Why patients need to learn to ask the right questions !

This article appeared in the New Indian Express.

" Dr. Aniruddha Malpani, Medical Director, HELP—Health Education Library for People, Mumbai, explains, “The only stupid question is the one you did not ask. Asking appropriate questions about your treatment and medicines will help you to acquire knowledge and will also keep the doctors and hospital staff on their toes.” Malpani says that patients must never take any medicine without asking: what it is, why it is used and what its side-effects are. “Remember, there are lots of patients and your physician sees many everyday,” he says."

Am I shooting blanks ?

While a lot has been written about what women experience during infertility treatment, not much has been written about the man's experience. Partly this is because men are usually reticent , and are not willing to share their feelings , in contrast to women , who understand the importance of sharing , and realize that by talking to other people, you can reduce your own emotional burden. The biggest fear which men have is that they are shooting blanks. In fact, this is one of the reasons why a lot of men are very reluctant to get their semen tested .

If there is a delay in conceiving, it’s much easier for him to assume that it’s his wife who has a
problem ! After all, isn’t it’s the wife's job to have a baby ? He also believes that if his sexual performance is adequate , their fertility must also be fine , so why bother to test ?

In reality , a lot of men are petrified that they may be shooting blanks . They are worried that the test will show that their semen may not contain enough motile sperm. After all, most men today know that about 40 percent of the time , it’s man who has a problem when a couple is infertile.

They are scared that if they do a semen analysis and then find out that the problem lies with them, they will lose face - not only with the wife , but with the rest of society as well. The fear of being found to be infertile is often confused with the stigma of being considered to be sexually inadequate, as they still do not understand the relationship between fertility and sexuality.

Lots of them are scared that they may have run out of sperm because they used to masturbate frequently as teenagers ; while others are worried that their penis is too small or that their erection is not hard enough or that their semen is too watery – all of which may point to having a problem with their fertility !
A lot of these fallacies are made worse by quacks who scare men into believing that “ night falls” are a sign of sexual weakness.  Men often don't know where to get reliable information , as a result of which they bottle up their fears and anxieties. It’s because of these repressed fears that many men are reluctant to get such a simple test like a semen analysis performed – because they are worried that they may be found to be lacking – a fear which they are  not willing to share with the wife or their doctor, which just exacerbates the problem .

What doctors can learn from actors

One of the major criticisms patient's level against most doctors is that they are cold and impersonal , and do not seem to care for them. I don't think this is true , because most doctors take up medicine because they want to help other people. However, it is possible that sometimes doctors may be so rushed and busy taking care of a large number of patients, that it may appear to patients ( and their family members ) that they are uncaring.

Doctors are often focused on their job of taking care of the patient and providing them with good quality medical care - of doing the intellectual rigorous work of making the right diagnosis; sorting through different possibilities ; making sense of the labs; and carrying  out the technically demanding procedures properly , that they sometimes forget that they need to put on a little more human face when they talk to their patients. Many doctors underestimate the importance of the human interaction , because they're so focused on honing their technical competencies . 

This is why a number of very successful world-class hospitals provide empathy training to doctors and nurses . They teach them scripts and acronyms which they need to follow in order to convey to their patients that they care for them as human beings. One criticism of these courses is that we are teaching doctors to be hypocritical – that these courses allows them to merely simulate empathy , rather than actually become empathetic. Let’s not forget that a lot of patients can be hypocritical as well ! How many times have you sat in front of your doctor , nodding your head and appearing to agree with everything he's saying , whereas in your heart of hearts you say – No way am I going to undergo this surgery ! A certain amount of simulation is perfectly natural in any human interaction , and if it helps to improve the doctor-patient relationship, this is all for the best !

This kind of acting can actually be  very helpful ! Once you start play acting empathy, sooner or later it becomes a part of your DNA and starts coming naturally to you. It becomes a part of your instinct , even though initially it may have been a role which you had to learn to play . Fake it till you make it is very sensible advise – and it works !

Studies have shown that you do not simply laugh because you are happy – it’s surprisingly equally true that when you laugh , you become happy. Thus, if you play act well , a lot of these emotions which you have to learn to feel will soon become second nature.

Neuroscience has shown that it's easy to fool the brain , which has a hard time differentiating between thoughts and reality ! It is possible to make the heart do what the head tells it to do !

A very important part of the therapeutic effect which a doctor has on a patient’s well-being is his personal presence.  We often pooh-pooh this is as being a placebo effect, but the fact remains that the doctor’s bedside manner can make a big difference in how quickly the patient improves. Empathy is an integral part of the doctor’s therapeutic role. Just like we need to teach doctors pharmacology and surgery, so they learn how to use drugs and the knife properly , we need to teach them how to use their personality and personal skills , in order to make their patients better .

If play acting helps them to do this , then I'm all for it. This is a very low-cost , low-risk intervention which doesn't have any downside . If implemented properly , it can help to make for better doctors , leading to happier patients - and if patients are happy , this means doctors will automatically become happier as
well !

Isn’t this cheating ? Is it fair to let patients believe that their doctor is feeling compassion and empathy,  when he really isn’t ? This is the way all of us learn our habits – both good and bad. Good doctors have been fortunate in that when they were in training, they had great role models whom they could emulate. It’s never too late – and all doctors can be taught to act as compassionate doctors !It's perfectly normal to stimulate feelings;  and I think once this is done efficiently, it’ll become a natural part of the doctor’s behavior , so that after a few times he will no longer need to pretent anymore – it’ll just come naturally. After all, most good doctors learn these skills by copying their seniors , who act as role models. Unfortunately , some doctors are never exposed to good role models , as a result of which they never pick up these skills . Tools such as play acting and memorizing scripts can help doctors to acquire these skills. They are critically important , because patients expect doctors to have them !

