ( ZPG) .Experts fervently believed that limiting population size held the secret to the future growth of the entire nation . This was completely logical, because too many people would end up consuming too many resources as a result of which they would never be able to come out of the poverty trap. Billions of rupees were spent on family planning program and trying to persuade and coerce couples to have no more than 2 children.

We now know that this theory was completely wrong, as a result of which we are now benefiting from the demographic dividend . The citizens of India had enough sense not to listen to the demographers and the experts .

Sadly, nothing has changed , and the experts to continue to focus on numbers – it’s just that the numbers we pay attention to have changed ! These days , the number which everyone focuses on is the child sex ratio , the hypothesis being that having one girl and one boy in order to have a sex ratio of one would be perfect for society.

Unfortunately, when you focus on numbers and ratios by putting the population first, we lose sight of the fact that populations consist of individuals . Our citizens should be making their own reproductive decisions , to maximize their own personal benefit. The ideal population policies which would be one which would create circumstances which would allow individuals to ensure that every child they bring into this world is a wanted child . Each family could then decide exactly how many children to have , and when to have them , without having to worry about what the government felt was the optimal number for them.

Unfortunately when we start putting numbers first ( because experts are good with numbers and not with people) , we end up creating all kinds of messes. Unfortunately, we don't even know what the long-term consequences of these decisions will be – and don’t have the humility to acknowledge our ignorance. Because everyone is singing the same tune, groupthink becomes the norm. In our enthusiasm to implement some of these policies , we end up creating a lot of inadvertent harm be forcing couples to make decisions they are not happy with. It’s easy to put this down to “ collateral damage “, and because it hurts an individual , it's not publicized and doesn't receive enough attention .

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Tuesday, June 26, 2012

How to get more patients - a guide for doctors

Here's a great article on - How to build your medical practice through referrals, blogs, and other powerful strategies. You can read this at

All doctors need patients , but not all good doctors know how to get patients. This can be a major tragedy, both for patients and doctors . A particular doctor may be very good , but he may end up sitting and twiddling his thumbs , while patients end up going to other doctors who may not be as competent or caring , but are better at attracting patients.

Rather than complaining about how unfair life is, doctors need to learn what to do in order to get more patients. The sooner good doctors learn to do this, the  better for them; for their patients; and for society !
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Patients and the internet

Internets = Parody motivator.

Thanks to the Internet , it is much easier today for patients to find information about their medical problem. However, the Internet is not an unmixed blessing and we see three kinds of patients , based on how they use the Internet.

The first is the intelligent patient , who is a sophisticated consumer of information , and understands how to use the web. He does repeated searches to progressively improve the quality of information he retrieves. He understands searching can be an iterative process – and he continues to update this knowledgebase on an ongoing basis. He can identify bad websites, so that he doesn't get misled by poor quality information . He knows which websites are reliable , so that he's capable of. Retrieving Information which is trustworthy and separating he wheat from the chaff. This is the model e-patient, who is active n forums and bulletin boards;  and may have his own blog as well, to educate other patients. This expert patient knows how to make the best use of the Internet , and can then have intelligent conversations with his doctor , based on his internet searches.

The second kind of patient is the one who gets completely lost and confused. He may be so fed up of the unreliable and conflicting information on the Internet , that he has just given up and has stopped trying to do searches. He feels that patients should not try to play at being doctors ; and that it's just not worthwhile to spend time on the net. If you have a medical problem, rather than waste time searching for information, it’s best to report to your doctor and ask him to fix your problem for you. While this is a reasonable solution if you’re lucky enough to find a good doctor , this may not always be the right solution - specially if your doctor does not have your best interests at heart.

The third kind of patient is the one who will spend a lot of time on the Internet looking for information , but because he's unsophisticated , he cannot separate good information from bad . He may get completely confused and lost and start drowning in an information overload. He may make his doctor’s life miserable, because he will come with pages and pages of Internet printouts of poor quality outdated information , and expect the doctor to sort out the good from the bad .These can be difficult patients , but because they are on the right track , with a little bit of guidance from the doctor had some handholding , it's possible to teach them to become intelligent consumers of health information , so that they can make better use of the Internet.

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Monday, June 25, 2012

Why we are seeing an epidemic of overtreatment

English: A small uterine fibroid within the my...
 A small uterine fibroid within the myometrium as seen on ultrasound 
Many women in the reproductive age group have fibroids. These are the commonest tumors in the reproductive tract – and most are small and don't cause any mischief . They are found only if you go looking for them  ! In the past, a lot women who had fibroids would not even be aware of their presence, because they had enough sense not to go to a doctor. However times have changed, because our technology has become so much better , and doctors have become very good at marketing their services.

Ultrasound scans are now done at the drop of a hat - and with an ultrasound scan , it's possible to detect fibroids which are as small as one centimeter – about the size of this O. Now  a one centimeter fibroid in the wall of the uterus is tiny and asymptomatic , and doesn’t cause any problems. However, when the sonographer reports a one centimeter fibroid as being 10 millimeters, and reports this “ finding “ in bold print, patients get worried , because they think it's an abnormality , and they want their doctor to fix it.

Doctors are always happy to do so , but in the past, when removing the fibroid involved surgery , patients had enough sense to say no , because they were understandably scared of going under the knife. However, now the technology has become so good that the surgery itself is minimally invasive. In fact , today you don't even need surgery to treat the fibroid - they can be shrunk , using high-frequency ultrasound waves . This is done under MRI guidance, and the technique is called HIFU or High-Intensity-Focused-Ultrasound .

The marketing departments of the manufacturers of these machines ( and the hospitals which they sell these costly devices to) are having a great time ! They run huge ads in papers and on bill boards, to target women ! “ Do you have a fibroid ? pelvic pain ? heavy bleeding ? Come to us – and we will treat it without surgery ! “

They claim to create awareness about this common complaint through these campaigns – and will even hold free camps, to help unsuspecting women discover that they have fibroids ! However, rather than inform women that most fibroids are quiet and can be happily left alone, they scare them into believing that these fibroids are responsible for all kinds of complaints , ranging from backache ; vaginal discharge; heavy bleeding ; abnormal bleeding and infertility. Now these are extremely common complaints in women and it’s a mathematical certainty that the majority of women who have fibroids will have one or more of these complaints. Usually, the fibroids are just innocent bystanders , so that “ treating “ the fibroid will not help the patient to get any better ! However, treating the fibroid will help the doctor because he can charge for his medical treatment . Even worse, since a lot of patients now have insurance to cover their medical treatment , they will often sign on the dotted line to get this “latest medical treatment”. Because they're not paying out of their own pocket , the risk of moral hazard leads to overtreatment.

