Wednesday, July 31, 2013

Doctors are treated like condoms

Medicine is becoming increasingly corporatized, and some doctors are very excited when they get offered a job at these hospitals.

They are promised a fat salary , and the job seems to be all they could ask for ! The hospital takes care of all the administrative hassles, so that the doctor can focus on taking care of his patients – and the hospital promises them that they'll have a long line of patients clamouring to see them. Doctors are not good managers, and are very happy if someone else does all the work of attracting patients; billing them; and providing the secretarial support they need, so they can do what they enjoy – helping their patients get better. Since this is all done under one roof, using high quality new equipment, the doctor does not need to run around from clinic to clinic to get more patients – and does not need to offer kickbacks to GPs to refer patients to him either ! This seems to be a win-win situation, and it often is for the honeymoon phase, which lasts a few years. At this time, the hospital is new, and they need senior brand name doctors to attract patients. This is why they offer great signing packages when they launch their hospital with a bang, and everyone is delighted in the beginning.

However, in a few years, once the hospital starts becoming profitable, they start showing their true colours. These are for-profit hospitals, which have a clear focus – how do we maximize our revenues ? They understand only one thing – numbers, and soon the management starts singing a new tune. They talk about targets which the doctors need to meet – bed occupancy; number of patients admitted; revenue earned; number of CT scans ordered ; and number of operations done. The focus has now shifted from providing high quality care to patients to earning more money.

Doctors who are high performers and who run the hospital's profit centers are treated as blue eyed boys. However , the rest are told to shape up or to get out. Most doctors buckle under this pressure, and will fall into line quickly, in order to save their jobs. They start doing unnecessary surgery and ordering too many tests, to get their numbers upto speed, so the management can give them a pat on their back and a bonus as well.

However, some doctors refuse to practice bad medicine . They still believe in putting their patients first, and refuse to overtest or overtreat. The management then starts employing sneaky measures to ease these doctors out of the hospital. They get colleagues in a department to compete with each other – and the " top performer's " numbers are used to set the benchmark which the others have to aim for. Salaries are set according to how well the doctor has met his target – and while those who do well are paid a bonus, the doctors who don't comply are pulled up. They are invited to the CEO's office, and
" requested " to improve their performance. If they don't improve, their contract is not renewed. Many are insulted , until they are forced to leave ( for example, the consulting time slots allotted to them are curtailed to one slot per week, so they have very few patients) . It's easy for the management to make a doctor's life miserable ! As a friend of mine who is a senior surgeon said - " I feel I have been treated as a condom – used and then thrown !"

Hospitals treat all doctors as being interchangeable – they are viewed as being cogs in a wheel. If a senior doctor becomes too expensive for them, they get a junior to replace him, because the "cost to company" is much less - and they really don't care about clinical acumen, surgical dexterity or bedside manner, because these are not numbers they can measure !

The fact that hospitals are focused on maximizing their profit does not mean that they are villains. This is to be expected – after all, they are answerable to their share-holders and cannot afford to fritter away money on expensive doctors ! The real problem is that doctors are so simple-minded. They seem to know only one thing – how to take care of patients. While they do a very good job at this, most of them have very few real-world skills, so it's very easy for the management to take them for a ride ! They have no unity and it's very easy to play one against the other.

So what happens when the hospital cracks the whip and the doctor tries to push back ? He soon realises
that he is between a rock and a hard place ! By the time he is 50 , he cannot afford to retire and neither can he afford to start afresh. He is forced to swallow his pride and accept all the rubbish which is doled out to him. He is furious about the fact that he spent the best years of his life working for the hospital and helping them to become successful, and is now being treated like dirt. He retaliates, by taking out his frustrating and angst on his staff – and his patients ! This is the major reason why morale in corporate hospitals is so poor. It's only their fa├žade which is beautiful , but because doctors feel devalued and unappreciated, they do not put their heart and soul in taking care of their patients.

