The flipped clinic model

Patient education tools should be delivered before the visit, perhaps via an app or online. During the visit, care providers should reaffirm what patients learned on their own.

http://fliptheclinic.org/yourflips/#more-1604

Bouncing back after a failed IVF cycle

A failed IVF cycle causes a lot of heartburn – for both patients and doctors. There is a lot of grief , acute short-term pain and lots of people start playing the blame game. Was the doctor negligent or
incompetent ? Or did the patient fail to follow the medical advice given to her ?

The truth is that there is a lot we can learn from a failed cycle , and this is why it's important to create a framework , so that we can analyze the failed cycle and increase the chances of success for the next attempt.

Basically, the problem could be either with the clinic or with the patient . I understand this is an oversimplification , but we can use this simplified model so we can drill down intelligently. If the problem was because the clinic was poorly equipped or the doctor was not experienced, then this is an easy problem to fix by just changing the clinic for the next cycle. However, many cycles will fail inspite of the physician doing everything humanly possible and providing the best medical care .

Unfortunately, patients have a hard time pinpointing what the reason for the failure was – especially if this was a result of medical incompetence ( for example, an inexperienced embryologist who ends up killing many eggs while doing ICSI) . The doctor will do his best to hide the truth,  and will try to cover up ( for example, by saying the sperm were of bad quality , and were not able to fertilise the egg !)

This is why openness and transparency are so important in an IVF clinic. It’s true that patients are upset when the cycle fails , and doctors don’t like having to handle angry and tearful patients. However, when the physician refuses to meet them or discuss the reasons for the failure or provide intelligent information as to why the cycle failed , this angers the patients even more. They suspect the doctor is hiding the truth from them.

In fact, a failed cycle can actually be an opportunity for a good doctor to create even more trust in the patient . He should be willing to analyze exactly what happened and why, so he can discuss the next action steps with the patient. This is why good documentation, including embryo photos ( which should be provided routinely and proactively at the time of the embryo transfer) are so important.

Sometimes the problem is a biological problem, such as poor egg quality. In these patients, no matter how good the clinic, the chances of being able to create good quality embryos are slim. This is why counseling patients honestly before the cycle starts is so important, so that they have realistic expectations of what the technology can do for them.  Sadly, doctors often overpromise at the time of the first consultation, because they want the patient to come to them for treatment, as a result of which they quote highly inflated success rates.

However , biology being what it is , sometimes the unexpected does occur, and even when the doctor has certain expectations , these don't always pan out . In life, we need to deal with some of these ups and downs . The best way of doing so is by being frank and forthright.  A good doctor will say – This is what we expected, and this is why we expected this; however, this is what actually happened, and these are the possible reasons for this. Based on this analysis, this is what we can do differently the next time .

One option of course is to change the clinic, but this is not always the right choice and should not be your knee-jerk response just because you are upset the cycle has failed. If you are happy with your doctor and the way he has treated you, you should continue with him – after all, he is likely to be more incentivized to try harder the next time around !

Not sure what to do after your IVF cycle had failed ?  Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly !

Information Therapy can prevent and treat Medical corruption

There's been a recent slew of articles in the BMJ and the Times of India about medical corruption. This is a good first step , because openness and transparency are effective means of treating this sickness.

However, while the articles do a good job of documenting the problems, they fail to provide effective solutions. Most of the solutions are impractical - after all, preaching to unethical doctors  that they need to start practising medicine ethically by refusing to take cuts and kickbacks is hardly going to help ! More regulation is ineffective because the regulators ( Medical Council of India) themselves are corrupt !

What's worse is that these articles just drive the wedge further between doctors and patients. Patients start treating all doctors with suspicion - and this lack of trust will prevent doctors from being able to provide high quality medical care to their patients .

A far more practicable solution is to cut out the middle man between the patient and the doctor. This is what causes the corruption in the first place, and unless we address the root cause, we will only be able to provide band aid therapy, and the problem will continue to fester.

This is where Information Therapy has such an important role to play.  If every doctor had their own website, patients would be able to reach out to them directly, so there would be no need for specialists to pay referral fees. Also, hospitals would be able to maximise their bed occupancy, so that they would not need to incentivise specialists to refer patients to them.

Since doctors would not need to waste money on paying kickbacks, their professional income would improve, and they would no longer need to accept bribes from pharmaceutical companies or commissions from labs and imaging centers.

Finally, since doctors would have to be open and transparent on their website, they would be able to create much more trust in their patients.

This is a solution which has a high degree of efficacy, with no side effects !

Join the discussion please - have suggested #medicalcorruption as a hashtag on twitter !

Doctors to reduce unnecessary medical testing

Top cardiologists of the All India Institute of Medical Sciences (AIIMS) here have decided to start an initiative called the Society for Less Investigative Medicine (SLIM) — a movement that aims to take on the growing menace of excessive medical investigations, starting with cardiology.

http://timesofindia.indiatimes.com/india/AIIMS-doctors-lead-the-way-wage-war-on-unnecessary-medical-tests/articleshow/37425725.cms

This is a step in the right direction, because it will help to reduce the epidemic of avoidable care we are seeing today.

However, both the Indian government and Indian health insurers are actually exacerbating the problem.

The government offers a tax rebate for " healthcare checkups" , thus incentivising citizens to go in for unnecessary medical testing , when they are well and asymptomatic   These tests produce a lot of "false positives" and create a large number of "worried well" citizens, who then go running to their doctor for medical attention.

Similarly, health insurers, who are meant to protect the health of their customers, pay their customers to go for "health checkup" schemes. Instead of helping them to remain healthy , they actually push them into seeking unnecessary medical care !

Want to learn how to protect yourself ? You can read how to Prevent 'Testitis' at
http://www.thebestmedicalcare.com/ch30-prevent-testitis_1.htm

If I were the health minister

My single point agenda would be - All doctors should have their own website !