One of the problems is that it's very hard to measure some of this stuff , because it is intangible. However, they can be judged indirectly. It's easy to measure patient satisfaction scores , and teaching doctors these skills has been shown to improve patient satisfaction scores , which is a very desirable outcome for everyone concerned – both patients and doctors.

If doctors can be taught to pretend to care for patients, this is good for patients , because they will feel cared for ; and good for doctors as well, because they will actually start caring ! Empathy has always been considered an essential component of compassionate care, and recent research has shown that its benefits go far beyond the exam room. Greater physician empathy has been associated with fewer medical errors, better patient outcomes and more satisfied patients. It also results in fewer malpractice claims and happier doctors.

Should pharmaceutical companies be allow to sponsor medical conferences ?

There is now a lot of hue and cry about the corrupting influence which pharmaceutical companies have on doctors. None of this is really new, but it is been brought into sharp focus recently . The Parliament wants doctors to prescribe only generic drugs , as compared to brand names , because these are significantly cheaper and equally effective. While there are guidelines laid down for doctors, which specify that they are not supposed to accept gifts from pharmaceutical companies, most of these are observed in the breach and happily flouted. The Pharmaceutical Council has now got into the act , and is tightening the screws on pharmaceutical companies , to ensure that they do not provide gifts and bribes to doctors.

Pharmaceutical companies have come in for a lot of criticism recently. They waste a lot of money on developing lifestyle, drugs, which make billions for them , but don't really help to improve the health of people. All the large pharmaceutical companies have been fined billions of dollars , for unethical marketing practices all over the world, which means they now have a very tarnished reputation.

Pharmaceutical companies have deep pockets and can be easy targets . The passage of this law will help prevent some of the more flagrant abuses which we have seen for so many years.

However, the fact is that laws are not going to make these unethical practices go away. There is just too much at stake , and the marketing departments of pharmaceutical companies are very clever. They have developed ways of bending the law and bypassing it , because they understand how important it is for them to influence the key decision-maker within the healthcare system - the doctor .

One of the most important mechanisms of influencing doctors is by sponsoring medical conferences. Pharmaceutical companies will spend crores of rupees to sponsor conferences , because this gives them an opportunity to influence thousands of doctors directly. Many of these conferences have become large circuses , with budgets of over a crore of rupees, pharmaceutical companies compete with each other to lure doctors at these events.

One way of plugging a lot of these loopholes is to ban pharmaceutical companies from sponsoring medical conferences. There's nothing wrong with medical conferences per se. After all , in theory at least, they are great ways of ensuring that doctors learn about recent medical advances and keep themselves up-to-date. Unfortunately, this is true only on paper. In real life , most of these conferences are held in five-star hotels and beachside resorts , and end up being parties for doctors , who are happy to socialize with each other , meet old friends; and play political games, rather than learn.

If doctors are serious about using conferences for continuing medical education , then they should be quite happy attending conferences held in medical colleges. However, the attendance for these serious medical low-budget , low profile conferences is one tenth of what it would be , if the conference was held in a five-star hotel.

Many pharmaceutical companies pay the doctors conference fees for attending these five-star medical conferences. They also pay for their tickets; and pay huge amounts of money for the privilege of having stalls at these conferences , so they can exhibit their wares. Because this has become such a lucrative business , a lot of pharmaceutical companies will do their best to influence the medical conference organizers , who are usually leading doctors , who are the office bearers of the concerned medical society .
Some of this can happen in fairly subtle ways , so that it's not obvious to the doctor that he is being seduced into practicing inappropriate medicine.

This is going to be a very unpopular suggestion , because doctors like attending medical conferences . They like going for all expenses paid holidays , because they can justify to themselves that they are learning a lot at these conference . Unfortunately , it has been proven that lectures are a very poor format of educating someone. It’s high time we started adopting the recent advances in digital educational technology , in order to ensure that doctors keep up-to-date with recent medical advances, without being exposed to the pernicious influence of pharmaceutical marketing , which medical conferences today provide.

Not only are conferences a bonanza for pharmaceutical manufacturers, they are also exploited by medical device manufacturers , who spend crores of rupees trying to convince pathologists and radiologists to buy their equipment. All this marketing ends up increasing the cost of the equipment – and this gets passed on to the poor patient  .

A lot of these companies justify their expenses by saying they need to earn money in order to develop new products , and invest in research and development, but in their heart of hearts they know that their money could be put to far better use , if they did not have to indulge in unethical practices to covertly influence doctors. This would give a far better rate of return , both for themselves , for patients , and for society at large .

However, companies today are in a soup. Even if one company is highly principled and decides to take the moral high ground and stops paying under the table in order to influence doctors, they will be at a disadvantage because the other companies continue to do so . This is why passing the law, which provides a blanket ban, will ensure a level playing field ; and will help everyone - the companies , doctors and patients , so that limited resources are put to the most cost-effective use , and we can all get the biggest bang for our hard earned bucks.

Treatment before tests ?

In medicine, it is traditional for the doctor  to do tests in order to come to the right diagnosis . He needs to identify what your problems are, so that he can then suggest the right treatment. This seems very logical and makes a lot of sense. After all, if the doctor cannot identify the problem, how can he suggest a solution ?
However infertility medicine is completely different. Unlike other branches of medicine , it is not a problem oriented - it is solution oriented. Patients don't come to a doctor and say - Please open my blocked tubes – they come to a doctor and say -  I want to have a baby !

