Monday, August 18, 2014

The do nothing consultation

The last few consultations I have done have been what I call “ do-nothing consultations “. This is when I tell the patient that they do not need my help in order to get pregnant  ; and that their best course of action would be continue trying in their bedroom.

This might seem to be very unusual advice coming from an IVF specialist . Because I am a senior specialist, most patients come to me for a second ( and often third ) opinion , in order to have their tests and investigations reviewed by an expert. Often they have been advised surgery by a gynecologist or infertile specialist, and they need to make sure they are getting the right advise.

The first patient was woman who wasn't trying to get pregnant , but had done an ultrasound scan ( as part of a super-deluxe corporate health check up scheme which her company had paid for, since she was a senior manager). This showed she had a 2 cm cyst, and her doctor had advised her that this could possibly be endometriosis , and that she needed a laparoscopy in order to confirm the diagnosis; and treat it. She had scared her that if it was left alone, it could rupture or spread and cause her to become infertile in the future.

The second patient had gone to her gynecologist because she was having a lot of vaginal discharge . Her doctor suspected “ PID” or pelvic inflammatory disease, ( a wastepaper basket diagnosis, which means precious little) and had asked her to do a pelvic scan to “diagnose” this. The scan showed she had a little bit of fluid in the pelvis. Now it’s quite common to find fluid even in normal women, but her doctor felt that the presence of this confirmed her diagnosis. She then did a blood test for TB ( an extremely inaccurate and unreliable test which checks for TB IgG and IgM antibodies) and when this came back as positive, she was triumphant that her clinical suspicion had been vindicated, labeled her as having “silent genital TB” and promptly put her on a 6-month course of anti-TB medicines !

The third patient was a 26 year old, who had gone for prepregnancy counseling to make sure she was normal. Her doctor picked up a small 5mm uterine polyp on the vaginal ultrasound scan can advised her that she needed to do an operative hysteroscopy to remove it. She warned her that the polyp would prevent her from getting pregnant – and that even if she did manage to conceive, the polyp would cause a miscarriage.

Patients need to understand that doctors are not fortune-tellers . They can't always predict what's going happen ; and often have a bias towards labeling everything they see which is out of the ordinary as being “abnormal” and needing intervention, because they have a bias for looking for problems and “ fixing “ these. They are worried that if they ignore an abnormal finding and this later turns out to be a serious problem, the patient may sue them for negligence. This is why they prefer practicing defensive medicine. They will never get sued for overtreating !

Also, it’s much easier to just “treat” every abnormality. This is much more  profitable ( because doctors get paid for performing interventions);  and ironically, this takes less time. If you tell a patient they can ignore the abnormality, it takes much longer to counsel the patient as to why masterly inactivity is the best course of action.  This is because the first question patients will ask is - How could that be possible ? After all, all the other doctors advised surgery ! How can you be so sure you are correct and they are wrong ? Isn’t it better to be safe rather than sorry ?

I have to explain to the patient that while it is possible that a small polyp on the ultrasound scan may reduce fertility, it is much more likely that this is an innocent bystander which is not causing any mischief and can be left alone. I have to explain that polyps are quite common in young women  and many fertile women also have small polyps ( but are blissfully unaware they have these because they have never needed to get an ultrasound scan done !) In fact, sometimes over-enthusiastic surgery can cause harm by causing scarring and adhesions. I also explain that if she fails to get pregnant in a few months , then we might consider intervention after an appropriate period of time .

Suppose the patient with the polyp comes back after six months, saying I am still not pregnant, and then she gets pregnant after removing the polyp, she is likely to resent the fact that i did nothing for six months, and wasted six months of her life in watchful waiting. Similarly, if the small ovarian cyst does not resolve but instead becomes bigger, she will think I was a bad doctor because I chose to ignore the“ abnormality” .

The problem is much worse when you consider genital TB. Most gynecologists in India seem to think that tubercle bacilli are lurking in the pelvis of every Indian woman!  The variety of tests done to diagnose“ silent TB “ in India are mind-boggling !  These include: blood tests for TB IgG and IgM; TB GOLD blood tests; tests for checking interferon levels; PCR tests – the list seems to be endless ! Most of these tests are not available anywhere else in the world, because they are unreliable and untrustworthy.

However, gynecologists merrily order panels of these tests  left, right and center. Many of them come back as positive, and the poor patient ( who does not have TB at all) is then subjected to 9 months of “treatment” with toxic antiTB antibiotics. Not only do these have side effects, they also waste precious time, thus reducing her fertility.

It takes a long time to explain the concept of “false positives” to patients – and why nothing needs to be done even if the test is reported as being “abnormal”. Patients are understandably reluctant to not to anything. They are worried that their “latent” TB is like a time bomb, which will spread and cause further damage if it is not treated promptly ! They also refuse to believe me when I tell them the tests are not reliable. After all, isn’t the fact that the doctor ordered the test and that it was done from a “reliable “ lab conclusive proof that the test is valid ?

The problem is that I am not a fortune –teller – but then neither is any other doctor ! All I can do is counsel the patient, and explain to them why doing nothing is often far better than doing something ! Not all patients are mature enough to understand this is approach , but masterly inactivity is an absolutely appropriate course of medical action , even though this is something which only senior doctors have the wisdom and confidence to advice .

This is why it is especially gratifying to see the relieved smile in the face of the patient when I tell her I don’t need to do anything at all for her. She is very happy that she doesn't need to go through even more tests and investigations in order to chase up what is most probably a red herring. Getting this kind of reassurance from a senior infertility specialist gives them a lot of reassurance that all is well. When I tell them that they can get pregnant in their own bedroom, and when they prove me right, the box of chocolates they gift me is the best reward which any doctor can get !

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