Why would doctors do this ? The incentive would be that doctors who published their own website would earn enough continuing medical education ( CME) credits to be able to renew their Medical Council Registration without having to attend any medical conferences. ( As we know, these conferences are a major course of medical corruption. Pharmaceutical companies fund these and use these as an excuse to fly doctors to exotic locations and put them up in 5 star hotels, so that doctors can enjoy an all-expenses paid holiday in the guise of educating themselves !)

You might ask - How does publishing a website contribute to a doctor’s medical education ?

 Since their website is their public face, doctors would take pains in order to create digital content which is useful for their patients. Doctors are meant to teach their patients – the word doctor is derived from the word docere, which means to teach. And we all know that the best way of learning something is to teach it ! Once doctors publish their website, they will forced to become more patient-centric. Patients will use the site to ask them questions, which they will need to answer, thus keeping them on their toes. They would have to use the latest digital technology once they go online, as they cannot afford to be left behind. In order to ensure they are one up on other doctors, they will invest in ensuring their online content is updated, reliable and easy to understand.

This is a win-win situation, which will help both doctors and patients. A website is a great way of helping doctors  to attract new patients ; and to ensure patient loyalty. Lots of patients are online , and if doctors have a website, it will be much easier for patients to find them. Importantly, doctors would not have to pay a kickback for referrals as patients would come directly to them. Their website would help them to reach out to patients from all over the country – and even all over the world !  They would also become much more available and accessible, as patients would not need to travel to reach out to them.

A website would force doctors to become open and transparent – they dare not lie on a website ! Competitive pressures would help to drive down costs. When some doctors start publishing their fees online, others will soon follow suit. This would help to remove the uncertainty which surrounds medical fees today, and doctors would not be able to pad their bills. Also, this clarity would encourage competition and some doctors would be forced to reduce their fees . This market pressure will help patients to get more cost effective care !,

The good news is that the new Health Minister , Dr Harsh Vardhan ( whose website is at www.drharshvardhan.com) used to be a practicing doctor , rather than a politician.  He uses the internet to express his point of view, and he understands first hand how important a website can be.


This simple solution will help doctors to put their patients first - and the government won’t have to spend any money to implement it. Even better, it encourages individual doctors to do what's right for their patients ! This is the kind of innovative policy decision which can have a very positive impact on the entire healthcare ecosystem.

Regulating doctor’s fees and hospital prices

There has been a lot of hue and cry about the Clinical Establishment Act. One of the hotly debated provisions of this law is the section which governs the fees which doctors and hospitals can charge. The law demands that doctors and hospitals publish and prominently display their rate card, so that patients know exactly how much they are going to have to pay for their medical treatment.

On first blush it appears that this section makes a lot of sense. After all, won't it encourage openness and transparency ? Isn't this good for everyone ?  Won't this curb overcharging ? Won't it stop doctors from taking fees under the table ?

Let's look at why the government wants to regulate medical fees . The government provides free medical care to poor citizens under a number of government health insurance schemes , and they need to know how much they have to budget for this. However, they find the lack of transparency in the medical fees frustrates their well-intentioned efforts.  This is exactly the same problem health insurers face as well. Because they have to pay for medical treatment , they need to know up front what the cost of treatment is going to be, so they can estimate how much to charge their customers .

However , a sore issue is the fact that hospitals will pad their bills when they find that they are going to be paid by an insurer. They overcharge , and hospitals will often markup the costs upto 3-4 times for what they would charge a patient who is paying out of his own pocket. Even worse, a lot of doctors indulge in fraud, and will bill the health insurers for fictitious patients and make-believe surgery, because they believe the health insurer has deep pockets and is a soft target.

Because of the moral hazard issue, most patients don't care , because it’s the health insurer who has to foot the bill. The problem of progressively increasing medical costs is getting out of control , which is why the government finds that it needs to crack down.

While I agree that it's a good idea to encourage openness and transparency , I also think this smacks of double standards . One criticism is that doctors charge too much . However, many lawyers will charge much more for just talking in court for 10 minutes, as compared to what a doctor does for doing a life saving heart operation which may take over 4 hours. In a capitalistic society, the price the doctor commands is set by the market , and as long as the patient is willing to pay what the doctor charges, it is an encroachment of an individual's autonomy to control this. If a patient feels the fees are too high, he can always find another doctor who charges less !

Sadly, the medical profession is a soft target and doctors make for easy whipping boys. They don’t have the unity to stand up for themselves. The law, on the other hand, is passed by lawyers, who do their best to protect their fellow-professionals ! These double standards are completely unfair, and if doctors and hospitals  are asked to put up a list of their fees, then lawyers and law firms should also be made to do so. The same set of standards need to be applied across all professions , and it's not fair that doctors and hospitals be singled out.

Another sore issue among regulators  is the fact that doctors and hospitals charge differential rates for the same procedure, depending upon whether the patient is admitted in the general ward or a deluxe room. This is a fact of life, and is true is most areas today. This is something we routinely see when we buy airline tickets. Not only will they charge much more for a first class ticket  ( even though from a functional point of view the plane takes all the passengers from point A to point B), they will often charge a hefty premium for exactly the same seat when the ticket is bought at the last minute, a practise called price discrimination.

If it’s fair for airlines to do this to  maximize their profits , I think it’s unfair to prevent doctors and hospitals from doing exactly the same. Why discriminate against doctors , just because they're defenseless ?

How health insurers can earn trust

The most important missing ingredient the healthcare system today is trust .

Life used to be much easier in the past, when patients could trust that their family doctor ( with whom they had a relationship for many years) would do what's right for them . Unfortunately , that trust has been eroded for multiple reasons .

The entire medical profession has damaged its reputation , and it's an open secret that doctors take kickbacks from pharmaceutical companies, labs, imaging centers and other doctors. Patients no longer trust doctors, and this lack of trust has affected the other players in the health ecosystem as well. Pharmaceutical companies are seen to be greedy corporates, who are out to maximize their profits at the expense of the patient’s wallet,.