Read more at http://www.drmalpani.com/treatment-before-tests.htm

What should you be thinking about during your IVF cycle ?

There many possible answers to this question ! For one, you need to focus on making sure that you're taking all your medications correctly and that your doctors are monitoring your cycle properly. You need to be well informed about your ultrasound scan and blood test results ; and you need know all the medical details about your follicles, eggs and embryos. Many patients spend a lot of time fantasizing about success, while others are paralysed by the possibility of failure. The most important thing you need to pay attention to during your IVF cycle is what you should do in case your cycle fails. This might seem paradoxical , and in fact a lot of patients get quite agitated when I give them this advise. They think I am being negative and pessimistic – and feel that I must not be confident of my medical abilities.

Read more at http://www.drmalpani.com/what-should-you-be-thinking-about-during-your-ivfcycle.htm

Why you need to be a contrarian

If you follow the herd, you are likely to perform exactly as well ( or as badly) as the herd performs ! Most people are quite happy to be average, because it’s comforting to be part of the crowd. Man is a social animal, and it’s much easier to just go along with what everyone is doing – after all, aren’t crowds supposed to be wise ?

Trying to think independently can be hard work – and this is something which few people are willing to
do . Sadly, most students today are not even able to do this, even if they wanted to. They have spent so many years in school , sitting passively while their brains are crammed full of facts , which they are then taught to dutifully regurgitate in their exams, in order to score 100%, that they are incapable of having a single original thought for themselves.

Most people believe that if you want to do well in life, you just need to follow conventional wisdom . This is why 10 years ago , during the dot com boom days , everyone wanted to be a computer engineer, because that’s where all the money was. Little did they realize that booms are followed by busts – and that when they plan , they need to think about what the world is likely to be 10 years from now, rather than deluding themselves into believing that it will be the same as it is today.

If you want to be average, then you should follow the crowd – after all, this is what the definition of average is ! However, if you want to be successful, you need to be different. Common sense will tell you if you follow traditional wisdom , you will never be able to stand out from the crowd.  It’s because most people just do what everyone else is doing that they end up not being successful – there are too many of them of them who have exactly the same skill sets, for them to have an edge over the others. It’s not easy to be a contrarian, because you need the courage of your convictions . It’s not easy to do something which other people dissuade you from doing , because they think you are barking up the wrong tree ! Most contrarians have a hard time because the crowd will give you hundreds of reasons as to why what you're doing is wrong. The crowd does not like to see the success of people who think differently from the way they do. This is disquieting and upsets their preconceived notions. They’d rather believe that the conventional wisdom is correct . Anyone who takes a contrarian approach is actually a threat to them , and this is why they will follow the Indian crab mentality of trying to pull everyone down to their level.

However, if you have done your homework well, can stick to your convictions ; and are confident of your strengths , there is really no reason for you to follow the beaten path. You are actually much more likely to be better off marching to the beat of your own drum. Just being a contrarian is obviously no guarantee for success. There’s very little point in`ng the opposite of what everyone else is doing simply because you want to be different and want to stand out. However, your chances of success are going to be much more your if you take this approach, provided you know  your strengths and play to them. You need to know in which areas you are expert enough to be a contrarian about - and then focus on these core skills and strengths, in order to succeed !

Why I do all my consultations myself

A new patient just called the clinic and asked the receptionist for an appointment with the doctor . She then asked, Will I get to see Dr Malpani ? My receptionist was a little surprised by this question, because I always do all the consultations myself. She explained our policy to the patient, who was quite pleasantly surprised, because she was used to seeing only assistants when she had been to other IVF clinics in the past.

We don't have any assistant doctors in our clinic and we take pride in the fact that I see all my patients myself . I also answer all my e-mails myself ; and Dr Anjali does all the scans , egg collections and embryo transfers herself . We have a very hands-on personalized approach in our  clinic . One problem with this is it limits the number of patients I can see , because it takes me about 20 minutes to do a consultation . This is quite unlike other IVF clinics, where the main doctor can see many more patients, because the initial history taking and consultation are done by a small army of assistant doctors. The obvious question is – Why don’t we employ an assistant and allow the assistant doctor to take the history,  so that I can increase my throughput and efficiency ? See more patients will allow us to increase our income considerably !

This is a conscious decision we have made , because I feel the major role of a doctor is talking to the patient and taking a history . This is the foundation of good medicine , and I do not want to outsource it to someone else. Other IVF doctors also realise this, but they only do a consultation for the VIP patients – the “ordinary” patient needs to see an assistant ! We treat  all our patients like VIPs ! While talking to the patient allows me to understand her medical problem clearly , this is something which a competent assistant can do equally efficiently. The reason I do this myself is that it provides a far more valuable function – it allows me to get a much better insight into the patient's psyche, as compared to just reading her medical notes. Talking one on one to my patient allows me to understand what the patient understands about her problem , and what she doesn't , so that she has more realistic expectations of what I can do for her . It also allows me to empathise with them ; and ensure that they are actively engaged in their treatment .

The time I spend with the patient during the consultation is extremely valuable to both the patient and me, It gives the patient confidence that I have understood her and her medical problem. Consultations are one of the things senior doctors do extremely well – and this is something which juniors may not perform as well. I am not saying assistants cannot be trained – of course they can ! It’s just that many doctors think taking a history and talking to the patient is not very important, because they are so focused on performing procedures ! After 20 years of experience, communicating with a patient is a skill which I I hopefully have mastered ,and this allows me to provide far better medical care to my patients , than using the traditional model of having an assistant take the history , so that I merely need to review it and then go over the salient points with the patient.

