Tuesday, February 28, 2017

Why IVF doctors continue to order useless tests and offer wasteful treatment

Patients who fail an IVF cycle are extremely vulnerable . This failure is often the last straw, because they are not sure what to do next. They have no idea why the cycle failed, even though the doctor was so optimistic at the time of the transfer. They are usually completely in the dark as to what was done, because most IVF clinics are remarkably opaque . They do not share information with their patients, and the standard explanation is - It is our clinic policy to keep all  IVF medical records for our files. Many feel quite hopeless , and this is why many go to another IVF clinic for a second opinion.

The new IVF doctor will often take advantage of their ignorance, depression and unhappiness . He will highlight all the tests which the earlier doctor didn't do , and say that the cycle failed because the earlier doctor was sloppy, and did not do the workup properly.  He will then proceed to rectify the problem, by ordering lots of expensive and sophisticated tests. Some of these are so " exotic " that they are only done in a single laboratory in the world, and they will ask the patient to get this test done only in that lab. The fact that no other lab in the world offers that test should actually be a red flag - this means that the test is unproven and untested , and its clinical value is still controversial.

However, patients are naive and come to exactly the opposite conclusion, because they are naive.  They interpret this behaviour as suggesting that the new doctor has access to highly specialised technology which the earlier doctor was completely ignorant about  - and this explains why the new doctor must be better !  The new doctor is also happy to point out that one of the reasons the earlier cycle may have failed is because the first doctor didn't order this advanced test. However, now that the patient is in his safe hands, he'll be able to  find out what the problem is , and fix it, thus increasing her chances of getting pregnant.

This sounds extremely logical, and patients are quite happy to do what the doctor says, without realizing that all these tests proven and haven't been validated.  The number of tests is mind-boggling, and seems to increase year on year. This includes: sperm DNA fragmentation tests; immune tests, such as NK cells testing;  endometrial TB PCR testing ; and ERA ( endometrial receptivity assay) testing.

So why does so much scientific quackery flourish in IVF? I think there are multiple reasons - both at the personal level, as well as the level of the medical profession.

As regards the individual doctor, he is liable to be waylaid by the same biases and prejudices every human being is susceptible to.  These have been well documents by Kahnemann, and doctors are not immune to this just because they are medical professionals. The much bigger tragedy is that they are completely unaware of their personal prejudices, because they are not taught basis critical thinking skills. They have never been taught to question, because success is medical college is a function of their ability to regurgitate the facts which they are forced to cram into their heads.

Doctors remember only their successes, and conveniently forget their failures. The individual clinician does not have a long term follow up of his patients, and cannot carry out controlled clinical trials in his practice. Let's look at a cohort of hundred patients for whom he advises these tests , and then "treats" the abnormality in all of them. Let's also assume that the tests are completely useless . Now, twenty of these patients will conceive - not because of the tests, but inspite of them ! However, because they will bring the doctor a box of chocolates, he will always remember them - after all, our brains are wired to remember memorable stories. The doctor will share this anecdote with everyone, and these successes will reinforce his belief that the tests are useful.

What about the other 80 patients for whom he did exactly the same tests and offered the same treatment, who didn't get pregnant. He would rather forget about them - or they will desert him, and find another clinic, which is why it's so easy and convenient to lose track of them . This explains why individual doctors have such strong biases about what they do, even though their protocols have never been validated properly.

Am I being excessively harsh and critical ? Perhaps - but this is only because I expect doctors to hold themselves to a higher standard of scientific integrity. The truth is that it's very easy to confuse cause and effect, and many events - including the success of an IVF cycle - are random.  Thus, if the patient gets pregnant after the "immune treatment", the doctor is happy to jump to the conclusion that it was his treatment which resulted in the pregnancy, because this is the way the human brain is wired .

While individual doctors maybe biased, why isn't the medical profession  as a whole able to fix the problem ? Shouldn't IVF doctors be able to get together and analyse the evidence objectively , so that they can collectively determine what "best practises" are for their patients. Can't these be offered uniformly across the board to all patients?  Why is there so much practise variation ? Why can't IVF doctors agree with one another ?  This is the holy grail, and this is what evidence-based medicine is supposed to offer. However, real life is far more complex, because of all the politics involved in the medical profession.

Thus, when experts disagree, they selectively quote the studies which reinforce their point of view, and trash all the rest. It's easy to bad-mouth a study you don't agree with by disparaging its quality. Either it was done too many years ago; or the statistical analysis was faulty; or the numbers were too small to draw a reliable conclusion ; or the results are suspect because they seem to be manipulated.

The truth is that like all of us, doctors also first make up their mind based on their emotions and personal experience; and then they selectively interpret facts in order to buttress their preconceived notions.  The danger is that because they are so sure they are right, they don't even realise that they are selectively massaging the data quoted in the medical literature to make it conform to their pet beliefs ! The truth is that the Devil can selectively quote the Bible to suit his needs - and doctors are also happy to do so!

Thus, if you point out that a research study shows that NK cell testing is useless, they will find a hundred reasons to criticise the study and point out its flaws.  This could include: the patients were not selected properly; the test was not performed properly; or the results were not analysed correctly.

They highlight the fact that the way they do the test in their own clinic is far superior to what the paper described, and given this shortcoming on the part of the researcher, they are justified in ignoring the results of the paper, which is completely opposite to what their personal experience shows. After all, when "eminence-based" medicine is at offs with "evidence-based" medicine, very few doctors will have the intellectual humility to accept that they might be wrong !

It's very hard for a doctor change his beliefs, especially as he gets older. When you are an "expert" who is invited to give lectures at conferences, you are supposed to have all the answers - and you start behaving as if you actually do.

Indian IVF doctors  are especially good at this. If they come across a high quality paper which casts doubts on their beliefs, they will trot out many reasons why the paper is flawed and why they are right. These include:
- Indian patients are different, and these findings don't apply to India
- My patients are different,  so these findings don't apply to my patients
- I am different , so these results don't apply to my practise ( because I am better than everyone else)

We are all subject to basic human foibles, and a major hurdle which stops us from correcting our prejudices is cognitive dissonance - how can you accept that you were doing something wrong all these years ?

In the past, these doctors would quote their "extensive personal experience" to justify everything they did. The most popular phrase was - " in my experience". Now that everyone knows how unreliable this can be, they have become much smarter. In that past, they would refuse to publish their research , because they did not want to be challenged. Now they have become even sneakier. They publish their papers in poor quality medical journals which call themselves "peer-reviewed" , but are happy to accept any paper for publication if the author is willing to pay the "publication fee" which they charge. The doctor will often "manufacture" the data ( usually by adding a zero to inflate the numbers of patients they treat, and doubling their success rates) , and then cite their "published research" as proof that their views are valid ! Sadly, predatory medical publishing has become widely prevalent  in India, and it's possible to get any rubbish published today. To add insult to injury, they don't even have to pay  for the publishing, because their friendly pharmaceutical medical representative will pay on their behalf, as part of their " continuing medical education " services to the medical profession! These journals are not even worth the paper they are printed on - but have become extremely popular in the Indian medical community today, because it's so easy to get anything published, and give it the veneer of   respectability !

Fed up of your doctor ordering too many tests ? Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

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