Patients need to learn that just because the doctor happens to find an abnormality, this doesn't mean that it needs to be treated ! We are seeing an epidemic of unnecessary intervention , thanks to clever marketing and the explosion of technology.

The only solution is information therapy , where patients have access to an objective reliable, unbiased source , which will provide information which they can trust . Patients need to learn that they can make the right decisions for themselves – and that there’s no need to “treat” something which is not causing them any problems !

While it's true that the high frequency ultrasound treatment represents a significant advance for treating selected women with fibroids ( as compared to regular surgery , because it saves the patient an operation), it is also equally true that it is no better than no treatment at all , because lots of fibroids don't need to be treated in the first place. This is something which people forget when they make comparisons, especially when they are out to promote and sell a particular kind of therapeutic intervention.

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Sunday, June 24, 2012

A book all IVF patients should read !

I am a big believer in Information Therapy. Smart patients get better medical care because they understand more about their treatment. This is especially true for IVF. Infertility is an emotionally charged issue , and it can be hard for patients to get reliable information.


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Marketing isure ovulation test kits in India

I was pleased to see a full page ad in today's Times of India, marketing I-sure ovulation prediction test kits in India.I am glad companies like Piramal Healthcare are addressing the needs of infertile women. It's because ovulation prediction test kits were not available in India , that we started selling them online 5 years ago.

Thanks to direct to consumer campaigns like this,  women ( and their husbands as well !) will learn more about their bodies and become more knowledgeable about their menstrual cycle. However, I am worried that they are propagating the idea that women are fertile for only 2 days during the cycle.  This is not true  . The fertility window is actually 5 days, because even though the egg may remain alive for only 24 hours, sperm do remain alive in the cervical mucus for 4-5 days. This kind of misinformation will just cause women to start panicking needlessly, and put more pressure on them to have "well-timed intercourse". This is especially true for career women, who have postponed childbearing. These are women who want control over their lives, and OPKs promise them this, because they can now monitor their ovulation However, forcing your husband to have sex on a particular day can only add more stress to your life !

This advertising campaign is going to be very good for infertility specialists. When women start using the kit and then don't get pregnant in 2-3 months, they are going to start thinking of themselves as being "infertile" , and will seek medical attention for reassurance that all is well. Doctors will be obliged to do testing to confirm that they are normal ,  and this will increase their workload ( though a lot of this testing will be completely unnecessary, because these women will have got pregnant in their own bedroom if they had simply been patient !)

I am sure lots of mothers ( and mother-in-laws !) will buy these kits for their daughters, to help improve their odds of having a grandchild quickly.

The website for the OPK kit at is quite disappointing .  I know that this is a marketing website, but I wish they had used this as a tool to educate women about their fertility.  This is such a great opportunity to provide Information Therapy to infertile women !

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Saturday, June 23, 2012

What doctors can do to improve the image of the medical profession

Icon from Nuvola icon theme for KDE 3.x.

Doctors are understandably angry about the negative image in  which they have been portrayed by Aamir Khan in his talk show, Satyamev Jayate.

However doctors need to accept the fact that they are also partly responsible for this sad state of affairs. Often, doctors don't have very good patient relationship management skills and they sometimes appear to be uncaring. This is often true when a medical mishap occurs and patient has a complication . Doctors will then get defensive , clam up and hide facts, because they are scared that the patient will sue them. This just ends up making a bad situation worse , because patients get vengeful that their doctor has abandoned them in their time of need – and they are not willing to forgive this callous attitude.

Another major component to this anger against the medical profession is the perverse pleasure which doctors taking in bad mouthing each other. Doctors seem to enjoy doing this because of professional rivalry and competition  and they seem to play an endless game of one-upmanship ! The subtext seems to be – “ That doctor is a fool – and you were a bigger fool to go to him. Now, if you’d come to me in the first place, this would never had happened ! “ It’s very easy to be wise after the event , but all good doctors know that none of is immune to errors , and that complications can arise, no matter how perfect the medical care . When listening to your patient, do remember that  patients sometimes tend to distort the facts and provide a very one-sided picture, which may be completely skewed and incorrect.

I wish doctors had the maturity to realize that every time they criticize a colleague, they are actually harming themselves. What goes around comes around – and tomorrow it will be his turn to hurt you , when your patient has a bad outcome and goes to him for a second opinion.

Now I am not saying that doctors need to engage in a conspiracy of silence. All they need to do is to be mature, and try to treat the patient who has had a complication  as if they had been providing care for the patient themselves. After all, most experienced doctors have made mistakes and seen patients who have developed similar complications under their care. Rather than assume that the other doctor was stupid or negligent, it’s far more mature to assume that he did the best he could ( based on what information was available to him at that time) . Hindsight wisdom is always 20/20 – but looking backwards does not help. The important thing is to fix the problem and get the patient better, rather than try to blame the earlier doctor.

Mature doctors, who take this approach, will find that their practise flourishes, because their colleagues appreciate the fact that they have tried to help them in their time of need ! Treat your colleague the way you would want to be treated !

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Friday, June 22, 2012

Looking for a social entrepreneur to promote Information Therapy in India !

We are a looking for a social entrepreneur who wants to leave a mark on health care in India , by empowering patients with Information Therapy. 

The Indian healthcare system has become sick. Doctors are illness experts , and not healthcare experts.  Patients are the largest untapped healthcare resource – and Information Therapy – the right information at the right time for the right person – can be powerful medicine !

You will run the Patient Information and Education Trust . This is a non-profit organization , founded by Dr Aniruddha Malpani and Dr Anjali Malpani, the founders of India’s Patient Education Resource Center, HELP.

Your mission will be to market, disseminate and promote the use of Information Therapy tools ( such as the Healthwise Knowledgebase) in India.  Healthwise is a non-profit organisation in the USA, where it is the market leader in developing patient educational content .  You will head a small team – and will be responsible for making sure things get done ! You need to develop and implement a business model which is sustainable and scalable.