A better way of increasing my efficiency would be to allow the patients to fill in a detailed medical history form, something which they can do online , or after coming to the clinic . I can review this form with them when I do the consultation. This will ensure that I spend quality time with the patient ; and will also allow me to get better insight into what my patient understands about her problem. It would help because then I wouldn't have to do as much writing when filling in the medical record, since most of it would have been done by the patient herself !

Are doctors who charge more better than those who charge less ?

There is a lot of variation in how much doctors charge for a consultation ; for doing surgery ; and for giving anesthesia during an operation . One question all patients ask is - Why is there so much variation ? The general perception in a free-market economy is that anything which costs more must be better ! This is why luxury goods cost more than ordinary goods ; why brand names charge a premium ; and why a Mercedes costs much more than a Maruti. People are willing to extrapolate this , and come to the conclusion that if a doctor charges more , he must be better than one who charges less ! This is a useful rule of thumb, which works reasonably well in real life . If  a doctor charges more than someone else and is still busy , this means he can get away with charging a premium - and the general perception mus be that he is worth the additional premium he charges.

Unfortunately , this is an imperfect market , and there are a number of exceptions. For example , there are still some doctors who will not charge more than what they consider is a reasonable fee , simply because they feel there is no need for them to enrich themselves at the expense of their patients . They are simple people , with a frugal lifestyle , who are contented with what they have .

Similarly, just because a doctor charges more doesn't automatically mean he's better ! There are some flashy doctors who are very good at marketing , and who spend a lot of money on furnishing their clinic and paying for PR (public relations ). They consider this overhead to be part of the “cost of doing business” and need to recover this additional expense from their patients by charging them more .

Sometimes, patients also contribute to this inflation of prices. When we first started practice, because our overheads were extremely low, we charged much less for an IVF cycle than other clinics did. However, patients felt that if they are charging less , this means they must be worse , which is why very few patients came to us . The moment we increased our fees to match the marketplace , our clinical workload increased  dramatically !

One thing which would help patients to judge whether they were getting value for money would be to encourage  openness and transparency in this area. We should encourage doctors to publish their fees on their websites . This can help patients to make comparisons , so that they can make better informed decisions. It would also help doctors themselves, because they would learn what other doctors were charging . This would help them to tweak how much they charge , so that they can then come up with solutions which work optimally for them and for their patients.

PESA ICSI success story at Malpani Infertility Clinic

We are from the Caribbean . I am 30 and my wife is 24 ,we got married 3 years ago,and we were trying to conceive from year and a half,but we couldn't made it ,it was so disappointing  when we were expecting a good news every month.We finally decided to visit a doctor in India when we were there for our vacation.We consulted a gynaec who suggested both of us to do some tests, and as per tests reports my wife had no problems for conceiving but my semen analysis reports showed that I had zero sperm count.It was very frustrating and annoying after hearing this news, it was our time to go back home.

After going back home each month was like a year for us.We started researching about the treatment over the net.We came across many hospitals and doctors who had a good history dealing with such treatments,there were many possible treatments for infertility,but we were not sure what exactly should be done in our case.We came across DR. MALPANI's site ,it looked very promising and homely.Then we started browsing over all the views and comments of all the previous patients of DR.MALPANI ,not even a single couple  was unhappy with his treatment and his staff hospitality .We decided to go to India and consult him.

September 2011 when we met him for the first time he put all the pros and cons possible in front of us and told us to have a second opinion if we wish too.He was very honest and kind,he suggested me to repeat the semen analysis again to make sure if it was a  obstructive azoospermia or an nonobstructive azoospermia. In my case it was absence of vas deferens which was the reason for my obstructive azoospermia.The DOCTOR decided to do PESA/ICSI in our case.The treatment was started and my wife use to take injections at the clinic where his staff use to treat us with great hospitality and they made us so comfortable with their humble and caring nature .

We had 5 embryos out of which 3 were fertilized and a grade A embryos,all of which were transferred after two days of the egg collection.

Then it was 14 days waiting period before we could know what will happen whether it would be a good news or a better luck next time.By the grace of God and Dr Malpani and his staff's hard work, we got a bonus with twins.I always believe where there is a will there is a way.

[email protected]
 

Is IVF treatment stressful ?

The general perception seems to be that IVF is an extremely stressful treatment . Being infertile is stressful , so it seems logical to jump to the conclusion that going through infertility treatment must be much more so – after all, so much rides on the outcome of the IVF treatment cycle !

However, an IVF treatment cycle can actually be a very positive experience . If patients follow certain guidelines, they are likely to have happy memories of the IVF treatment , irrespective of what the outcome is ! The trick is to have realistic expectations from the treatment.

Remember that IVF treatment gives infertile patients their best shot at getting pregnant , so that if you do an IVF cycle, you have peace of mind that you did your best so that you have no regrets later on in your life. Also, IVF treatment is elective treatment , which you take by choice - no one is forcing you to do this. Doing IVF allows you to exercise your own free will and decide – Yes, this is what I want to do , because it maximize my chances of having a baby. This can be an empowering experience , and you can look forward to it , because you're trying to control what is happening to you, rather than just being a passive victim of either a low sperm count or blocked tubes. In one sense , you're trying to write your own destiny , with the help of medical technology – what more can a human being do ?