Similarly, health insurance companies are generally perceived as being gatekeepers , who do their best to try to block access to medical treatment , in order to keep their costs down and their profits up. They are considered to be bloated bureaucratic organizations, manned by heartless clerks, who do their best to refuse, reject and delay claims.

This creates a lot of resentment and angst in the patient , who feels his treatment is being wrongfully denied . This often sets up a conflict between the doctor and the insurer as well . Doctors now believe that insurers  are trying to strangle them by capping their payments; and even worse, are starting to play doctor and second guess them , by performing utilization reviews, and judging their medical decisions.

The problem  has been that health insurers have been very short-sighted. Financial transactions have been their only points of contact with their customers so far. Thus, they talk to the customer only when they want to collect the annual premium; or when the customer submits a claim, which they need to pay.

While they are happy to collect the premium every efficiently, they can be extremely tardy when it comes to paying the claim. Since the customer interactions are usually done under negative circumstances ( after all, no one likes paying a premium when they are healthy; and it can be very stressful to have to fill out medical insurance claim forms when one is ill !), it’s quite natural that the general perception of health insurers is negative. They are treated as a necessary evil, which one has to put up with, much like the tax man.

This is such a shame, because health insurers can do so much to create positive interactions with their customers ! If health insurers want to earn their customers’ trust , they need to be proactive . The best way of doing this is by providing their customers with Information Therapy .

Knowledge is power , and a patient desperately hunts for reliably trustworthy information about the his problem when he is ill, to ensure he is getting the best medical care.  This is why patients spend hours trawling the Internet , googling for information. While the information should ideally come from their doctor, most doctors are too busy to educate their patients.

Internet searches can be very frustrating, and Dr Google sometimes causes more harm than good, because patients are not sophisticated enough to differentiate good information from bad.

Health insurance companies can position themselves as being the preferred first point of contact when their customer has a medical problem. They can provide patients with Information Therapy – prescription strength information, which is provided to the right person , at the right time .

Patients can be very vulnerable, and if the health insurance company proactively provides them with trustworthy, reliable, and easy to understand health information, they will be able to convert their customers into raving fans !

Not only is this very good for creating a positive buzz , it also makes a lot of business sense for insurance companies to invest in this. Providing Information Therapy before the patient goes to the doctor , helps the patient to have an intelligent conversation with his doctor, and saves the doctor time as well ! It reduces avoidable care and unnecessary surgery and medical treatments. Doctors are much more respectful when they have to treat a well-informed patient ! A good doctor and a well-informed patient can form a partnership which will ensure that patients get the best possible medical care.

If health insurers adopt this model, they will be able to earn their customer’s trust, and this is invaluable !

Can free medicines really help to improve medical care ?

The Maharashtra health minister just announced that in order to improve healthcare for the citizens of the State , the government is going to provide medicines free of cost in government hospitals .  Statements like this grab headlines, because they project that the government as taking concrete steps towards making medical care more affordable .

How can anyone argue with this proposal ? Isn’t it the government’s responsibility to provide healthcare for the poor ? And if they cannot afford it because doctors and hospitals are greedy and charge too much , doesn’t it make sense for the government to intervene and provide this free ? What could the possible harm be ?

Sadly, the law of unintended consequences ensures that these populist steps cause more harm than good. Measures such as this are announced before an election ( the Maharashtra Assembly State election is just around the corner)  and are always helpful in getting a few more votes, but we know from bitter experience that subsidies never work well in real life. The ground reality is that when the poor patient goes to the hospital medical store to fill the prescription which has 5 medicines on it, 9 times out of 10, the store keeper will hand over a strip of aspirin tablets, and claim that the rest of the medicines are “out of stock”. It seems that they are always out of stock ! The reason is that most of them are sold in the black market , to enrich corrupt government and hospital officials . 

Poor patients do not benefit from these schemes, but the reason government officials are very fond of launching these is because government officials do benefit from them ! These schemes are a great way of making money ! They are big-ticket items, which usually add up to hundreds of crores. The tender is usually awarded to a “ friendly company “, and the process allows scope for a lot of corruption. Even worse, this money comes from the taxes we pay, and is just being wasted. WE also need to think of the opportunity cost. These funds could have been better utilised for other more constructive purposes.

Patients rarely value anything which is given free – and most of them still believe that the medicines provided in government hospitals and sub-standard and of poor quality. They do not trust these, and prefer buying branded medicines using their own money.

Rather than try these cheap popularity stunts, it would be far more effective for an enlightened Health department to provide free Information Therapy for patients . This is such a huge opportunity for the government ! While patients are hungry for information, their problem is that they are not sure if online information is reliable or not. If the government provided this, not only would this be trusted, it would also allow the government to prove that it was spending its funds sensibly, in order to improve the health of its citizens !

Even better, this is an intervention which does not have any side effects . Bad doctors will no longer be able to take patients for a ride by exploiting their ignorance . Good doctors would be happy with this solution, because it’s much easier to talk to a well-informed patient, and it would save them time.

Endometriosis - should we treat the pain or the infertility first ?

Many patients with endometriosis have both infertility and pain , and often receive poor quality medical care. They are confused as to whether they should treat the pain first, or focus primarily on their fertility. While having a baby is an important long-term goal for them , getting relief from their pain is often far more urgent. Their pain  causes them a lot of distress, and they need a quick solution for this.

When they go to their gynecologist ( most of whom are not infertility specialists ), the doctor prioritizes the management of the pain . Sadly, this ends up harming their fertility in the long run.

Often the pain is suppressed by “ treating “ the endometriosis with birth control pills , danazol or GnRH agonists. These can provide dramatic pain relief, which can be very reassuring for the patient. However, while taking the medicines, she cannot get pregnant, and this medical treatment wastes valuable fertile time, as her biological clock ticks away .

The other popular technique for managing the pain is surgical. While laparoscopic surgery is touted as being “minimally invasive”, the truth is that often this unnecessary surgery reduces fertility as normal ovarian tissue is also removed along with the cyst wall of the chocolate cyst, thus reducing ovarian reserve. This trade-off is very shortsighted, and a few months of pain relief often translates into a lifetime of infertility.