You should be a medical graduate - MBBS , with a MBA or MPH

Please email me your cv to [email protected], and tell me what you hope to accomplish !

Bad doctors ? or bad patients ?

English: A doctor examines a female patient.
When a patient has a bad medical outcome , he is quite happy to blame his doctor. Unhappy patients feel that the doctor was incompetent or negligent or didn't make the right diagnosis and provide the right treatment. They are  often angry and resentful - and they need to vent their bile – and the doctor is often an easy target. Watching TV shows like Aamir Khan’s Satyamev Jayate just adds fuel to the fire . Sadly, getting a second opinion from another doctor often makes a bad situation worse ! Doctors are quite willing to badmouth each other , and because of professional rivalry and competition, they seem to play an endless game of one-upmanship !

Patients love playing the role of the passive victim. However this does not help anyone ! Rather than blame the doctor for not doing a good job , patients need to learn to take responsibility for the quality of medical care they get. This is really not as hard as it sounds. During an emergency , patients may have very little say  in their medical care, but the vast majority of medical problems require planned elective medical treatment , and patients can easily educate and inform themselves about their options , so they can make the right decision.

I agree this was difficult to do in the past , when all the medical knowledge was locked up in medical books and journals, which only doctors could access. However, in this day and age , when we are awash with medical information written for patients, so much of which is so easily available online for free , I'm not willing to be so sympathetic when the patient complaints that the doctor did not explain anything to them.
I do agree that it is the doctor’s job to educate the patient, but I also feel that it's the patient's job to make sure that they're well informed. Just like you can't afford to leave everything up to God , you can't afford to leave everything up to your doctor either.

Patients need to learn to take responsibility for the quality of care they get. Just like one of the most important decisions they make is selecting the right doctor for their problem , making sure they've done their homework so they have realistic expectations of what the doctor can do for them is equally important. This is why information therapy has such an important role to play in improving medical care  !

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Thursday, June 21, 2012

Age is not equal to wisdom

A patient having his blood pressure taken by a...
A doctor criticised a comment I had made in one of  my posts. I had written -  '' It’s easy for doctors to “ do something “- this is what they are trained to do, and this is often the knee-jerk reflex of junior doctors. It’s only senior doctors who have a lot more clinical experience and maturity who are likely to advise that you it’s sometimes more effective to do nothing at all''

This was her comment. – “ I think you are being harsh and judgmental on junior doctors here. First of all, it is very hard to define 'senior' and 'junior' because they are relative terms  . I am at 40yrs of age, I may not be a senior doctor but I am not junior either. Instead of saying junior or senior I would probably say some doctors are more pragmatic than others- they treat the problem arising from a condition rather than treating the diagnosis itself. Like in the case of fibroids, they should only be treated with only if they are creating problems and not just because they are there !  Whether a doctor 'waits and watches' or 'treats aggressively' depends on what sort of experience and training they have had in the past rather than their age. Not all junior doctors are aggressive and not all senior doctors are conservative. I did my basic training (MBBS and MD) in India and subspecialty training in UK and it was the training in UK that taught me to be pragmatic, not my age.”

She is absolutely right, and I do agree that age is not equal to wisdom. Sometimes, 30 years of experience  may just mean 30 years of making the same mistake repeatedly ! Yes, there are very mature junior doctors – and some very immature senior ones.

While it is true that chronological age does not always correlate with intellectual age, in general, younger doctors are more optimistic about what medical technology and their professional expertise can accomplish. Most of their learning comes from text books, which usually describe “text book cases”,  where the course of the disease is predictable . It’s only when they start treating patients in real life that they realize that patients’ bodies  have not read the textbooks – and that diseases will behave in complex and unpredictable fashions !

Secondly, most of a junior doctor’s the learning occurs in hospitals. Now, while hospitals are fascinating collections of patients with complex medical problems and exotic diseases, the “ bread and butter “ problems which patients present with in real life are completely different from those which affect hospitalized patients. Hospitals are showcases of medical sophistication, and junior doctors get to see how teams of specialists and advanced technology can help seriously ill patients to get better . However, real life is much messier – and doctors in clinical practice usually do not have access to the army of specialists or wealth of resources which they had when they were medical students and residents. They learn they have to do a lot more with a lot less – and that they do need to consider the financial impact of their medical decisions as well.

Hospitalized patients usually have serious problems which need intervention , which is why they are in hospital in the first place. However, ambulatory patients ( seen in the clinic ) have a completely different presentation – so that even though the “diagnosis” maybe the same, the management needs to be completely different !

Over time, a doctor’s text book learning gets tempered with maturity. They learn the limitations of medical science , and start to appreciate how poor we are at predicting the course of a particular disease in an individual patient. The natural history of a disease in a patient can be very variable, and because so much of this depends upon the patient’s idiosyncratic responses, we learn that every patient is different, and we need to respect their individuality.
As they mature, doctors learn to respect their patients and to listen to their patients and their preferences. They realize that they do not have all the answers ; and that they can learn a lot from their patients. They figure out that many patients will get better on their own ; and some will improve, even inspite of the medical treatment we force down their throats. Not all abnormalities need treatment , and watchful waiting is often the best course of action for many shadows picked up on scans and routine checkups.
Some young doctors mature very quickly , while some seniors remain blissfully unaware of these facts. Rather than depend upon the doctor’s age or reputation, it’s best for patients to understand their disease, so they can partner with their doctor.

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Wednesday, June 20, 2012

Why do doctors have such large egos

English: Livingston, TX, 9/25/05 -- A doctor t...

One of the commonest complaints patients have about doctors is that they refuse to listen to them. Many doctors talk down to patients , and often treat them as little children , who don't understand anything and need their hand held. They will often not listen to the patient's perspective - and very few will actually factor in the patient's preferences when formulating a plan of action. Many patients find this patronizing attitude of doctors very infuriating , because they want to be treated as intelligent adults.