Equally importantly , there is no medical risk involved in the IVF treatment, when it’s done properly. Unfortunately, there are still lots of myths and misconceptions that the hormone injections used in IVF make you fat; or increase the risk of breast cancer . You should do your homework , rather than listen to these old wife’s tales. The IVF hormonal injections are natural hormones, which allow us to rescue the eggs which would have died anyway. They get excreted in the urine promptly, and do not have any long term consequences. Being armed with information therapy can provide a lot of positive energy when you're doing your treatment.

The biggest problem is that IVF patients often have not been counseled properly , as a result of which they often have very unrealistic expectations of success rates . Patients need to understand that the outcome of an IVF cycle is always uncertain , simply because human reproduction is an inefficient. enterprise – both in the bedroom, for fertile couples, and in the clinic, for infertile couples. No matter how good your doctor , once the embryo has been transferred into the uterus, we cannot control whether the embryo will implant or not. While it can be hard to come to terms with this uncertainty , once you factor this in , you realize that all that you ( and your doctor) can do during the IVF treatment is your best – and the rest is out of your hands. This is exactly what the Gita advises – do your duty , without expecting any reward in return. This kind of philosophical approach towards IVF treatment will help to make the cycle itself much easier to cope with , so that it’s easier to cope with the IVF emotional roller coaster ride.

One major advantage of IVF treatment is it helps you get in touch with other infertile couples . A major problem with being infertile is that you often feel isolated and ostracized . It seems that everyone else - office workers , friends, colleagues and relatives - is  having babies. However, when you go to an IVF clinic , you get a chance to connect with lots of other infertile couples . It gives you a chance to network with them, and this provides invaluable emotional support . You realize that you are not crazy – and that there are many others who are in exactly the same boat you are in – you are not a freak.

Going through an IVF cycle can also create bonding between the husband and wife . It’s when he sees his wife taking the IVF shots daily, that some husbands finally understand the depth of the emotional desire and the strength of the biological craving which a woman has , when she wants to have a baby. When he sees that his wife is willing to go through so much trouble in order to have a baby , he becomes much more empathetic , and has a much better understanding of her feelings – something which helps to make the marriage even stronger.

If :

You decide to do IVF treatment because you choose to do so of you own free will, for purely selfish reasons;
You have realistic expectations ; and
have been counseled properly ,
You will find that an IVF treatment can actually be a very positive experience , rather than being a negative stressful one.

It’s up to you ! If you take an active role , so that you are in control of your life, rather than thinking of yourself as a passive victim , you are likely to be happy with your IVF treatment – and getting pregnant is then just the icing on the cake !

What the Dean of KEM Hospital can learn from the President of UCLA !

Watch this great talk by UCLA Medical Center President Dr. David Feinberg. It’s the remarkable story of how UCLA changed its culture from “you’re lucky to see us” to “we provide acts of kindness.” I do hope Dr Sanjay Oak, the Dean of KEM Hospital will watch this !

Anti-tubercular treatment, genital TB and infertility - Letter to the Editor

This Letter to the Editor was published recently in the prestigious medical journal, Human Reproduction.

There are a still a lot of myths and misconceptions about genital TB and infertility in India . A large number of infertile women in India are being treated for "silent" or "dormant" or "occult" genital TB, based on a positive TB PCR test ! This kind of overtreatment can cause a lot of harm.

http://humrep.oxfordjournals.org/content/early/2012/07/18/humrep.des268.full?keytype=ref&ijkey=qBYiovjFKx7zznK

Why do doctors have such little clout ?

We respect our personal physician , and whatever he says carries a lot of weight. We trust him and follow his orders . Since doctors are highly respected professionals , one would expect that the medical profession itself would carry a lot of clout. Unfortunately, this is not true. There are a number of laws which are passed , which regulate the medical profession, but which are very doctor - unfriendly . They seem to have been drafted without considering any input from doctors at all. In fact, even though doctors vociferously and actively speak out against these draconian rules , their voices are not heard and these bills are passed and become laws.

Doctors are not unreasonable people and they are happy to follow sensible regulations . It’s just that many of these laws are so terrible , that it's impossible for a practicing doctor to comply with them. This is why doctors oppose some of these laws tooth and nail – not because they don’t care for their patients, but because these laws will unleash an Inspector Raj, which will allow babus and clerks to exploit doctors.

One would expect that if doctors unitedly opposed these laws, they would never get passed.  After all , can’s doctors make their voices heard ? Can’t they put up a united front and actively stop the passage of these laws, which only seem to hurt everyone, and not to do any good at all.

Unfortunately, even though doctors have a lot of personal clout as individuals , it seems that as a profession we've not been able to get our voice heard. There is no one respected individual who speaks for the medical profession. Usually , it’s an association which is supposed to represent professionals, and while there are a number of medical professional societies, the sad truth is that the doctors themselves are so busy fighting in order to become presidents and secretaries of the societies, that they do not have any unity. So much bickering and back biting goes on within these associations that that no one respects them at all – not even the doctors whom they are supposed to represent ! The office-bearers within these associations are so busy fighting with each other for plum posts that they seem to forget that they were appointed in order to represent the views of the entire medical profession.

Just think for a minute . If the President’s or PM’s personal physician told him that a proposed law was bad for doctors and patients, don’t you think the President or PM would listen to him carefully ; accept his input ; and make the necessary modifications ?  Unfortunately, we don't seem to have got our act together as doctors , as a result of which we do not seem to be able to reach out to these key decision-makers, even though every important decision maker in this country has their own physician , who is a member of the medical association .

