Thursday, April 30, 2015

I don't know - an IVF specialist shares the truth

IVF patients have lots of questions.  Why is my sperm count so poor ?  Why was the fertilisation rate so low?  Why didn’t my embryos implant even though they were Grade A embryos?  Why isn’t my uterus lining improving?  Most of the time we don’t have very good answers for them, so the truthful answer is - I don’t know.  Perhaps a better answer would be - We don’t know, because when I tell the patient I don’t know, they sometimes wonder about my competence , and how well informed I am.

Patients have very unrealistic expectations from their doctors.  They expect their doctors to be omniscient and hopefully omnipotent as well - someone who fix all their problems , so that they can stop worrying about their infertility. Their dream is to find a doctor who will be able to give them a 100% guarantee that he will give them a baby.  Their approach is simple -  I’ve come to you, and you’re the best, and I trust and know you'll  give me a baby . I don't need to break my head about what’s happening and why, because I know you'll find the solution . They want a doctor who has all the answers - someone who’s a fount of wisdom , and who can give them the confidence that he knows exactly what he’s doing.

Part of the problem is that this act would then be a sham.  The truth is that biological systems are extremely complicated and messy , and we really don’t have all the answers.  It’s very easy to make a pretense of answering the patient's complex questions by running tests , in order to be able to make a diagnosis to keep the patient happy . The tests give us some answers, but the problem with this approach is that a lot these results are completely irrelevant and pointless . The doctors are then so focused on treating these " abnormalities " that they lose sight of what the underlying problem is.  It’s far better to be honest with the patient and share our ignorance , and tell them that we don’t know. 
There is no reason for patients to panic when we tell them we don’t know.  After all we are not a research institute - we are an IVF clinic which tries to help infertile couples to have a baby . The good news is that even if we don’t know what the problem is, we are very good at crafting solutions which allow us to bypass the problem , and this is all for the best.

As I keep on reminding my patients, the quality of my answers depend on the quality of their questions , and there’s little point in asking pointless questions.  Rather than ask questions such as - Why didn’t the embryos implant ? a far better question would be - What can we do in order to get the embryos to implant the next time?  This way, both doctor and patient can respect each other because the doctor is being frank and transparent , and not pretending to know more than he really does. A good doctor truthfully shares the boundaries of our medical knowledge.  The patient can be comfortable that the doctor’s not hiding stuff or patronizing her by fobbing her off with "pseudo-answers". She can see that the doctor . and is leveling with her and that they can work together to find a solution so that she can have a baby.

I agree that this kind of fuzzy ignorance is not a very comfortable situation to be in, but the reality is that it’s something which we deal with in our daily life all the time.  For example, when we invest in the stock market, no matter what your financial advisor may say or who the talking head expert on TV is, we can never be sure whether the share we buy will go up or down.  Life is full of uncertainties,  and this is as true in IVF as it is in other fields . The sooner we acknowledge this, the easier it will for patients and doctors to deal with this on a mature basis.

When a patient asks me a question, I sometimes deliberately say, “ I don’t know the answer, let’s look it up.”  I’ll deliberately do a search for them , and go to a curated and reliable website, and we’ll read the answer together.

This is contrary to everything I was taught as a medical student , when I was told that it's important to instil confidence in patients by showing off that I know everything.  Some doctors still play games with their patients by pretending to know everything, but I don't think it's possible to fool all the patients all the time anymore !  Some patients aren't happy with my answer, because they don't like being treated by a doctor with " limited " knowledge , but more mature patients appreciate the fact that I am being honest with them.

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