One of the reasons doctors have such large egos is because they have a very high opinion of themselves. Usually, they have a track record of always doing well in school. They are used to being complimented as being intelligent students , because most are academically bright ; and they have spent many, many years slogging and studying huge textbooks , in order to master an extremely complex body of medical information . They are justly proud of their technical proficiency and skills. This is why they don’t have a high opinion of laypeople , who they think understand very little about biology or about how their bodies work.
Also, most doctors have been trained in a system which emphasized a paternalistic approach towards patients. Doctors were supposed to take care of the patient and make the right decisions for them. This is why some senior doctor sometimes find it hard to treat patients as partners.
Also, many doctors are extremely busy , and because the number of patients will always be far more than the number of doctors , the amount of time they have to spend with each patient is extremely limited. This is why they try to see as many patients as quickly as possible . One way of maximizing patient flow and throughput is by telling patients what to do  and not engaging in a discussion. This is why patients often feel that their questions were satisfactorily answered; or that the doctor just made all the decisions unilaterally, without explaining what their alternatives were.
One of the other reasons doctors have such huge egos is because they are used to being treated as God. In a hospital , doctors are the cock of the walk. Patients hang onto their every word ; and they are followed by a retinue of nurses and assistants, who blindly follow their orders. If you're used to being treated as the captain of the ship, it's very easy for this to get your head , as a result of which you start thinking that you know everything there is to know ; and that patients ( who know so much less than you do, because you’ve spent a lifetime mastering this complex science) should just listen to what you tell them to. If they had more sense, they'd know that you have all answers, and that all they need to do if they want to get better is to listen to you.
Doctors aren't used to being challenged by their patients , and many feel threatened by patients who ask them too many questions. They will often fire these patients , as a result of which most doctors tend to only see compliant patients who quietly accept everything they say as being the gospel truth.

As a result of this , the general perception on the part of patients is that doctors are arrogant and look down on their patients. This is why , when things go wrong, patients can get extremely vengeful and angry. This is why there is so much criticism about the medical profession on bulletin boards and at cocktail parties.

Most doctors are intelligent – and if they willing to recognize that this is a problem , they are smart enough to be able to change their approach , so as to find a solution. One simple answer is to spend more time with their patients . However, because time is such a precious commodity and such a scarce resource for most doctors , it's very hard for them to be able to implement this solution.

This is why doctors need to invest in time extenders, which could include assistants and patient education tools , such as websites. Even if they cannot educate the patient themselves, they can leverage technology , to be able to make sure that the patient knows exactly what they are going to do.

In my experience, it’s only those doctors who are not sure of themselves , who have large egos . In reality, their egos are very fragile, which is why they don’t like being challenged or questioned. Good doctors are much more down to earth because the unpredictability of real life teaches them humility very quickly !

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Tuesday, June 19, 2012

What I expect from my patients

Conversation between doctor and patient/consumer.
Conversation between doctor and patient/consumer. (Photo credit: Wikipedia)
Patients have a long list of the attributes they want in their doctor. Because they are spending money on their medical care, they expect their doctor to be skilled, compassionate,  caring and available .

However, just like patients have a list of what they want from their ideal doctor , doctors have a list of what they want from their ideal patient !

In the beginning , when doctors are starting practice, they cannot afford to be choosy about what kind of patients they accept , because they need to make a living . The young doctor is happy to see whoever comes to him. However, over the passage of time , as doctors become more senior, they can afford to be picky and choosy about what patients they want to treat , and which they don’t.

I have a set of criteria which I use in order to select patients who I think are right for me , and for those whom I think I am a good choice, I'm not trying to be arrogant – I just believe that patients get the doctors they deserve , and doctors get the patients they deserve . When both the doctor and the patient are on the same page and have the same philosophy , they are likely to be happy with each other. If not, they are likely to be unhappy , and this is not good either for the doctor or for the patient .

I expect my patients to do their homework and become experts on their problem. I expect my patients to provide inputs into the treatment we offer them, rather than be passive and blindly agreeing to whatever I say. Yes, this does involve a bit of effort on their part , but it’s well worth their while investing time in doing so, because it helps me to provide better medical care for them. As a doctor, I create and provide tools to help them to learn more about their illness.

It's not that I would refuse to treat a patient who didn't meet my criteria – it’s just that the quality of care which I can provide to patients who are willing to work towards meeting my expectations is far better than what I can provide to those who do not. Not only does a doctor’s wish list of an “ideal patient” make for happier patients and happier doctors, it also helps to improve the outcome of medical care.

For example , if an IVF cycle fails , I expect my patient to have been prepared for this failure because she understands exactly what is within our control , and what is not. I expect my patients to have a plan of action – and to have a Plan B, so they do not go to pieces when riding the IVF emotional roller coaster. I expect my patients to be able to interpret their own medical results ; and have an opinion about what their options are , and what is likely to work for them. I may not see with them eye to eye , but am happy to work towards reaching a consensus.

The kind of patient whom I do not want is the one who's completely clueless – the one who says , “Here are your fees, doctor - do exactly what you want and give me a baby ! “These patients worry me , because they have very unrealistic expectations of what I can do for them.

I admire and respect expert patients – those who do their homework, and ask me intelligent questions. They keep me on my toes, and help me to grow.  The really smart ones also educate me, as they teach me to be empathetic and responsive to their needs.

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Monday, June 18, 2012

Why doctors deserve all the bad press they get

Indian Medical Association
Indian Medical Association (Photo credit: Wikipedia)
Doctor bashing has become a very popular pastime in India over the last few weeks . Aamir Khan's show, Satyamev Jayate is repeatedly taking potshots about the poor standards of medical ethics ; and newspapers are full about how greedy doctors are aborting female fetuses and distorting the sex ratio in India.

The biggest tragedy is the profound silence from the medical profession . Even though a lot of this criticism is completely unfounded, we Indian doctors deserve the bashing we are getting. This is because we are keeping quiet , and our silence is being misinterpreted as a confession of guilt. Why are Indian doctors silent , when they are at the receiving end of so much damaging criticism, much of which is completely false and unfounded , Why, if one doctor is found to be guilty of female feticide , are all ultrasonographers and gynecologists being  treated as potential criminals ?

The reason is simple - because doctors are not standing up and explaining their perspective or point of view. Even though doctors have a number of medical professional societies which are meant to present their viewpoint ( such as the Indian Medical Association ), the fact remains that there is a not a single respected senior medical spokesperson who can talk on behalf of the profession.

Our senior medical doctors have let all of us down. Ideally once a Doctor becomes senior, he owes a responsibility to society and the medical profession . After he is retired and is no longer seeing patients , he should be devoting his time towards making sure society understands what doctors stand for . IN case a doctor is criticized , these senior doctors should be able to stand up for him and present his perspective, rather than let only a one-sided ant-doctor viewpoint prevail.