Rather than blame the politicians for passing laws which are unfriendly to us, we need to blame ourselves, because we have failed to project our viewpoint with enough force and vigor to the people who count. This is the reason doctors are being bulldozed ; and these doctor unfriendly laws are being passed. The biggest tragedy is that all these rules will not hurt only doctors , they will end up hurting patients as well . Doctors will soon learn to game the system in such a way that they will pass on the costs of these laws to their patients. By then , it'll be too late to undo the damage and all of us will end up paying the price in the long run.

The reason the voice of doctors is not listened to with a little more respect is because doctors themselves do not speak with a united voice !

How to make decisions – a guide for the infertile couple

It’s often hard to decide what to do when you are infertile. There are always many options – and lots of confusion, because there are so many choices. Often, patients will fall into the trap of paralysis by analysis, and many need a helping hand to guide them in the right direction. The situation becomes more complex when the husband and wife don’t see eye to eye; or when there are external family and social pressure to pursue an option you are not comfortable with. Not being able to afford the treatment just exacerbates the complexity of  making these decisions, A wrong decision can prove to be extremely expensive – not just financially, but emotionally as well ! Suppose you go ahead with the adoption , even though your mother in law does not approve? Will she accept her grandchild ?Will he be treated as a part of the family  ? What are the long term consequence of the decision ? Will your husband be able to love a child born of donor sperm as his own ?

I feel you should make these decisions for purely selfish reasons. Unless you are happy , you will never be able to keep anyone else happy. You should concentrate on maximizing personal happiness , so that you can share your joy with others. Everything else will fall into place . Some people prefer becoming a martyrs – I will forego the IVF treatment, even though I want to do this more than anything else, because it is too expensive. I will sacrifice my happiness for the sake of my family members. This doesn't help at all. Often, this gesture is not appreciated , because they don't even know that you're making such a big sacrifice on their behalf. Secondly , you are likely to resent the fact that you made a decision , which was not in your best interests , for the sake of someone else. You expect to be praised for this – and when this is not forthcoming, you will start feeling that what you did was in vain. Ironically , if you had discussed this decision with them, they would most probably have told you to do what your heart tells you ! People who really love you will help you to do what’s best for you ! Rather than worry about others, it is important to listen to your head – and your heart. These decisions need not be justified or rationalized, because  no one else has the right to sit in judgment on you.  Some of the questions are complicated , and the bottom line is there are no easy answers. You can't go by what others have done – and there is no established track to follow. There is no such thing as a wrong answer , if you decide the answer for yourself.

Remember that love gets multiplied , it doesn't get divided. If you want to add another child to your family, not only will you love that child a lot , your will continue loving your existing children as well !

Why IVF failure can be so devastating

The fact that the cycle may fail is the major fear every IVF patient has to confront. An IVF failure can be a major personal devastation for many patients. This is because many infertile couples will treat the failure as a personal failure - when their IVF cycle fails , they blame themselves for the failure .

There are multiple reasons for this. Many infertile have self-esteem issues , and think of themselves as being flawed, because their bodies don't work properly, which is why they have not been able to get pregnant in their own bedroom. They start the cycle by carrying a lot of emotional baggage , and the failure just exacerbates these issues.

Read more at http://www.drmalpani.com/why-ivf-failure-can-be-so-devastating.htm

Judges , doctors and double standards

Doctors are treated as respected professionals and held in high regard , because we expect them to take care of our health when we are ill.  We hold our judges in equally high regard , because we expect them to dispense justice impartially and fairly, whenever there are disputes between citizens . Judges, like doctors, are professionals who’ve studied a body of knowledge ; and who are then appointed to serve on the bench because they are expert at what they do, and have a good reputation.

However , what amazes me is the double standards we use when we consider the mistakes and errors made by judges and doctors . When  a doctor makes a mistake ,patients want to beat him up or sue hom. Participants in talk shows want these doctors to be hanged or locked up in jail !

Yes, it's true that there are bad doctors , and that these doctors do make mistakes because of negligence. However, it's equally true that there are judges who deliberately pass biased orders for personal financial gain. When these facts come to light , these judges are arrested , but what's remarkable is that no one hosts a talk show and bemoans the facts that our judiciary is corrupt – and there is no public clamor for bad judges to be locked up in jail.

If anything , the scope for doctors making mistakes is far more than for judges , because doctors deal with biological science ; medicine is imprecise ; and we cannot predict or control how an individual patient’s body will respond. Judges have a relatively simpler job to do , because they have to interpret guidelines , laws and statutes which are laid down by other people. We know that lots of decisions made by judges are routinely reversed on appeal – which just emphasizes the fact that even though judges are experts , they don't claim to be infallible ; and we accept this as an integral and healthy part of our judicial system’s checks and balances.

Why we can't use the same set of standards when we deal with doctors ? When doctors make mistakes, why aren’t we willing to be equally charitable and accept the fact that not all errors occur because doctors are negligent or careless ? Patient are not scared of doctors ; and it's easy for us to badmouth them, because they can't stand up for themselves. However, we are scared of saying anything derogatory about judges, because we may be hauled up for contempt of court !

When the actions of bad judges are highlighted in the press, remember that it's usually the good judges who get hurt the most, because each article is a slap on their profession. Their professional reputation takes a beating when fellow judges misbehave and good judges cringe the most when they read about these activities. It’s exactly the same for doctors . When the actions of bad doctors are sensationalized, it’s the thousands of good doctors ( who do good in their own way every day) who are hurt the most. It is not fair to tar everyone with the same brush !

15 ways to make a baby - article in Hindustan Times

15 ways to make a baby (And why you’re ready to do so)

Tavishi Paitandy Rastogi, Hindustan Times

Till as recently as a couple of years ago, mothers-in-law asked uncomfortable questions, intrusive relatives cast aspersions and couples hung their heads in shame for not having kids in the first few years of marriage. Not any more.

Easy availability of information online has played a big role in changing old mindsets, especially in urban India. Most young people are coming around to exploring newer, more successful ways to procreate.

Even as most experts stand by the view that the best and the most fun way to make a baby is inside a bedroom, people are more aware of “other ways” to procreate. “Having a baby has always been a wonderful thing. And, thank God, people are now not just discovering but also making use of and talking about the ‘other ways’ rather comfortably,” says Mumbai-based infertility specialist, Dr Aniruddha Malpani.

Actor Aamir Khan and Kiran Rao’s baby boy was born via surrogacy

Poor quality embryos in an IVF treatment cycle

When the quality of embryos in an IVF cycle is poor, the patient is understandably upset and wants an explanation. A good embryologist will sit down and try to explain to the patient what the various causes for poor embryo morphology are. However, a lot of doctors will try to pull a fast one by telling the patient an untruth.

One of the commonest reasons doctors trot out for poor quality embryos is poor sperm quality. They tell the patient - it's because your husband sperm morphology was abnormal ; or because his sperm DNA fragmentation levels were very high, that your embryos are of poor quality.

Read more at http://www.drmalpani.com/poor-quality-embryos-in-an-ivf-treatment-cycle.htm

Celebrities and IVF

I was recently reading an article online about film stars who have used IVF in order to have a family.

In the past , when celebrities underwent medical treatment, this was often a closely guarded secret, which they did not share with the rest of the world. It's therefore heartening to see that film stars are willing to be much more open about the fact that they are using technology in order to complete their families.

Read more at http://www.drmalpani.com/celebrities-and-ivf.htm

What should a doctor do if he feels another doctor is incompetent ?

Doctors are usually well informed about the professional competency and skills of their colleagues, because they work in the same hospitals and see the same group of patients. Most doctors are aware of which of their colleagues are proficient – and which of them are downright incompetent and dangerous. While doctors are happy to refer their patients to competent colleagues , what do they do when  they know that another doctor within the hospital is incompetent ? This is often an open secret – one of those things which all the professional staff is aware of, but which is carefully hidden from patients.

Most doctors will take an attitude of – It’s really none of my business , so why should I do anything ? My job is to take care of my patients, and I will do just that ! Why should I interfere with someone else’s work ? They pretend not to see any evil, or hear any evil, which is why they will not speak any evil ! ( For example, one of India's busiest IVF clinics is run by a skin specialist - a fact which everyone knows, but does nothing about).

There are multiple reasons for this silence.

Doctors are professional colleagues , and you do not want bad mouth them , because if you are labeled as a whistleblower , you are likely to be ostracized. Equally importantly, there is no easy mechanism by which doctors can point out which of their colleagues are problem doctors. Who do they complain to ? Complaining to the medical council or the hospital administration is difficult and time consuming -  and most busy doctors don't want to poke their nose in some other doctor’s life , or stick their neck out !  The common justification is – Why should I bother ?. I have enough problems of my own to handle , without taking on someone else's ! The fear that your colleagues may disapprove of your actions means that keeping silent is the easiest course , and that's what most doctors tend to do ! If junior doctors see that their seniors are keeping quiet , they believe that this is the standard of behavior which is expected of them , and they model this. The other fear is that if you do bring attention to the fact that a colleague is incompetent, people will think you're doing it because you're jealous , are want to bring down your competition . This is why most doctors turn a blind eye to the incompetence of other doctors.

It's easy to justify this by saying - I'm not my brother’s keeper ! My job is to take good care of my patients, and as long as I'm doing this, why should I bother about what someone else is doing ? It’s this kind of silence which leads to an ever-increasing number of incompetent doctors , who cause a lot of harm to their patients. As a result , the reputation of the entire medical profession takes a beating . The general perception seems to be that the medical profession cannot police itself (or even worse, will not police itself ) as a result of which society is now appointing outsiders (including policemen , bureaucrats and NGOs ) to make sure that doctors toe the line. Sadly, because they are outsiders and do not understand the doctor’s job and the pressures he faces in the daily grind of medical practice, this kind of policing often causes more harm than good.

Why is IVF treatment so expensive ?

I often see lots of infertile patients who could get pregnant if they did IVF treatment. Unfortunately , they just cannot afford to do an IVF cycle for financial reasons, as a result of which  they end up without a baby. Imagine the amount of heartburn and frustration this causes – when you know that you can get pregnant with IVF, but that you will not be able to do so because you can't afford the treatment !

This causes a lot of anguish for IVF specialists as well. It’s heartbreaking when you know that you have a medical solution , but you cannot offer it to the patient because they cannot afford it. Of course, this is not something which is unique to India - it applies all across the world . The question we need to ask ourselves is – What can we do to make IVF more affordable ?

In India, it would make a big difference if the government accepted the fact that family planning and welfare does not just mean limiting family size, but also helping couples to achieve their desired family size . If government hospitals and medical colleges started offering IVF programs , they could easily afford to do so cost-effectively and very inexpensively. It’s high time we did this, because it’s tragic that we are turning out M.D. gynecologists from medical colleges in India who have never had any exposure to IVF treatment. These gynecologists are underqualified , and this is a shame . Offering IVF in these hospitals would end up killing two birds with one stone. Not only would this allow us to provide quality care for infertile patients ; it would also ensure that we are training the next generation of gynecologists properly !

The other major issue is the fact that health insurance companies refuse to cover for IVF treatment . They use all kinds of flimsy excuses to reject infertility claims, by stating that infertility is not a medical disease – it’s just a lifestyle illness, which is why It doesn't need to be covered . The reason they can get away with this ridiculous claim is because they have deep pockets ; and because infertile patients aren't willing to get together and fight for their rights. I wish infertile patients would get together to form an NGO which would establish that infertility is a medical problem ; and that medical insurance should cover treatment for it, just like it covers treatment for other illnesses !. This single simple step would make a world of a difference to a large number of couples , who would then be able to afford infertility treatment.

In fact , this is actually a great business opportunity for a clever insurance company . A smart health insurance company could actually offer a fertility insurance package , which people could gift to newly married couples ! Most married couples have no problem getting pregnant , as a result of which they would never need to use this insurance package . However, because they would pay the premium , the insurance company would be able to collect enough money from fertile couples, which it would then use to help infertile couples to have a baby . It’s possible to come up with lots of clever solutions , if we just apply our minds.

Why is IVF so expensive in the first place ?  One of the reasons is because doctors charge so much ! Doctors use all kinds of reasons and excuses for our high fees ( we have invested so many years in our training ; IVF needs expensive equipment; the disposables are expensive, and so on). While these reasons are true , it’s also possible for a clever doctor to come up with a disruptive innovation , and use economies of scale , to be able to deliver IVF services cost effectively to more patients, just like Sankara Netralaya has done to make cataract surgery much more affordable ! Doctors need to develop a clever business model, so that they would be able to treat a much larger number of patients using a “ focused factory “ approach . It’s possible to easily achieve these volumes in countries like India, because we have such a large population , of which such a significant proportion is infertile.  Developing and adapting innovative technology (such as the use of vitrification for freezing ) to improve success rates will also play a major role in making this dream a reality.

Making use of quacks

One of the major problems with the Indian healthcare system is the large number of unqualified quacks who dispense medical care . These quacks can be dangerous. They give injections for no good rhyme or reason , creating infections transmitted by unsterile injection practices ; they use antibiotics indiscriminately , leading to the propagation of antibiotic resistant bugs; and they often make the wrong diagnosis, causing needless suffering.
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While it's true that quacks can cause a lot of harm, we need to accept that they are a fact of life in the present Indian healthcare system. Whatever our personal view about them maybe, the fact that they continue to flourish means that they must be  serving a useful function in society . We need to take advantage of the fact that they have an extremely efficient network , and use this, so that they can provide good quality healthcare, rather than continue to be a menace .

We need to stop looking down on quacks and treating all of them as crooks. Just like there are good doctors and bad doctors, we need to acknowledge that there are bad quacks and good quacks ! Rather than concentrate on rooting out the bad quacks, we need to focus our attention on the good quacks , so that they become better !

Quacks have been self-selected and have a lot of courage and hubris – remember that it’s not easy to set yourself up in practise as a doctor, if you do not have the requisite training !  Not all quacks are greedy – some do this because they have a desire to heal people . We need to tap into this !  This is a useful internal drive , which helps them to provide care to others. This is one of the traits we try to select for , when we recruit medical students for medical colleges - and quacks , simply by virtue of the fact that they have been in practice for so many years , have actually proven that they have this particular trait !

Many quacks have been in practice for many years. The reason they flourish in underserved areas is because trained doctors are not willing to put up with the hardships involved in practicing in these settings ( extremely poor slums; or remote villages). They have a certain social standing ; the community respects them , and is willing to trust them. Rather than force qualified doctors to practice in areas they do not want to,  we can tap Into this trust , and leverage the efficiency of the quack, so we can make them more productive healthcare workers, rather than treat them as being a menace to society.

While it is true that they can be dangerous , it is also equally true that by providing them with the right information , they can actually become useful frontline healthcare workers. Most quacks would much rather provide a useful good-quality service , rather than a bad one. They know that if even one of their patients dies  as a result of a medical complication , they may be beaten up by the relatives . Each death ends up damaging their reputation and their source of livelihood. This is why it's in a quack’s best interests to make sure that he has access to reliable information – and many of them are very eager to learn ! They have a lot of real life practical knowledge, which they have learned from experience. If we teach them the basics : what medicines are useful and which ones are harmful ; what their limitations are ; what the danger signs of some serious illnesses are; and when they need to refer patients to specialists or hospitals, we can make good use of quacks , so that they become productive citizens .

Let’s not treat quacks aP enemy – this is an approach which is doomed to fail. Until we can train enough qualified doctors to provide high quality primary health care to all our citizens ( which is a long way off !) the next best pragmatic approach is to train quacks, so they can do a better job. We need to identify the successful quacks - the ones who have  a good reputation, and provide them with mentorship and training, so they can become better at what they are doing !

I agree there are bad quacks – those who are cheats, and who prey on patients’ ignorance. However, this does not mean that we should tar all quacks with the same brush ! For example, many quacks have a superb bedside manner – and their ability to communicate with their patients is brilliant ! These are valuable skills which they have learned after many years of practice – why not make use of them ?
If we legitimize the status of quacks, won’t this be unfair on regular doctors who have spent many years training to acquire their professional knowledgebase ? Not necessarily. We are trying to create win-win relationships , where a quack knows his limitations; and will promptly refer the complicated patients to a trained doctors, so that both can continue to co-exist and serve society.