Patients with endometriosis who have both pain and infertility are far better off concentrating on getting pregnant. They should prioritise getting pregnant first .

Once they conceive, they will be pain-free for the nine months of their pregnancy and while they are breast feeding. Pregnancy can also often have a positive impact on the natural history of the disease, and many women find their endo pain goes away after they have had a baby.

But how do they cope with their pain while waiting to get pregnant ? The trick is to learn to manage the pain more aggressively. Sadly, this is not something most doctors teach their patients to do well.

The commonest mistake endo patients make is that they wait for their pain to become unbearable before taking pain-killers. They are scared that they will get addicted to pain killers; and are worried about the long term consequences of taking too many analgesics. Many of them manage their pain so poorly, that they end up having to go to the ER for taking injections , because they pain is unbearable. When this happens 2-3 times, most are very happy to sign up for surgery ! The real tragedy is that the surgery is often not needed. What they need is to learn to manage their pain more intelligently.

Endo pain usually creates problems for the 3-4 days during which they have their periods. This means that most patients know exactly when their pain is going to strike. Rather than wait passively and miserably for the cramping to start , they need to begin taking pain killers before the pain starts. They need to take adequate doses, around the clock, for the 3-4 days of their period. This ensures that they have adequate blood levels of pain killer during their painful periods. This will allow the painkiller to act much more effectively, and make the pain much more bearable.

So why don’t doctors teach them how to manage their pain ?  For one thing, doctors would rather be doing surgery ! For another, they are worried that taking pain killers on a long term basis can have side effects ( such as causing kidney damage) . However, remember that the patient will end up taking medicines for only about 3-4 days every month. ,This means that even if she needs 4 tablets daily, she will take only about 10 tablets during the entire month. This kind of intermittent use, even if it is chronic,  will not cause harm. Taking inadequate doses of pain killers as a result of the fear of side effects is worse, because it results in the pain not being treated properly.


If they take the pain killer properly, their ability to manage their pelvic pain becomes dramatically better . This allows them to take a more patient, mature long term approach, and they don’t go to pieces everytime their period starts. Similarly, learning simple techniques such as using lubricants during sex or trying different sexual positions can help to relieve pain during sex as well.

By using an aggressive approach to treating the pain conservatively , they can focus on getting pregnant , rather than running to the doctor for pain relief.

How to find the best doctor

Doctors and patients know that the decision about which doctor you go to for your treatment is often one of the most crucial choices you need to make. However, this decision if often made on the basis of a mix of hopes , hunches , secondhand advise , old wives tales , and a google search.

While we all like to think that we act in rational ways , the key medical decision about whom to trust our lives with is often based on a gut feel. In order to try to make a more informed decision, we gather information from all kinds of sources – doctor friends , other patients, the chemist , family members , our general practitioner , websites and bulletin boards.

The trouble is that often this information is poor quality because it comes from sources which are not always reliable . One would expect that the doctor could be trusted to be the best source of medial information. After all, he is a medical expert , and won’t he give you advise which is in your best interests.

This is why most patients think that if they can find the right doctor, they will be able to get the best treatment . Unfortunately , this is often no longer true. There are lots of additional influences such as cuts and kickbacks and bribes from pharmaceutical companies which act as negative externalities. These could the doctor’s ability to make the right decisions, so that doctors who continue to act in a fiduciary capacity and put their patients first are few and far between .

So what is the poor patient meant to do ? Some try to keep on second-guessing everything their doctor tells them!  They doctor shop and go around looking for a second or third opinion . Others will go online to see what Dr Google says.

I’d like to offer a better alternative. You need to consult an expert , whose advice can be trusted , and someone who will always be available when you need it , and who can be counted upon no to exploit is ?

So how do you find this expert ?

This expert can be you , if you you're willing to put in the effort . I am not suggesting that you join medical school ! All I  am saying is that you take an intelligent interest in your treatment; and polish your skills, so you can differentiate between reliable information and hype. An expert patient is someone who understands a lot about himself , and also understands what medical science can offer , and what its limitations are. Thanks to the internet, this has become much easier to do !

This will dramatically improve the quality of care you receive , because a good doctor and an expert  patient make an unbeatable combination !

Computers in the clinic - Oversold and Underused

Oversold and Underused is the title of a book,  where "  one of the most respected voices in American education argues that when teachers are not given a say in how the technology might reshape schools, computers are merely souped-up typewriters and classrooms continue to run much as they did a generation ago. In his studies of early childhood, high school, and university classrooms in Silicon Valley, Larry Cuban found that students and teachers use the new technologies far less in the classroom than they do at home, and that teachers who use computers for instruction do so infrequently and unimaginatively.


Cuban points out that historical and organizational economic contexts influence how teachers use technical innovations. Computers can be useful when teachers sufficiently understand the technology themselves, believe it will enhance learning, and have the power to shape their own curricula. But these conditions can't be met without a broader and deeper commitment to public education beyond preparing workers. More attention, Cuban says, needs to be paid to the civic and social goals of schooling, goals that make the question of how many computers are in classrooms trivial."

http://www.amazon.com/gp/product/0674011090/ref=as_li_ss_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0674011090&linkCode=as2&tag=hackeduc-20

It's uncanny how similar this is to the problem which doctors face with EMRs today ! The common denominator seems to be that the technology is thrust on the end-user, where it just ends up disrupting workflow, rather than helping them to be more productive and useful.

Doctors and patients - To , for and with

These are valuable prepositions to remember when we talk about what we can do to fix a broken healthcare system . Today, most doctors behave as medical experts. They have authority, and when patients come to them with their medical problems , they are supposed to provide medical care and advice to them . This is a paternalistic relationship , where the doctor does things to the patient. This could be in the form of  tests and treatments. Not only are doctors trained to do this , patients have also traditionally been brainwashed into expecting doctors to do this to them. This works well for certain problems – for example, medical emergencies.