Senior medical doctors can carry a lot of clout . They have a lifetime of professional experience and skill; and are usually highly regarded and respected . Moreover , since they are retired, they do not have any vested interests , and therefore can be relied upon to be truthful and to provide a  reliable objective viewpoint. They would have the courage to criticize doctors who were guilty of malpractise – and would also have the guts to support those who were blame-free , but were being painted as villains by the press.

Unfortunately , senior doctors don’t fulfill this vitally important role . Some will continue seeing patients all their lives - while others will go on pursuing other interests and hobbies . Also, the medical associations in India are set up , they have become highly political bodies . There’s a lot of jockeying in order to become an office bearer in these societies, so that usually doctors who are in active practice who head these associations. Because they are professionally active , their first priority is taking care of their own patients, as a result of which they do not have the time or the energy or the standing be able to carry much weight with the press . This is why, NGOs and activists who have unpleasant things to say about the medical profession often find that they can pretty much say what they like , and there is no response from the medical profession. It becomes a one-sided slinging match, and everyone is happy to take potshots at the silenced doctor.

There is no one to stand up for the doctor today . The individual doctor who is being criticized is completely helpless , and with all the glare of media criticism on him, there’s precious little he can do to salvage his reputation , or present his point of view. The media has already made up its mind, and is happy to crucify him. They do not realize how short sighted they are being – and that each one-sided negative article is another nail in the medical profession’s reputation.

On one hand, we want doctors to behave as upright ethical professionals, We expect our personal doctor to devote all his time and energy and skills to caring for us. On  the other hand, we treat his fellow professionals as being potential criminals. If we use these double standards , what kind of outcome do we expect ? Unfortunately , the doctor’s colleagues and his medical association aren’t of much use either ! They are too busy taking care of their own patients , to bother about his plight or come to his rescue.

“ Ask not for whom the bell tolls, it tolls for thee ! “ This silence on the part of senior medical doctors and medical societies is actually going to hurt all doctors. If we do not stand up for our colleagues today , who will stand up for us when we run into problems ourselves ? It’s not that the media is always biased - but when the media is looking for an alternative point of view from doctors, they find it very difficult to actually find a doctor who will provide them with all the medical nitty-gritty and details,  so that they can then provide a fairer perspective of the problem. Most doctors do not have the time or the energy or the ability or the inclination to be able to talk to the press , as a result of which the medical profession is never adequately represented . On the other hand, doctor-bashing politicians , NGOs , activists and talkshow hosts have a field day because they can pretty much say what they like , with no one having the courage to challenge them. Their one-sided skewed message gets picked up by the media - and the repeated publishing of an one-sided message which projects doctor as criminals will start changing attitudes in society at large , as a result of which everyone will start thinking of doctors as being crooked.

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Sunday, June 17, 2012

IVF success story after embryo adoption

We have been married for 14 years and we lived apart for 4 years since he was outside the country on work. As soon as he returned we started to go for treatment in India.  They did laparoscopy to find if there was any problem in my ovaries. They didn't t tell us anything and they did an IUI which did not work.

Then at 2002 we came back to work in Qatar. Again we started taking treatment for baby but nothing worked out as my ovaries are not producing eggs. At last we lost hope and we started looking for adopting a baby, but we found a lot of difficulties in this process after going through lot of legal formalities.

That time , one of my sisters told me about Malpani clinic and she gave me web address and telephone number. Immediately I started going through website, and on reading the success stories , it gave me a lot of confidence. I started sending mails to Doctor Anirudha and would get a reply within few hours .

We explained about our situation and asked for embryo adoption . He asked us to take relevant tests which turned out to be normal . We were happy to meet doctor in Malpani Clinic. He talked very positively and explained about the procedure. Our treatment commenced on April and Dr Anjali Malpani transferred 3 embryos on April 24th . She spoke to us positively and nurses and staff over there are very cooperative and so kind. After embryo transfer we stayed in Mumbai for 3 days and we returned back to Qatar.

We just waited for 14th day blood test - and when I tested positive for pregnancy , my eyes filled with joyful tears and immediately we thanked God and Malpani for our . My pregnancy is progressing well . We thank everyone in the clinic .

[email protected]

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Saturday, June 16, 2012

Why the VIP syndrome results in overtreatment.

I recently saw a patient who had had a miscarriage . The pregnancy had been uneventful and at seven weeks a routine ultrasound scan had shown a healthy intrauterine pregnancy. However, she had some spotting after this , and when she went for her next scan to her doctor , he noted that the gestational sac wasn't growing ; that the yolk sac was very large; and the baby’s heartbeat and become slow . These are all ominous signs which suggest impending fetal death , and he told her that this meant that the pregnancy was not healthy , and that she should allow it to miscarried normally . He then went on to see his next patient , without realizing that he had given her very bad news , without giving her the time to absorb the impact or ask him any questions. While his clinical advise was perfect, he was not being very empathetic, because he'd forgotten that this was a healthy young woman who come for a routine pregnancy checkup, just to confirm that everything was fine . Instead of being able to reassure her that all was well, he was having to tell her that she was about to lose her baby – the worst possible news a doctor can give to a pregnant woman !

What he actually needed to do was to sit down with her and prepare her that he had some major bad news to convey. Unfortunately, he did this in such a cold dispassionate manner, that she got put off.  Even though she is very articulate , she never had the chance to share her feelings with her doctor . She then took the next logical step – she want to another doctor for a second opinion.

This doctor put her on medications such as progesterone , to “ support the pregnancy “; and recommended a follow-up scan after 2 days. As expected , on the next scan the baby’s heartbeat had stopped completely , and she did a D&C to terminate the pregnancy.

The patient came to me for a third second opinion , and had lots of questions. She wanted to know if her first doctor had messed up by not providing her with progesterone support . If he had given her progesterone support , would she have been able to stop the miscarriage from occurring ? Was it her low progesterone which had caused the miscarriage ? She was understandably upset and agitated and I did my best to explain the facts to her.