Monday, July 29, 2013

Social surrogacy for non-medical reasons

Traditionally surrogacy has been reserved as a treatment option for women whose uterus was absent or was irreparably damaged . It is an expensive treatment option , which involves a lot of coordination as well as legal issues to make sure that the child is handed over to the intended parents. However, we are now seeing an interesting trend , so that there are women who are no longer using surrogacy for medical reasons , but for social reasons !

These are women who know that they are able to carry the pregnancy themselves, but who decide for social reasons not to get pregnant themselves , but to use a surrogate instead. They have a wide variety of reasons for choosing this route. Some are very busy and successful career women, who don't want to take a break in their professional career , as this will harm their chances of becoming the CEO. Others are models who don't want their figure to altered as a result of pregnancy. Some feel it's just too stressful for them to go through pregnancy , and if they don't need to do it themselves , and can get someone else to carry a baby for them, then why shouldn't they use this option ?

This raises a number of interesting ethical issues ! Is it right for the doctor to accept such requests, even when there is no valid medical reason for doing surrogacy ? Or is the doctor being very presumptuous by refusing such requests ? After all , these are intelligent, educated successful women, who know their own mind . If this is what they have decided they want the doctor to do for them, is it ethical on the part of the doctor to reject these requests, just because he feels they are not medically appropriate ?

After all, if a decision is made by a patient , doesn't the doctor need to respect her autonomy ? If there no downsides to doing surrogacy for social reasons , shouldn't patients be allowed to choose for themselves ? These are thorny issues , and we don't have all the answers as yet .

It's interesting to see how reproductive technology which was originally developed for treating medical problems is now increasingly being used for social reasons . For example, egg banking , which was originally invented as a method to preserve the fertility potential of young women with cancer,  is now far more commonly used by women who want to postpone childbearing for nonmedical reasons !

Saturday, July 27, 2013

IVF processes and outcomes

When patients do an IVF cycle, the only thing really care about is the outcome – they just want a baby ! If life were perfect , then every time the patient had a perfect IVF cycle , she would get pregnant . Unfortunately, human reproduction is not an efficient enterprise , and the outcome of an IVF cycle is always uncertain. This is because biological processes cannot always be influenced by the doctor and we have very little control over what will happen to the embryo after we transfer it into the uterus. The sad reality is that we cannot manipulate the process of implantation This is not something which must patients want to hear . It's an uncomfortable feeling knowing that no matter what you do, you can never be sure what the result of the IVF cycle will be – each IVF cycle is effectively a gamble , which you may have to repeat multiple times , until you achieve success.

This is why it's important to differentiate between processes and outcomes . While outcomes cannot be controlled , the process itself can be, and a good IVF clinic will follow good processes. Now if life were always, fair good process would always lead to good outcomes, so that everyone's happy. Unfortunately, good processes can lead to bad outcomes , and an IVF cycle can fail because of circumstances which are beyond the doctor's control.

While mature patients understand this , most patients are not sophisticated enough to appreciate this, and if the IVF cycle fails , they are understandably upset and frustrated . They will often vent their anger on the doctor , complain about his clinic, and even write bad online reviews that he's incompetent and has not done a good job , even though the process he followed may have been perfect . Conversely, we do have bad IVF clinics , where patients do get pregnant, in spite of the fact that they follow bad processes . This is just plain dumb luck - and is particularly common in very busy clinics who will do lots of IVF cycles for young patients who don't even need IVF in the first place ! These clinics will obviously have a high success rate , as a result of which their reputation in the community will spread , because patients are not sophisticated enough to understand that the good outcome was not a result of good processes, but because of smart patient selection ! As a result, some of these doctors continue to fool some of the patients some of the time . Finally you have clinics which follow bad processes and therefore have bad outcomes. These will shut down in a few years – but only after having caused a lot of harm !

When a cycle fails, most patients cannot differentiate whether the bad outcome was because the doctor followed bad processes , or whether it was a result of plain bad luck, even though the processes were followed perfectly.  Unfortunately many IVF doctors are not transparent ; and few patients are willing to invest the time and energy in order to understand the process which were used. Consequently, many clinics get away with fooling their patients , by preying on their ignorance .

Just like it's important for a good doctor to follow good processes it's equally important for a patient to become a good patient and do their homework , so they understand the difference between good processed and bad processes, no matter what the outcome !

Wednesday, July 24, 2013

Wombs for hire

Surrogacy means many things to many people. For infertile couples it’s a chance to have a child. For working women, it’s a shot at parenthood without a mid-career break. For surrogate mothers, it’s big money. And, of course, for the lawyers and doctors, it’s big business. Rashmi Pratap takes a look at the flourishing business of surrogacy.

Tuesday, July 23, 2013

Age and fertility

A woman's age is always a sensitive topic - and this is true, no matter how old she is. If she's infertile, she is likely to become even touchier about this, because she's aware of the fact that she has a biological clock which she cannot rewind. As she ages, she no longer has all the time in the world in order to have a baby.


Make my baby for me. And, oh, I'll pay extra for twins

It's not just Bollywood celebrities. Many affluent Indian women are opting to have a surrogate child simply to avoid the pain of pregnancy, finds Shuma Raha

Is this the ultimate in outsourcing ?

Monday, July 22, 2013

Check on your doctor before check-up

Check on your doctor before check-up, 1 in 5 via management quota
Back-of-the-envelope calculations show that about 1 out of every 5 doctors passing out each year could be those who bought seats in medical colleges. 
The huge amount of money which politicians can make out of capitation fees and management quotas has led to an explosion of medical diploma mills ( who are allowed to call themselves medical colleges) which churn out doctors who are poorly trained and poorly qualified. Sadly, the Medical Council of India has failed sadly in ensuring medical education standards are met - it's easy to make doctors buckle under political pressure.

All the more reason that patients need to do their homework before seeing a doctor. Just the fact that your doctor has a MD degree is no longer enough evidence of his competence !

Information Therapy can help you to save your life !

Sunday, July 21, 2013

In search of fair babies, Indians chase Caucasian donors for IVF

This article in the Times of India describes changing trends in babymaking.

I'd love to hear your comments !

Is it understandable that because we have high expectations from our children, if people want to have children with certain characters, we should allow them to use technology to do so ? After all, isn't this why men look for fair brides, so they can have fair children ? Isn't this technology a logical extension of fulfilling their desires ?

Or is this is a misuse of technology ? Are parents being greedy and too demanding ? Do "designer babies" represent a downward slippery slope where children are treated as a commodity which can me made to order ?

Mommy at 40?

Can you postpone motherhood? Clinically, it is possible, Dr Aniruddha Malpani tells Amy Fernandes.
Red the article in Today's DNA newspaper !

Wednesday, July 17, 2013

Should I freeze my eggs ?

I just completed a consultation with a single 38-year-old banker who wanted to freeze her eggs. She said, " Doctor , I have still not been able to find the right guy to marry , and I am not getting any younger . If at some point I do want to have babies, I want to freeze my eggs now so that I don't have to worry about the increased risk of birth defects or reduced fertility as I get older ".

I explained to her that we could freeze her eggs, but my concern was that she may have already missed the boat ! The right time to freeze eggs is when they are of good quality, and there are lots of them. From a biological perspective, this should be done when a woman is young - preferably at the age of 25 !

I understand it's unrealistic to expect 25 year old women to freeze their eggs . When you are young, and you have your whole life ahead of you, the probability of being able to find the right person , and then settling down and have a baby in the bedroom is extremely high ! However, if you postpone this decision until you cross 35 , even though egg freezing still remains a viable option , the reality is that the success rate of having a baby with these frozen eggs does drops dramatically if the freezing is done after the age of 38.

This is because ovarian reserve declines with age,  and while the decline varies from patient to patient, it does mean that the success rate with egg freezing goes down . So what advice should a specialist give to a woman who wants to consider freezing her eggs ?