However, this is not the best model in a lot of other situations . Rather than think of patients as objects for whom things need to be done , doctors need to treat them with respect as people for whom they're providing service. This is the concept of the leader as a servant. Doctors are in a service profession , which is designed to help patients who come to them in their time of need.

The final stage is when doctors do things in partnership with patients. Here, patient are treated as intelligent adults. While the doctor brings his medical expertise to the table , the patient brings his own thought processes , his emotional baggage , his hopes, fears, dreams, needs, wants and expectations .

Working together, they can create a win-win partnership , where they do what is right for the patient using a combination of the doctor’s expertise as well as the patient’s expertise .

This will allow us to get the best possible outcomes , in terms of improving quality of care ; curbing unnecessary treatment ; controlling costs, improving patient satisfaction; and reducing physician burnout;

The health insurance industry is sick

Customers buy health insurance so that when they fall ill, they do not have to worry about the cost of their medical care . One would expect that their health insurers would do their best to help their patients to get better , but once you get admitted into hospital , unfortunately the ground reality is completely different. Health insurance companies spend a lot of money in advertising how great their service is and how useful their policies are in case of an illness. However, the real-life experience which patients and doctors have with health insurance is completely different .

There are many reasons for this , and one of them is the fact that most health insurance companies think that doctors and hospitals are crooks. They have lost so much money thanks to medical fraud perpetrated by healthcare providers), in the form of inflated medical bills and fictitious claims for operations performed on non-existent patients , that insurance companies don't trust doctors or hospitals anymore .

Sadly, it is the good doctors who are harmed the most as a result of this lack of trust . Their legitimate claims are often denied; or payment is held up or delayed, because insurance companies have introduced so many checks in order to prevent fraud and protect themselves. These serve as additional friction points , which serve to frustrate genuine customers .

Thus, hospitals often find that payments are delayed; and patients are often angry and upset that their claim is rejected simply because of a clerical error in submitting the form !

Even worse, an unintended consequence of this safeguard is that it harms the quality of medical care patients receive. For example, insurance companies insist that patient's submit their original hospital and medical records with their claim, when they want reimbursement . The problem is that the company will often sit on these records for long periods of time. As a result, when the patient needs to go for a follow-up visit or get a second opinion , the poor patient does not have her original medical records ! I think this is ridiculous ! Medical records are the property of the patient and it’s not right that the health insurance company keep them. The reality is that they often do so for extended periods of time, while “processing the claim”, and is extremely unfair on patients as well as their doctors , who have been denied access to valuable information which they need to treat the patients.

Health insurance companies have become lumbering dysfunctional bureaucratic organizations which have still not learned how to put their customers first . The good news is that this is an extremely fixable problem , using technology. In the USA , the insurance company does not ask for the original patient records . Indian companies continue to do so because they've been doing it for many years , and have been getting away with it . It’s high time they started using technology cleverly, to provide better customer service and expedite claim processing. An efficient way of doing this would be providing patients with their online electronic personal health record . Since these are online, submitting and processing these would be frictionless. Not only would it make the patient’s life a lot easier, it would also help to reduce transaction costs for the company, and would also help to prevent fraud, because auditing claims is much easier when it’s done electronically.

Believing is seeing - how doctors fool themselves and their patients !

The British doctor Richard Asher noted in one of his essays for doctors:

‘If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better, too. I believe this accounts for the remarkable success of some of the less gifted, but more credulous members of our profession, and also for the violent dislike of statistics and controlled tests which fashionable and successful doctors are accustomed to display.’

Asher R. Talking sense (Lettsomian lecture, 16 Feb, 1959). Transactions of the Medical Society of London, vol LXXV, 1958-59. Reproduced in: Jones, FA, ed. Richard Asher talking sense. London: Pitman Medical, 1972.

http://www.testingtreatments.org/tt-main-text/thumbnails/background/believing-is-seeing/

This is why so many IVF doctors continue offering "immune therapy" such as IV Ig for patients with high NK cells and repeated IVF failure !

What is wrong with health insurance today

Just like the healthcare system is broken, the health insurance industry is malfunctioning. They think of themselves as being in the insurance business , not the healthcare system. The problem is that they think of themselves as being financial intermediaries, who help customers to bear the financial shock of falling ill. This means that all they do is provide illness insurance – and not health insurance. This is why the IRDA ( Insurance Regulatory Development Authority) in India – the regulatory body for the insurance industry) is a part of the finance ministry , rather than the health ministry .

This is the reason they have such a short-sighted focus; and their primary interest is boosting their bottom line, rather than improving the health of their customers. This is why their interactions with their customers has always been so negative. They only engage with them for financial transactions – when they need to collect the annual premium; and when they need to pay the claim. Most customers are also very unhappy with health insurance companies, because they have an unsavoury reputation of denying valid claims ( for flimsy clerical reasons). Hospitals and doctors also do not like dealing with them, because they delay payments ; and try to play doctor after the care has been provided by using procedures such as utilization review to second guess the doctor.

The good news is that the health insurance industry in India is realizing that the old models can no longer continue to work. The entry of Cigna TTK in India  should help to shakeup and reinvent the industry. Their focus is on promoting health, rather than just paying for medical care and they are taking advantage of the years of experience Cigna has as a global health payer.

By putting the customer’s health first, they are creating a win-win situation. They gain customer loyalty because their customers can see that the company is helping them to improve their health. This is a great USP, which they use to differentiate themselves from the competition – especially for the highly profitable policies bought by individuals ( as compared to the group policies bought by corporate, on which most companies are still losing money) . In the long run, this focus will help them to improve their bottom line as well, as the claims ratio is likely to drop when their customers remain healthy and do not fall sick.

Hopefully, other health insurance companies in India will also soon follow their lead ! One of the most cost effective ways of doing this is by empowering patients with Information Therapy and health coaching. Population Health Management is a model which is still new, and by using a clever match of technology and low-cost doctors, India can become a world leader in this space.

Anecdotes can be harmful to your health !