From a medical point of view, the treatment which the first doctor had advised was absolutely appropriate. With the help of the ultrasound scan , he had made the right diagnosis of a nonviable pregnancy . Since the commonest cause of a non-viable pregnancy is a genetic problem in the embryo, no amount of medical treatment or progesterone support can change the outcome . If the baby is genetically normal and is going to die , it will , no matter what we do. It's not like he didn't know this , but he did not take the time and trouble to explain this to her. The second doctor knew this and could have explained the facts to her, but was mature enough to realize that what the patient needed was handholding . She therefore provided her with medical treatment , which she knew would not change the outcome in any way , but would help to clam the patient , because of the semblance that something was being done . In one sense this was unnecessary medical intervention , because it was not going to change the outcome, but the fact that the doctor did something meant that the patient felt a little more reassured and comfortable.

Patients need to understand that sometimes doctors do things which are clinically correct but which may seem hard hearted and cold-blooded, because they have not been able to achieve emotional rapport with the patient and are not able to explain why they are  advising a particular course of action. This was the problem with the first doctor , who was clinically competent, but emotionally incompetent.

Doctors often need to make a judgment call , based on their own gut feeling , as to what they feel the patient in front of them needs. Sometimes , VIP patients end up being harmed , because they're often overtreated , without any clinical benefit at all.

The best policy for most doctors is to sit down and explain to the patient what is likely to happen – and the limits of our ability to be able to influence the course of the disease. Unfortunately, time is a luxury which most doctors do not have enough of , as a result of which they are  forced to short resort to shortcuts  - not all of which can be right.

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Friday, June 15, 2012

The difference between unexplained infertility and incompletely evaluated infertility

A number of gynecologists are very quick to label patients as having unexplained infertility. They do the basic tests , such as a semen analysis ; an internal examination ; a HSG and an ultrasound scan – and if all these results are normal , they tell the patient that we do not know why you're not getting pregnant and label her as having unexplained infertility.While it is true that about 10 percent of infertile couples will actually have unexplained infertility is also equally true that this diagnosis is often misused because doctors do not perform a complete evaluation.


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Thursday, June 14, 2012

Why it’s hard for doctors to leave well enough alone

When a doctor sees an abnormality ( either during clinical examination or lab testing or scanning) , his gut reaction is to “ treat “ it, remove it or correct it . Doctors are trained to worry about what can go wrong - and the first thing they think of when they see a scan or lab result is – what’s abnormal ? What problems and complications can arise as a result of this abnormality ?

Let’s take the example of fibroids noted on a routine ultrasound scan . The doctor is worried that the fibroid may grow ; or may cause a miscarriage . They therefore they recommend that the patient remove it now, to prevent problems in the future. Patients often will accept this advise , because they don't want problems either.

What they fail to realize is that doctors are not good at predicting the natural history of a lot of what they see. This is because of the nature of their work – they get to see only the few women who presents as patients, because they have problems as a result of their fibroids. They forget that there are lots of completely healthy women who also happen to have fibroids and go through completely uneventful pregnancies , without even realizing that they have fibroids !

A lot of fibroids are incidental findings , and they often don't cause an symptoms or problems all - many women will happily carry their fibroids to their grave. Unfortunately, given the way doctors are taught to think – look for problems and fix them – they will often jump to the conclusion that a fibroid always causes problems - and it is therefore better to remove it when it is small , rather than allow it to grow and create problems leter.

Suppose the doctor advises the patient to do nothing . Masterly inactivity is often the best advise , but this can be a difficult course of action - both for the patient , and for the doctor . For one thing , patients often demand treatment. If they have something inside their body which should not be there, they want it treated. They will often seek a second opinion – and if the new doctor is more aggressive, he will advise surgical removal . The patient’s confidence in her first doctor may get shaken up – why didn’t he advise surgery ? Maybe he isn’t competent enough to do the surgery ?

Now if the doctor’s advice is to do nothing , and if you remain problem free, you are happy, but not very grateful or appreciative ( after all, the doctor didn’t do anything, did he ?) However , if the doctor advises you to do nothing , and you are unfortunate enough to end up with a problem , not only are you likely to badmouth the doctor for not advising surgery , the doctor may also feel guilty that she did not advise treatment at the time of the first visit.

Unfortunately , doctors are not fortunetellers and cannot predict what the course of a particular lesion will be in a particular patient . This is why it's important that doctors share their philosophy of being conservative or aggressive with the patient , so that both the doctor and the patient are on the same page .

It’s easy for doctors to “ do something “- this is what they are trained to do, and this is often the knee-jerk reflex of junior doctors. It’s only senior doctors who have a lot more clinical experience and maturity who are likely to advise that you it’s sometimes more effective to do nothing at all. While doing nothing sometimes can be hard to do , this often has a far better outcome , because unnecessary interventions can create their own sets of problems as well.

Remember that it’s not that doctors are trying to scare patients – it’s just that the doctor’s world view is slanted towards looking for problems – and trying to fix them ! Also, in case the doctor does not fix the problem, he is at risk for being sued for negligence, in case something goes wrong. This is why there is a lot of pressure on the doctor to “treat” everything he sees !

Ironically, if the doctor does intervene and the treatment causes problems,  patients are much more willing to forget and forgive these complications – after all, wasn’t the doctor just doing his best to treat the original diagnosis?

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Wednesday, June 13, 2012

Why doctors tend to overtreat

Doctors are medical experts and we trust that they will provide us with the right advice when we have a medical problem. Unfortunately, sometimes doctors do not provide the right advice – but this is not because they want to cause harm, but rather because of the way they are trained and the way the medical profession has been set up.

Let me explain.

I recently saw an asymptomatic patient who had a large single 8 cm fibroid in her uterus. Fibroids are common benign  tumours in young women and are a result of the multiplication of the smooth muscles cells of the uterine wall. She was advised surgery to have the fibroid removed. She was 24 years old and wasn't planning to have a baby for another year . She had just gone for a routine examination , and on feeling her abdomen , her doctor noted that her uterus was enlarged . She suspected she had a fibroid, and an ultrasound scan confirmed this diagnosis. She advised her that she needed it removed. She went to a gynecologist for a second opinion , who agreed that she required the surgery , and that's why she had come to me.

I explained to her that the natural history of fibroids can be extremely variable . Many of them, even though they are large , often don't cause symptoms or  problems . They don't always increase in size and are definitely not cancerous . If she was asymptomatic , one option was to leave it alone .