In the best of all possible worlds , the best time to freeze eggs is when you don't need to - when you're young and have lots of them ! However, in real life , there are very few women who will consider an option which is expensive - and one which they may end up not using at all.

The trouble is that when women are good candidates for egg freezing -  between the ages of 30 to 35 , they have so much going on in their life , and rightfully feel that their chances of finding the right person and getting married are so high , that they still not willing to consider the possibility that they may have difficulty having a baby in the bedroom when they want one. The biological clock is still quite muffled at this stage in a woman's life ! This is why it's usually when they start crossing 37 that they start exploring all these additional options . They may have heard stories from their friends, who needed to do IVF to have a baby. This is wake-up call for them, and they are prodded into exploring their reproductive desires much more closely. While we are happy to do egg freezing for any woman, no matter what her age ( after all, he cannot become younger, and it's better to do it late than never !) , the reality is that they may not have such a great success rate , and it would have been much better for them to have done it earlier, rather than to have postponed making this decision for so long.

So should I freeze her eggs or not ? This is always a hard decision to make - especially for something which is elective treatment , and which can be quite expensive ! This is a decision which the patient has to make, and I am the kind of doctor who is very reluctant to tell patients what to do, I feel my job is to be a counselor , and allow them to come to their own decisions.

I help them to consider the pros and cons of both paths, and they suggest they take the path of least regret, so that they have no regrets afterwards.

This was my explanation. Suppose we do freeze your eggs , and then you find Mr Right the next month and then have a baby in your own bedroom - how much will you resent the fact that you spent your money on freezing your eggs and never used these frozen eggs ? On the other hand, suppose we don't freeze your eggs , and then you decide you want have a baby at the age of 42 , and learn at that time that you can't because your eggs have become too old. How much will you regret not having  frozen your eggs when you were 38 ? These are very personal answers - and they will vary from person to person ! The best thing to do is to choose whichever path causes you the least regret ! These are obviously very individual decisions , which are not to be taken lightly , and it involves using both your head as well as your heart .

It's very easy for a doctor to say - This woman has come to me for egg freezing , so I am going to go ahead and do it for her - and from a doctor's perspective , it makes a lot of sense to do so, because doctors get paid for performing procedures ! From a financial point of view , it makes no sense for a doctor to say no to a patient who wants egg freezing. However, patients need to have realistic expectations of what we can do with these frozen eggs, which is why doctors need to counsel them and arm with them all the facts.

The woman came back after 3 days and said - " I know I am 38 and my eggs are old, but I am not getting any younger , and if I freeze my eggs , even if I do find someone and have a baby in my bedroom, these eggs will always be available to me as a backup option . In any case, even if I end up not using my frozen eggs. I won't feel bad about it. " I was happy to hear this, because it's crystal clear that she's thought through things logically and analytically , and then come to a decision which she is comfortable with.

Patients need to remember that egg freezing offers hope -  not a guarantee. If patients have unrealistic expectations of medical treatment , they are likely to be unhappy with the doctor , and unhappy patients make for unhappy doctors.

Monday, July 15, 2013

The home pregnancy test showed two lines !

" Yes, it is a positive. I saw a positive hpt almost 4 years back, in 2009 January. If that embie had managed to become my baby, my child would have been three and a half years by now. I need to remember that little embie which gave me the strength to hold on to hope and keep trying. I am feeling so calm and serene. No overt emotions are there. After expecting this for a long time, I feel surprisingly numb. I am grateful that I had a positive. I know from now on it is a long journey and I wish I get the strength to face whatever comes my way. Surprisingly, I am not afraid of the future.
I take this opportunity to thank my Dr. I am a very difficult patient to deal with - both scientifically and emotionally. He was always kind and compassionate. He never made me feel that I am stupid or irrational. His team is as wonderful as he is. "
You can read the rest of the post at Manju's blog at
We are very excited and happy for Manju   - and our prayers and best wishes are with her.

A new journey now begins !