I see lots of patients who demand/ request that I treat them with unproven treatments, such as Intravenous immunoglobulins for treating high NK cells. When I ask them why they think this will help, the commonest answer is - I read about a woman who had failed 4 IVF cycles and who then got pregnant after taking IV Ig !

The trouble is that one swallow does not make a summer - and anecdotal successes cannot be relied upon because medicine is such a complex science. Often, these women get pregnant inspite of the treatment, not because of it ! This is why controlled clinical trials are so important !

However, it's not just patients who get swayed by these success stories - we doctors also get unduly influenced by them. We are human, and we remember our successes ( who come back to us with a box of chocolates) and forget our failures ( who move on to another doctor !)

'Our brains seem to be hard-wired for anecdotes, and we learn most easily through compelling stories; but I am aghast that so many people, including quite a number of my friends, cannot see the pitfalls in this approach. Science knows that anecdotes and personal experiences can be fatally misleading. It requires results that are testable and repeatable. Medicine, on the other hand, can only take science so far. There is too much human variability to be sure about anything very much when it comes to individual patients, so yes there is often a great deal of room for hunch. But let us be clear about the boundaries, for if we stray over them the essence of science is quickly betrayed: corners get cut and facts and opinions intermingle until we find it hard
to distinguish one from the other.’

Ross N. Foreword. In: Ernst E, ed. Healing, hype, or harm? A critical analysis of complementary or alternative medicine. Exeter: Societas, 2008:vi-vii.

http://www.testingtreatments.org/tt-main-text/thumbnails/background/anedotes-are-anecdotes/

Why do doctors continue to do the wrong things ?

When I tell patients who have been treated with a toxic and useless 9 month course of antiTB medicines ( because their endometrium was PCR positive for TB ) that they have received poor quality treatment, they get very frustrated. Their commonest complaint is - Why did my doctor provide me with the wrong treatment ?

Here are some possible answers !

‘We [doctors] do things, because other doctors do so and we don’t want to be different, so we do so; or because we were taught so [by teachers, fellows and residents (junior doctors)]; or because we were forced [by teachers, administrators, regulators, guideline developers] to do so, and think that we must do so; or because patient wants so, and we think we should do so; or because of more incentives [unnecessary tests (especially by procedure oriented physicians) and visits], we think we should do so; or because of the fear [by the legal system, audits] we feel that we should do so [so-called ‘covering oneself’]; or because we need some time [to let nature take its course], so we do so; finally and more commonly, that we have to do something [justification] and we fail to apply common sense, so we do so.’

Parmar MS. We do things because (rapid response). BMJ. Posted 1 March 2004 at www.bmj.com.

Surrogacy Checklist for US citizens who want to do surrogacy in India

Surrogacy Checklist for US citizens from Aniruddha Malpani

This list is courtesy one of our expert patients.

If you have more questions and need hand-holding, please email him at [email protected].

Health care fraud

The $272 billion swindle - Why thieves love America’s health-care system

http://www.economist.com/news/united-states/21603078-why-thieves-love-americas-health-care-system-272-billion-swindle

The problem is equally bad in India, where most government insurance schemes and health insurers have accepted that fraud is part of the "cost " of doing business !

Sadly, this hurts honest doctors and good hospitals ( and their patients as well) , because all healthcare providers are now being treated as crooks , and payments are delayed or denied.

The good news is that health insurers have an opporunity to fix the problem by investing in technology. If they invest in Information Therapy and EMRs, the electronic trail will encourage openness and transparency, and make it much harder for cheats to perpetrate fraud.

Tandem IVF for older women

One of the newer options we can now offer older women is Tandem IVF – a unique combination of fresh IVF with their own eggs, along with frozen donor eggs as a backup plan in the same cycle.

This allows them the flexibility of attempting IVF with their own eggs, with the backup safety net of using donor eggs in case they do not grow eggs at all, inspite of aggressive superovulation. This allows them to have their cake, and eat it too !

How does this work ?

Older women know that the major limiting factor in their IVF success is their eggs. As women get older, their ovarian reserve declines – and both the quantity and quality of their eggs declines . As a result of this, they are likely to have a poor ovarian response, which means we may get few eggs, and poor quality embryos . This significantly reduces their chances of success.

Even though their head understands this , and they know that using donor eggs would maximize their chances of conceiving , their heart finds it difficult for them to accept the fact that they may need to use donor eggs . Lots of them still want to give themselves their best shot of trying to get pregnant with their own eggs. They hope that with the help of new technology, better IVF success rates and a more experienced clinic, they will be able to reach their goal.

In the past, the standard option for these patients was sequential IVF. We would do IVF with aggressive superovulation for them, and if this failed, we would move on to donor egg IVF in the next cycle. While this did give them peace of mind they had done their best, this took more time and was more expensive.

We can now offer a new option for these patients , because we have a very active frozen donor egg IVF program , which allows patients to have their cake and eat it too ! We start an IVF cycle for these patients, and reserve frozen donor eggs for them at the start of their IVF cycle. If they respond well and produce good quality embryos ( and many older patients with poor ovarian reserve respond surprisingly well when monitored carefully) , we transfer their own embryos in that cycle and do not use the frozen donor eggs, so that their only additional costs is the frozen egg reservation fee.

If, on the other hand , they do not respond well, rather than cancel the cycle , they can go ahead and use the frozen donor eggs in the same cycle , provided their uterine lining has grown well. This allow us to save the cycle , and is a great option for older women who want to do IVF with their own eggs and are also willing to use donor eggs in case their ovarian response is poor.

While this option does cost more, it has the advantage of saving them time. Patients need to think carefully about the pros and cons , before deciding on this option . Being able to offer additional new options to infertile couples helps us to maximize their chances of having a baby !

Tandem IVF treatment is appropriate for women who have a low ovarian response or who produce low-quality eggs and who want to give themselves the best possible chance of using their own eggs for pregnancy. As mentioned above, in a tandem IVF treatment the donor eggs are not the first choice; they are part of a backup plan and are used only when the possibility of achieving pregnancy using the patient's eggs is low or absent.