She was concerned as to what the impact of the fibroid on her fertility and her pregnancy would be. The earlier gynecologist had scared her that the fibroid would interfere with her fertility ; and could also cause a miscarriage , in case she did get pregnant , because it would compress the baby during the pregnancy.

I explained to her that the problem with doctors is that they only look for problems ! After all, it’s only when people have problems that they start thinking of themselves as patients and seek out a doctor. All the women who have fibroids but are symptom-free and have uncomplicated pregnancies never need to go to a doctor , as a result of which doctors are often not aware of the fact that lots of these fibroids never cause any problems during pregnancy . This is why the natural history of some of these conditions is hard to study . Asymptomatic people don't seek medical attention , and are therefore difficult to find and to follow-up.

This is why doctors often have such a jaundiced view of life . They expect that any abnormality which they find on a routine examination or scan will cause medical problems. Actually , this is completely skewed logic . Because doctors only see patients with problems , any abnormality which they find during their examination of a patient is likely to be clinically significant. However, the significance of exactly the same finding in an asymptomatic person is completely different. Lots  of completely healthy, normal people will also have abnormalities , which do not get picked up because they never need to go to a doctor for an examination in the first place. This bias results in a “ tip of the iceberg phenomenon” so that doctors will conclude that any abnormality which they see ( irrespective of whether or not the person has any complaints) needs to be treated.

Unfortunately , not only does this lead to a lot of overdiagnosis , it leads to overtreatment as well - and sometimes this treatment is not always benign . Many medical procedures can  end up causing more harm than good. Surgery for removing a fibroid ( myomectomy) can cause scarring ; adhesions , and bleeding - and sometimes even lead to a  hysterectomy, if the doctor needs to control excessive blood loss ,

Part of the problem is that patients expect doctors to be experts - and because doctors treat themselves as being experts who know everything there is to know about any medical problem , they will often not acknowledge the limits of their own knowledge . We refuse to accept that we have large areas of ignorance, because we only get to see patients who have symptoms - and do not have the opportunity to study the natural history of these lesions in asymptomatic healthy people.

This does not mean that the medical profession is engaged in a conspiracy of finding problems in people and then treating them. It just means that the way the medical profession is set up , there is a natural bias for most doctors to aggressively treat problems they find, even though sometimes the treatment may cause more harm than good.

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Tuesday, June 12, 2012

Why do some doctors do so many tests after a failed IVF cycle ?

When an IVF cycle fails , many IVF specialists will run a panel of expensive tests, in order to find
out “ why the cycle failed”. They often do this because of pressure from their patients , who want to know why the cycle failed. The honest answer is – We do not know, but few doctors have the guts to tell patients the truth. Patients want answers – and the easiest way of providing these is by running more tests , to see if we can uncover more problems . This seems like a perfectly logical and sensible approach, which is why patients who have failed IVF cycles will be subjected to a battery of expensive exotic tests in many clinics.

However , this is an extremely illogical approach. Not only are most of these tests very expensive , they are actually quite useless , because they provide very little useful information. A lot of these tests will be abnormal even in normal fertile couples , and do not give us any useful information. Doctors  do them, simply because they need to pander to the patient’s insistence that something new be done, just because the first cycle has failed . Doctors run the tests to keep their patients happy - and to stop the patients from asking more questions.

Sadly, patients don’t want the truth – they want answers ( even if they are incorrect !) If the doctor tells them – “ We do not know why the cycle fails” , the doctor is worried that the patient may start doubting his expertise. This is why doctors are forced to manufacture “pseudo-answers” – and the more esoteric they are, the better ! Doctors have learned to position themselves as “experts”, in response to patient demand for omniscience from their physicians !

The reason why this is such an illogical approach is that if the tests were really useful, the doctor should have done them even before starting the first IVF cycle itself ! After all, , the patient and the doctor should want every IVF cycle to succeed – whether it’s the first or the second ! If the tests are useful , the identifying problems before the first cycle itself starts  would allow the doctor to “treat” the abnormality, thus allowing the first cycle itself to succeed, rather than fail.

The fact of the matter is that there are very few tests which provide much useful information in an IVF cycle . This is why doing a number of expensive tests after a failed IVF cycle is extremely illogical and doesn't serve much purpose. These tests include immunological tests; tests for endometrial function ; and sperm DNA fragmentation tests. The reason the list  is long just testifies to the fact that all of them are pretty useless.

So what is the solution? It’s important that doctors spend enough time counseling patients prior to the start of the IVF cycle, so that patients have realistic expectations of their chances of success. If this is done properly, patients will not go to pieces if the first cycle fails – and will be able to take the failure in their stride, rather than demand that the doctor provide them with answers. This is because they are now well-informed enough to realize that embryo implantation is a messy biological process over which we have very little control – and that it’s not possible for us to track the fate of the embryos after we have transferred them. Remember that human reproduction is an inefficient enterprise – whether it’s being done in the bedroom, or in the clinic !

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Monday, June 11, 2012

Why has the reputation of doctors taken such a beating ?

Once upon a time, the medical profession used to be a considered a noble one. Doctors were highly regarded and were often revered. Today, however, the newspapers are full of the misdeeds of doctors.  Doctors are being treated as potential criminals, out to abort female fetuses , in order to make a profit. Aamir Khan’s talk show , Satyamev Jayate, featured angry patients who provided many instances of how corrupt and unethical doctors are – and to what lengths they will stoop in order to make a quick buck.
Reading all these negative articles about doctors breaks my heart. Most doctors are good human beings and are trying to do their best in order to get their patients better. They spend many years slogging and mastering difficult technical skills , so that they can become competent professionals. I am sure most readers will agree that their personal doctor is a good person.

Unfortunately, there are a few bad apples in any profession  and this is as true for medicine as it is for any other profession. However, just the existence of the fact that there are a few bad doctors is not what the problem is. The problem is that doctors have failed miserably in policing themselves and pruning these bad apples.

Most doctors are aware of the ethical standards and technical competence of their colleagues. They know which doctors are good - and which ones are terrible. Unfortunately, there seems to be a conspiracy of silence  and doctors will not talk ill about other doctors in public. When doctors converse amongst each other, they will often describe how atrocious the behavior of some of their colleagues is – but they will not bring this to public attention, out of a misplaced sense of professional loyalty.