Donor egg IVF success story for a nurse from the USA

I am Sangeetha a Registered Nurse of Indian origin who now lives in the USA. I have been married for 8 years have been and trying to get pregnant for the same amount of time. We started with so many IUIs  (artificial insemination) in the USA with no success and decided to do our first IVF in India where our  parents lived. That time I was a novice patient and later realized that I was victimized by the care I had received from that clinic. I would say that it was a very unpleasant experience and caused us extreme frustration.


Saturday, July 13, 2013

Doctors are bottlenecks

Doctors think of themselves as being indispensable . Most have pretty high self-esteem – after all, in order to successfully get through medical college , you need a lot of physical stamina and mental energy. You need to perform well academically , in order to graduate , and if you are used to being in the top 10 % of our class, you start thinking of yourself as being special !

The fact that their patients are so dependent on them – and that they are willing to wait patiently for hours for their advice , it’s easy to understand why doctors get used to being put on pedestal. It's hard to think of yourself as being only human, when you occupy such a superior position, which is why lots of doctors think that they play a role which is indispensable . They take pride in their academic knowledgebase as well as their professional skills , and feel that no one else can do quite as good a job as they do – all doctors have a superiority complex !

While it’s true that doctors are valuable , it's also equally true that a lot of the stuff which doctors do can be easily and quickly done someone else who's a much less expensive resource ! Often, this person would do a better job , because he does it again and again, and becomes expert at doing it !

Doctors should try to make themselves redundant , so that they are able to delegate their duties – either to an assistant , or with the help of technology. This would allow them to free up their time , which they could then devote on things which they find more intellectually challenging. The use of physician extenders and physician assistants are a real world example of cleverly using human help in order to improve their efficiency .

Another simple tool is to use technology to educate patients - for example , by using videos or online elearning courses designed for patients , so they can learn stuff for themselves , without having to ask the doctor the same questions ( which many doctors often get tired of providing the answer to !)

Any doctor who develops tools and techniques to free up his time can then leverage this in order to improve his personal productivity. Since all doctors have similar pain points, this can also provide the nucleus of a valuable product or service , which lots of healthcare systems would be happy to pay for, in order to make their physicians more efficient !

Friday, July 12, 2013

Indian language patient educational materials on cancer

It breaks my heart when I see what a poor job the Indian government does with educating patients. Sadly, even hospitals are no better - and there is precious little educational materials available in regional languages for Indian patients. This is a crying shame - for a country which prides itself on offering world-class medical facilities - and which is the IT powerhouse of the world.

Fortunately, when I see the initiatives taken by individuals to address this deplorable state of affairs, my faith in humanity is restored.

Please check out the excellent series of patient educational booklets which JASCAP has published in India regional languages . They are generously giving these away free on their website - and my heart is gladdened to see that there are humans who care and can transmute their personal suffering into gifts for

Celebrities and IVF

The private life of celebrities has always been an area of great interest to the average person , which is why they hog so much of the limelight. Their life is tracked with great interest, and anything which happens to them gets splashed all over the media. This is why whenever a celebrity does IVF , this is often front-page news . Readers and TV channel viewers want to know all the gory details. Why did they need IVF ? did they use donor eggs ? or a surrogate ?

Reporters have to do a lot of digging to get at the truth – and this has consequences - some of which are good , and some of which are not. The details of the celebrity’s personal medical problems become the staple of cocktail party gossip – and there’s lots of exaggeration and distortion. I'm sure most celebrities would rather keep this part of their life private. However, given the fact that they have chosen to be a celeb, this is one of the trade-offs they accept - the sacrifice of their privacy . What happens in their lives seems to be pretty much grist for all mills – and it all gets rehashed many times.

One of the advantages is that there is a lot more public awareness about IVF and the medical illnesses which it can be used to treat successfully. The acceptability of a lot of these procedures in society ( which originally were considered to be taboo topics ) increases considerably . Thanks to the media coverage and publicity which these stories generate, a lot of people believe that if a celeb can do surrogacy, so can I ! They start exploring this option , as result of which there are many more patients who start asking for these procedures. While increased awareness is always good , because patients are much more aware about what can be done to help them solve their problems , the downside is that that there are lots of inappropriate requests for these procedures , so that even patients who don’t need such expensive and complex treatment start clamouring for them.