A tandem cycle essentially incorporates a reserve plan from an egg donor in case the patient’s natural eggs are not effective. The biggest advantage of tandem IVF treatment for women with low-quality eggs or a low ovarian response is that it gives them the best chance of becoming pregnant in a single cycle without completely ruling out the use of their own eggs for pregnancy.

At the end of the process you get to decide what combination of your own eggs and donor eggs to use.

• İf worst comes to worst and your own eggs do not develop well then you have the donor eggs as back up so you do not have to go through another IVF cycle.
• This also gives you the opportunity to try at fırst with just your own eggs, freezing the donor eggs for a future cycle without facing the cost of 2 separate cycles.

Need more information ?  Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!

My Fertility Choices?

" An on-line survey of over 4000 childless women and men between the ages of 20 and 50  was done (click here to learn more about the survey). The findings of that survey showed that while most people expected to have children in the future, they didn’t have the information they needed to make informed fertility choices – information about the fertility life span, or what fertility and assisted reproduction treatments and family building options are available, what they cost and how effective they are. This web site has been developed, in an ongoing effort to help fill that gap."
http://myfertilitychoices.com/about-2/why-my-fertility-choices-2/

This is an extremely impressive website - and infertile couples will find the section on decision making and relationships extremely valuable !

Freezing eggs and embryos - suspending time !

Time reports that a study of 200 women found that, "half of those pursuing degrees in sports or education would consider freezing their eggs to give them the option to delay starting a family, while more than 8 out of 10 women pursuing a medical degree said that they would do so." A second study in Belgium found that half of the 15 women interviewed would freeze their eggs in order to take the pressure off of finding a partner in time to utilize the woman's fertility.

I'm not really shocked at the results. Certainly, as IVF has become commonplace, attitudes surrounding IVF have relaxed and many see the idea of egg freezing as a great leap forward in allowing women the same gamete safeguards given to men, especially when it comes to preserving fertility prior to undergoing medical treatments that would impair fertility. Men have been able to freeze and thaw their sperm for years, but it has only been in recent years that scientists have been successful in freezing eggs.

http://www.blogher.com/three-ways-egg-or-embryo-freezing-are-changing-fertility-world

Social egg freezing can be a great insurance policy for women who are in their 30s and want to postpone having children.

Need more information ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?




 

IVF success story at Malpani Infertility Clinic

We sincerely hope that no couple has to face infertility issue, but if you do, then Malpani Infertility Clinic is the blessing you need. Therefore, we would like to share our wonderful experience at Malpani Infertility Clinic.

After 4 years of trying conception, we starting exploring IVF options in our city. At the 1st clinic we approached, the doctor asked us to undergo Uterus TB Test. We were sceptical about unnecessary invasive tests/surgeries. So, we started browsing about the necessity of this test. That is when we happened to know about Dr. Malpani's free second opinion option. We asked him about this test, and he promptly replied back stating that if TB Gold test was negative, then this test was not required.

We tried convincing our doctor but in vain. We visited another IVF clinic, where they asked us to perform Laproscopy and Histroscopy before IVF even though there was no tubal blockage. Again we used Dr. Malpani's second opinion, and came to know that these surgeries were not required in our case.

We would like to highlight on the fact that at most of the IVF clinics, there are long and hectic waiting periods and medical history is being conducted by junior doctors in contrast to Malpani Infertility Clinic where you directly talk about all your problems to Dr. Anirudhha Malpani himself. Also, a lot of them offer only "one size fits all" kind of treatment, which results in wastage of time and money, not to mention the mental stress associated with it. You may end up doing expensive tests and surgeries, which may not even be required for you.

When we received 2nd email from Dr. Malpani, we started reading blogs and information provided on his website. We then realized the stark difference in the quality of treatment offered by Dr. Malpani as compared to other IVF doctors. We continued seeking advice over email from him for our doubts from time to time, and always got prompt response from him.

This convinced us that Dr. Malpani was definitely the right choice for us. After that when we met him in person, we were pleasantly surprised to know that he recognized our previous communication just by reading our name from a sheet of paper.

After talking to him, our faith in him was further reinforced when we saw that he understood and discussed the anxiety and social pressure that we were going through. He clarified our vision by asking us to focus on our goal of having a baby rather than getting distracted by issues like Oligospermia and PCOS. Also, we were comforted by his assurance that we need to be patient, and he would make it work for us.

After visiting Dr. Malpani, we started the treatment, and by God's grace and Dr. Aniruddha and Dr. Anjali Malpani and their staff's hard work and caring attitude, we are now expectant parents in the 1st cycle itself.

Our experience was so smooth that we never realized that we were undergoing such a major treatment. They never discouraged our queries or concerns about the smallest of things.

Some of the other things we would like to throw light upon are:
1. Customized treatment for every patient
2. Good use of technology not only for treatment but also for managing patients
3. Very professional environment, yet personalized attention to every patient

Dr. Malpani has raised the medical standards so high that shifting to a gynaecologist/obstetrician for the rest of the pregnancy period brings with it a mental barrier, and it seems that it will be a while before we can trust anybody other than Dr. Malpani completely.

We wish them all the very best in their endeavour to help infertile couples become proud parents.

Thanks and regards,
Sarang and Deepali Ladda.
 
[email protected]

Pregnancy destroying factor – taking patients for a ride

Infertile couples are emotionally vulnerable , and it breaks my heart when I see them being taken for a ride . Sadly, doctors do this by exploiting their ignorance.

An infertile patient recently sent me an email. Her doctor has told her that her “high levels of pregnancy destroying factor”  were preventing her from getting pregnant and she was very worried. Since I had never heard of a pregnancy destroying factor before, I asked her to send me the report which her doctor had given her. This is what she sent.

I promptly did a PubMed search ( PubMed is a database of the world’s medical literature) for pregnancy destroying factor, to learn more about this “new” test.  I found out to my dismay that there is no such factor, and no such test !