Unfortunately, this “ see no evil, hear no evil and say no evil “ attitude has now come back to haunt doctors. In the past, society expected the medical profession to police itself . Since doctors have failed so miserably in doing so , it has now decided to allow policemen to perform this role.

Unfortunately, this is not something which the policeman can do very well , as a result of which this mess is going to get a lot worse in the future. Must policemen will treat every person they see as a potential criminal - and this is exactly what they are going to start doing with doctors now. While it's true that doctors are going to pay the price, patients will suffer even more.

This has already started to happen. Thanks to the PNDT Act, many  doctors are refusing to do ultrasound scans for pregnant women , because it's become too much of a hassle to comply with all the technical minutiae of the Act. This means that pregnant women are going to be deprived of one of the most useful advances in medical technology,  as a result of which their medical care is going to suffer.  What a shame !
One we start treating all doctors as potential crooks, this will start becoming a self fulfilling prophecy.

Patients will stop trusting doctors and doctors will start over-testing and over-treating to protect themselves. If anything goes wrong ( whether or not the doctor’s treatment was correct or not), the patient and his family will suspect that the doctor was negligent and will want to exact revenge. This will setup a negative vicious cycle which will quickly spiral out of control.

Trust between doctors and patients  is vital . Treating all doctors as potential crooks will result in a  breakdown of the doctor patient relationship. This will end up reducing the efficacy of medical care, and all of us will suffer !

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Saturday, June 09, 2012

How sustainable is the Narayana Hrudayalaya model for healthcare ?

Narayana Hrudayalaya is often touted today as an Indian healthcare success story. It is supposed to be a great model of how to provide high tech medical care for the poor at a low cost. It has received many awards – and has been featured in the Economist and as a Harvard Business School study as well. In fact, the Aamir Khan show  , Satyamev Jayate, projected Dr Devi Shetty as an ideal role model for all Indian doctors to copy.

What amazes me is that no one factors in the hidden subsidies which have been provided to Narayana Hrudayalaya, which allow it to function the way it does! There are 3 major components to the costs of providing medical care:

1.    Salaries of health care professionals
2.    Cost of medical equipment
3.    Real estate

In Indian cities, by far the biggest chunk of the cost is that of the land – and private hospitals have to take loans (on which they have to pay interest at market rates ) in order to buy land to construct their hospital building. This is a huge part of the “cost of doing business” for the healthcare industry.

What bothers me is that no one talks about the fact that the land on which Narayana Hrudayalaya constructs its hospitals is given to it for a song. Incidentally, this is true for most large “charitable” hospitals in India. They claim to be charitable by promising to provide free care to a certain number of patients, in order to qualify for the grant of free land by the government. Once the hospital has been constructed, they happily break all the rules – after all, who is going to check ?

Everyone feels good about all these fancy new hospitals which are supposed to symbolize how India is shining ! India is becoming a medical superpower and a magnet for medical tourism, which is being projected as a multi-billion dollar industry. However, the reality is that this gifted land is a hidden subsidy – it’s the exploitation of a public asset for private gain. Of course, there’s nothing new about this. Industrialists and politicians do this all the time – and Narayana Hrudayalaya’s neighbor,  , Infosys is an excellent example of a highly profitable company which is happy to exploit land gifted from the government, because they are “ creating jobs “and “ earning valuable foreign exchange”.

Gifting prime real estate land in this fashion just ends up distorting reality, because this gift of hundreds of crores  does not show up anywhere on the balance sheet ! Of course, it’s not fair to single out Narayana Hrudayalaya  – they are just following in the footsteps of “ charitable hospitals “, which do this all the time. Using political clout, they grab the land , and promise free care at the time of signing up . They end up creating 5 star corporate hospitals which charge an arm and a leg – and forget all their promises when their operations start. The Seven Hills Hospital in Andheri, Mumbai is a great example of this; as is the Kokilaben Ambani Hospital. If doctors in private practice had access to free land to build their private hospitals , they would be able to provide care at much less than these hospitals charge !

Of course, this misuse is not limited to h als only . Another great example of how this largesse is exploited by people in power is the large number of private educational  institutes which have come up in India in recent times. These have huge sprawling campuses and practically all of them are owned by politicians , who have built these institutes to convert public land to private property !

I don’t expect human nature change and I am mature enough to accept that it’s perfectly reasonable for people to exploit whatever sweetheart deals they get – after all, we are all human ! What bothers me is the hypocrisy - Narayana Hrudayalaya and the other hospitals should not pretend to be holier than
thou ! It’s OK to be greedy and money is good , but it’s not right that these hospitals pretend to be low cost and charitable , when they are not.

This is not something which is limited to India either ! An article published in June 1997 highlighted how many of the world’s most highly respected “charities” in the USA also take advantage of the same loopholes ! As the article Charities on the Dole, states “ .. But the provision of charity--like profit making itself--isn't always what it seems. The bane of free economies has long been the businessman who eschews market competition to seek favors from the state. He slants the process in his favor, using an unfair advantage or imposing disadvantages on his potential competitors. The U.S. government has pioneered the practice of doing the same for charitable organizations. Government at all levels funds the nonprofit sector to the hilt, corrupting the idea of compassion. “

What about the low cost insurance program which Narayana Hrudayalaya has pioneered ? Isn’t this praiseworthy ? The idea of doing bypass surgery for one tenth of what a US hospital charges for poor  Indians is very commendable,  but this hides a subtle danger, which no one seems to have bothered to point out – the bane of unnecessary surgery, done simply to earn healthcare insurance revenue , which is provided “free” by the government. Bypass surgery ( which is what Narayana Hrudayalaya originally specialized in) is very dramatic surgery , but it’s also the most overused operation , and the one which has been documented to performed most unnecessarily as well ! There’s the temptation to do bypass surgery for everyone which cardiac complaints , whether they need it or not. Who’s doing the independent medical audit to check if the long lines of patients waiting for surgery really need this at all in the first place ?

Given the way India operates, Narayana Hrudayalaya is healthcare’s blue-eyed boy which is unlikely to ever be critically analysed by the powers that be . However, the good news is that thanks to the internet, the most important people in the healthcare system – the patients – are finally getting a chance to provide their personal feedback. It’s worth reading what  Narayana Hrudayalaya’s patients feel about the services they provide.

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