This is partly a result of the poor quality of reporting in the press . because it's not possible to provide enough medical background in these stories. Also, many reporters feel that because readers are not interested in the medical facts, they often provide only skimpy medical background.

However, thanks to these celebrities, a lot of these, topics have now become mainstream , so that it makes it much easier for IVF doctors to discuss some of these treatment options with patients because there's been so much coverage of them ? And, another side effect is that a lot of IVF doctors who treat celebrities become celebrities in their own right !

Thursday, July 11, 2013

Cuts and kickbacks for doctors

It's a fact of life that kickbacks, cuts and commissions have become an integral part of the healthcare system in India. In fact, this is one of the reasons why healthcare has become so sick. However, you disguise them - in the form of referral fees ( the euphemism which corporate hospitals use when they pay family physicians to send patients their way); or consultancy fees ( the dignified term which pharmaceutical companies use to incentivize doctors to prescribe their brands), commissions are ubiquitous have become an accepted norm in the medical profession.

A lot of this was started by pharmaceutical companies, who provide doctors with freebies in order to influence them to prescribe their drugs. Doctors have become so used to getting so much stuff for free from pharmaceutical companies - ranging all the way from trips to go overseas to cars and even apartments, that most of them take these gifts as their right. They feel they are entitled to them, and do not even question the morality of their behavior.
  • While all doctors know in their heart of hearts that it's unethical to take these kickbacks it's extremely easy for them to justify what they do !
  • All doctors, including the leading lights of the medical profession do it, so why shouldn't I ?
  • I can't afford to take a holier than thou attitude - how will I be able to afford to pay the capitation fee to send my children to medical college ? 
  • Since everyone else in society is doing it, ranging from politicians to bureaucrats to policeman, so why should I be any different. Should doctors be held to a higher ethical standard?
While it's great to get free stuff, most doctors feel uncomfortable about taking kickbacks. Most of us do have a conscience, and while we learn to justify our behavior, taking kickbacks is not something which most doctors would rather do - they'd rather earn money honestly !

A lot of us fail to realize the harm these ubiquitous kickbacks do. For one thing they make the cost of medical care much more opaque , as a result of which patients often don't understand why certain tests are being advised; or why a particular brand of drug has been prescribed, even though it costs much more.

Patients are smart enough to know about the kickback system, because it's so pervasive. This causes them to start distrusting their personal doctor. They start treating the entire medical profession with suspicion, and this poisons the doctor-patient relationship. Patients no longer look upon doctors with high regards, and if they cannot trust their doctor, it becomes much harder for them to heal.

It's unfair on honest doctors as well. Everyone gets tarred with the same brush, so that patients automatically assumes that all doctors must be on the take !

I don't think there's any point in preaching to doctors that they should not be taking cuts and kickbacks because this is unethical. Good doctors know this - and bad doctors are going to improve.

We need to understand that cuts are given purely for financial reasons, and this is what we need to address. Cuts and kickbacks exists because there is a middleman - and the only way to cut out cuts would be to cut out the middleman. Thus, the reason a diagnostic center provides a kickback to doctors is to incentivize the doctor to refer patients to them. However, if diagnostic centers could reach out to patients directly, there would be no need for them to go through the middleman, and they would not need to provide these kickbacks anymore. This would help them to cut down the costs of their tests, thus helping patients as well.

A number of studies have shown that the healthcare industry is amongst the most corrupt in the world. This is a crying shame. The only way to fix the system is by encouraging openness and transparency and the internet provides us with a great platform in order to do this.

By making intelligent use of the internet, the healthcare insurance industry has a great opportunity to clean up the system. By publishing the costs of tests and medicines online, they can share this information with patients. Armed with this information, the patient has a much better sense of exactly how much each test should cost. He can then intelligently question the padded bills he gets, and by behaving as an intelligent consumer, he can get the most cost-effective testing done for himself, without having to depend on a referral by his doctor.

Agreed that it takes time for the system to change, but the good news is that it's possible for this to happen. And this is a great chance for us to start to clean up the system - something which is in everyone's best interests - patients, doctors, and society.

Wednesday, July 10, 2013

Medical Council of India, doctors and advertising

The Times of India recently reported that the Maharashtra Medical Council is taking action against doctors for advertising their skills.

Whether or not to allow doctor to advertise has been a thorny issue for many years – not only in India but in the US as well . The traditional approach has been that doctors are professionals , and that advertising is below their dignity because they're not businessman. The belief used to be that there was no need for good doctors to advertise, as patients would come to them because of their reputation.

However, we need to acknowledge that times have changed , and that we need to change with them. The purpose of advertising is not merely to flaunt the doctor's skills or to solicit patients - it's a very efficient mechanism of allowing patients to know what special skills doctors can offer ; which specialist are available;  where they are available ; and how much they charge for their services. This is important information , which allows patients to select the right doctor for themselves. This is especially true in a democracy which is a capitalistic society , because patients have the freedom to choose . Patients are no longer passive recipients of medical care - they have become active consumers , who have the right to know what choices are available to them. By depriving them of this right , the Medical Council is actually doing them a disservice.

This does not mean that doctors should be given a free hand and be allowed to advertise at will. Some of the advertisements actually make me cringe , when I see how inaccurate and unreliable they are. Not only do they misguide patients, they also demean the dignity of the medical profession. However, that's no reason to throw the baby out with the bathwater . It's possible to find a middle path which creates a win-win situation for doctors and for patients.

The Medical Council can treat this as an opportunity, so that they can project themselves not just as a body which is responsible for governing the medical profession , but one which is enlightened enough to put patients first ! One way of doing this is by ensuring that the information which patients want is easily available to them - and the best of doing this is going online. Thus the Medical Council website should become the first website for patients to visit, whenever they have any questions about any medical problems.

If the Medical Council site provided Information Therapy , patients would then be able to make much better informed decisions. Not only could they learn about more about their medical problem , the Medical Council would also provide a list of all the registered bonafide doctors , who are qualified to provide care about their illness.

Doctors would be allowed to provide information about their services on the website – and because it's an official site, the information can be regulated and controlled . There would be standard guidelines which everyone would need to follow , to make sure there was a level playing field . This would be a much more ethical and transparent way of making sure that everyone's interests are adequately met.

Not only would patients be happy, because they would have all the information they require in one place, but good doctors would be happy as well , because they could refer their patients to this website .

By not allowing doctors to advertise at all , the Medical Council is doing a disservice , not only to patients, but to doctors as well. By preventing patients from getting access to information about specialized services , patients are left in the dark ,and are forced to rely on a family physician to refer them to the right doctor. Sadly, as we all know, doctors will often not refer patients to the best specialist, for extraneous reasons.

The Council is also doing a disservice to the thousands of junior doctors who are starting practice . Banning advertising is very good for senior doctors like me , who have a well-established practice, and lots of patients. It's easy for me to get more patients, thanks to word of mouth. But what about the young doctor who is just starting practice ? How is he going to be able to get patients unless he has access to a platform which will let patients know about his special skills ? Preventing advertising actually encourages kickbacks and commissions , because it prevent doctors from reaching out to patients directly. Doctors are then forced to incentivize middlemen to refer patients to them – and this will make the practice of giving cuts even more entrenched.

While it's true that advertising  can be misleading, and can allow bad doctors to prey on helpless patients., if advertising is done properly, it can actually help to cut down healthcare costs . Doctors will be forced to be open and transparent - and in a competitive marketplace , patients will be able to know exactly what the fair price for a particular service is, so they know exactly how much they should be paying .

This is a great opportunity for the Medical Council to reinvent itself , and to keep up with the times , so that they can be of service not only to the medical profession , but to patients and society at large . The Medical Council can prove that the medical profession puts patients first , by providing a platform which all doctors and patients can use as a trusted source of information .

By taking this leadership role, the Medical Council can help to position India as a medical powerhouse of the world !

Monday, July 08, 2013

Free IVF app !

IVF treatment is complex and expensive. It needs a lot of coordination and monitoring.You have a busy life style and need to know in advance what is going to happen when, so you can plan your work around your IVF schedule. You cannot afford to forget your meds or miss your appointments !

MyFertilityDiary is a free app for android smartphones which can help you organise your life and manage your IVF treatment efficiently ! 

The unique heart of the app is the Treatment Calendar. This has prepopulated schedules for the commonest infertility treatments , including the various IVF and IUI protocols. You can modify this schedule this for your own treatment, as needed. The app is designed around a Calendar/Organiser which allows you to organize your life. You can set reminders, so you remember their appointments and their medications.

It has a full medication calendar. It helps you stay organized by scheduling duration, frequency and number per day. With each medication, you can add notes for dosage, and set reminders to help you stay on schedule.

Navigating through the fertility world can be an arduous process and, at times, overwhelming. My Fertility Diary simplifies the journey...

You can download this free at Get The App - Android Play Store

There's more information about the app at

But I trust my IVF Doctor

A lot of patients ask me for a second opinion after their IVF cycle fails. In order to try to help them, I need some basic medical data about their IVF cycles, such as: how many follicles did they grow; how many eggs were retrieved;  and photos of their embryos. Some patients get very agitated and upset when I ask these questions because they often don't have this basic information. When I ask them why their documentation is so patchy and why they are so poorly informed, the standard answer is - This is all my doctor provided me. When I tell them that every good IVF clinic routinely provides a written treatment summary and embryo photos, they get defensive and say - I trust my doctor, so why do I need to know all this detail ?


Surgeons and perverse incentives

There is a lot of criticism that surgeons do too many unnecessary operations and that all this overtreatment increases the cost of healthcare . Even worse, all this surgery doesn't help to improve patient outcomes – and can actually result in harm.

While there is truth in this criticism, we also need to understand that society itself is partly responsible for the sad state of affairs. After all, if you teach and train surgeons how to do surgery , and then you pay them to perform surgery, it’s very irrational to expect them not to do surgery ! After all surgeons are homo economicus as well and will maximize their personal benefits .

It’s not that they are greedy or unethical. They have a particular worldview , and often suffer from tunnel vision . All they are taught is how to operate and when you have a hammer in your hands, you see nails all over the places ! Unfortunately, very few surgeons are taught when not to operate !

It's possible to wax eloquent about the importance of medical ethics and why and how doctors need to be professionals , who should not operate when not required. However, we can talk till we are blue in the face , but we know that the reality will not change. Just like financial advisors will push a particular product , because they are paid to do so , doctors also are likely to respond in exactly the same manner! It's unfair to hold them to a superhuman standard , because this is extremely unrealistic and smacks of wishful thinking.

However, there is a solution – we need to develop  clever ways in which we could incentivize surgeons not to do surgery ! There was a  time in the US not too long ago, when repeat cesarean sections were the norm because obstetricians would get paid much more doing a cesarean section , rather than allowing vaginal birth ( VBACs). It’s only when insurance company started to refuse to pay for repeat cesarean sections that the VBAC rate decreased from virtually zero percent in private hospitals to up to 50 percent - which is what the optimal number should be !

We need an entrepreneur who can come up with a clever solution which will help to ensure that surgeons do not benefit by doing unnecessary surgery. One solution is to slap penalties for doing unnecessary surgery , but this is something which is very hard to implement in real life . Clinical decisions are rarely made by following a cookbook protocol slavishly - we need to come up with more ingenious methods .

One of the best methods would be empowering patients with information , so they can discuss non-surgical treatment options with their surgeon ! We need to align incentives for both patients and surgeons – and find ways to pay surgeons for not operating ! Retired surgeons, who are no longer active in the OR can provide lots of useful insights !

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