This clearly means that this lab has very cleverly coined an emotionally charged term, and reported these results, without bothering to inform the referring doctor that this test has not been proven or validated.

Now, if this was being done on a research basis or clinical trial setting, I think this would be acceptable.  The patient would provide informed consent, and would not be charged for the test. The doctor could specify that data was being collected for clinical validation ; and could compare the levels of this putative factor in fertile patients and infertile patients, to see if there really was a difference or not. This clinical trial would take time to perform; and could then be submitted for peer review to a medical journal, for validation. Ideally, the results would then have to be duplicated by other labs, to ensure that the findings were correct , because there is always the risk of false positive findings.

However, by charging patients to do a test which has not been established, one can only imagine the amount of harm which is being done. Patients are clueless about the limitations of the test , and what it means. Sadly, most referring infertility specialists are equally clueless as well. They are happy to refer patients for this test, because it’s new, and has been marketed cleverly.

When the result comes back as positive, both doctor and patient are very pleased. The doctor is happy that she has “pinpointed” the problem, by ordering a new, sophisticated and expensive test, which is available at only one lab in the entire world ! The patient is also very impressed by how smart her doctor is.

The doctor now proceeds to “treat” this problem with all kinds of therapeutic interventions, such as steroids, IVIG  and intralipids. . The medical literature is full of all kinds of treatments which reproductive immunologists have used for treatment, without their efficacy ever having been proven in clinical trials. Patients are desperate and are happy to clutch at straws.

The major irony is that some of these patients will get pregnant after taking treatment – often, inspite of the treatment ! The doctor will forget all her failures ( because these patients will get fed up and go to another doctor); while the success stories will sing the doctor’s praises to the entire world. These anecdotal success stories will create even more bias and confusion – and make a bad problem even worse !

Patients often believe that the very fact that the test is being offered means that it must be reliable ! After all, aren’t there rules and guidelines which regulate and govern what medical tests can be performed ? How can doctor offer tests which have not been proven ? The sad truth is that there is no regulation or medical oversight for medical testing – and patients need to do their own homework for themselves, which is why I am writing this post.

So what’s the lesson to be learned ? If your doctor advises you to a get a test done ( especially if it is expensive and available only at a “highly specialized” lab), please be skeptical. If tests were really useful, lots of labs would start offering them – after all, everyone wants to help their patients !

Don’t get duped by fancy medical jargon, just because this is on a computer printed report . These reports just create a façade of medical knowledge , but they are just a lot of cloud and smoke, and mean very little. Real life biology is complex , and both patients and doctors need to accept this reality.

How IVF can reduce stress levels

A lot of infertile women don't want to do IVF because they are worried that IVF is very stressful . They are anxious about having to take so many injections ; they have heard lots of horror stories about the side effects of the hormones ; they are anxious about spending so much money ; and the biggest worry of all is the uncertainty involved with IVF – that even after spending so much time, money and energy, the cycle may fail.

While it is true that IVF treatment is expensive , please do remember that a baby is priceless - and that IVF is the fastest and most efficient way of getting pregnant quickly. While IVF can be stressful , not having a baby can be equally stressful ! The fact that you're not getting pregnant , and have to keep on trying month after month , without ever being sure when it’s going to work, can be very difficult to live with. This chronic daily low-level stress can cause a lot of personal unhappiness and marital disharmony. It changes a person's personality – and infertility affects self-esteem and sexual desire.

For these women, IVF can actually be a great way of reducing their anxiety and stress levels ! Rather than sitting and hoping and waiting for something to happen ( which can be very frustrating), they now have the opportunity to regain control and actually do something which dramatically improves their chances of achieving their goal.

They know they are taking treatment which can maximize their chances of getting pregnant . Rather than just passively praying and waiting for things to happen naturally , they have taken the initiaitive to change their fate. Since the fact that nothing has happened for so many months can be extremely corrosive to their self-esteem, the fact that they are now actually doing something can be extremely good for their confidence . They know that they are now moving in the right direction and are making progress.

This means that even if the IVF cycle doesn't give rise to a pregnancy , they still have peace of mind that they are giving in their best show – that they are putting in their best efforts and are not leaving any stone unturned in their quest for a baby.

I advise patients – Please come to when the anxiety of coming to me is less than the anxiety of making  a baby in your  bedroom !

In reality, if IVF is done properly in a good clinic, the physical stress involved in an IVF cycle is minimal. We are kind and patient-friendly and don’t make patients wait for hours on end or give them painful injections. They need to come to the clinic only five or six times . We make sure our patients are well-informed, so that can actively participate in their treatments . They know exactly what is happening and how their cycle is progressing. This knowledge gives them a lot of comfort and boosts their self-confidence and sense of control.

Sadly, a lot of IVF treatments are not carried out properly in many IVF cycles. They needlessly add to the patient’s stress, by doing daily blood tests and scans – most of which are not needed. Patients need to wait for the results – and there is little privacy because they are often herded like cattle since there are so many patients being treated at one time. It’s often an impersonal assembly line approach – and patients are clueless about what is happening. The senior doctor is never available and they can only get information in little dribbles from the juniors and nurses ( who are often very poorly informed themselves !)

The treatment is often badly -organized . Because many clinics do the IVF cycles in batches and depend upon an embryologist or doctor who flies in from out of town, they are disorganized, and don't share information up front with the patient. Even worse, many actually hide information from the patient , by not telling them how many eggs were collected or not providing them with photos of their embryos.

If IVF is done properly, it can actually be a great treatment to reduce stress and anxiety levels for infertile couples , because rather than depend upon Mother Nature ( who can be very inefficient and unkind for infertile couples), IVF allows us to give nature a helpful push in the right direction !

IVF allows you to seize the initiative, so you no longer have to be passive, helpless and powerless.  Taking treatment at a world-class clinic will maximize your chances of success and give you peace of mind you did your best , so you never have any regrets in the future that you did not give yourself the best shot at having a baby.

Need some help ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !