The Patient's Doctor

How much should doctors charge ?

2009-07-03T10:24:00.002+05:30

One of the great mysteries of medicine for patients is why doctors charge what they do. Some are amazed at the fact that bright young doctors are willing to slave for hours for patients whom they do not know, for an income which is not bad , but which is much less than others ( bankers , for example) command. They admire the fact that doctors are willing to work for 24 hours at a stretch ; and to get up at two o'clock in the morning for emergencies. It can be an arduous lifestyle which disrupts both personal and family life - something which it's not possible to compensate for simply by money.

On the other hand, most patients feel that doctors charge too much. They envy the Mercedes many doctors drive ; and the fact that they take Wednesday off for playing golf. Many resent the fact that they have to pay hundreds of dollars for medical procedures which may just take a few minutes.

Also, it’s a well-known fact that the fees charged can vary considerably – not only from doctor to doctor – but from patient to patient as well ! Patients would be much happier if the medical costs were transparent.

The truth is that the amount which doctors charge is often a mystery for doctors themselves. Most doctors are not very good businessman; and fees are usually set for reasons which are beyond their control.

Since they are used to working for free during their the medical training and residency , young doctors often quite uncomfortable collecting fees for their professional services when they first start weighing hundreds of thousands of dollars in debt. Most use market criteria to set their fees – and charge what other doctors are charging. While this is a useful rule of thumb, in many cases it can be too much- while in others it’s too little.

Many, who are idealistic when they are young, charge enough to make a comfortable living , so that they can cover their expenses , and still have enough to keep the family happy. This is easier to do in smaller towns in India for example , but extremely hard to do in the US , where doctors will start their practice often owing hundreds of thousands of dollars in debt to cover their loans to pay for their educational tuition fees.

Other doctors , who are hard-nosed businessman ,take a much more pragmatic viewpoint . They do an informal market survey to study how much patients in their community are willing to pay for their services – and price these accordingly.
Some doctor will deliberately charge a higher fee than the competition. This is especially true for senior doctors , who feel they have earned the additional income because of their experience and expertise. Others do so because they want to create an air of exclusivity about them , because they know that patients often misinterpret high fees as being equal to a better quality of service. After all , if a doctor charges more, it must be because he is better !

This is especially true for fields such as cosmetic surgery, where patients pay directly for their services, and there is intense competition for patients. Some doctors deliberately charge a premium, not just in order to maximize their income , but to convey that they are better than the rest. However, remember that higher is not always better. On the other hand, lower fees are not always a bargain either !

What I doctors who charge less ? Some doctors are financially quite comfortable , and because they have low overheads , they are willing to charge just enough to cover their costs. They charge enough to cover their staff salaries and electricity costs for example , but they often end up underpaying themselves. Ironically, though the doctors charges less because he doesn't need much money to be contented, the disadvantage of charging low fees is it often conveys to patients that the quality of services may not be as good !

This is why it's quite common to see an escalation of prices. Once one doctors increases his fees , the others often have to do so , in order to toe the line. Fortunately , this is true in the other direction as well, and of one doctor drops his prices , many others will do so as well , in order to stay competitive.
In places like the US where third party payers dominate the market, the ability of the doctor to set his own fees is practically zero. He pretty much has to charge what the third party is willing to pay. As medical insurance becomes prevalent in India, this is going to be true here as well , where the insurance companies are soon likely to call the financially shots.

In countries like the UK, which have a nationalized health service, doctors do not have to worry about how much to charge , because this is a decision which is taken out of their hands . For many doctors, this can be a blessing !

While many doctors pride themselves on their professional skills , and take pride in the fact that they couldn't be bothered about money, the fact of the matter remains that medical private practice is also a business , and unless doctor learns how to charge the right amount for his services, he will often end up underpaying himself. In the long run , this may mean that he may not be able to invest in either updating his professional skills or buying state-of-the-art equipment , both of which can lead to poor quality medical care. He will then end up losing his patients to corporate hospitals, which are extremely good at maximizing their profits. Doctors need to find the right balance, so that they can both enjoy their financial income, as well as their emotional income. Earning money is not a sin just because you are a doctor; and if this money is utilized to improve patient care, this is good for everyone involved.

Converting people into patients !

2009-07-02T10:26:00.003+05:30

I recently received this email from an infertile couple. Her gynecologist had recommended a routine vaginal ultrasound scan, which was reported as follows.

Both ovaries are normal in size and shape. There is a well defined hypoechoic cystic lesion in both ovary measuring RT - 11x12.5x10.3 mms with volume 0.7ccs and LT - 12.8x14.3x15.4mms with volume 1.5ccs. It shows marked low level internal echoes and small focal calcification. No evidence of free fluid in pelvic cul-de-sac.Hence bilateral small ovarian lesion -endometrioma.

Their gynecologist had advised them medication to resolve the cyst; and a repeat scan after 6 weeks to confirm the cyst had disappeared.

They wanted a second opinion, as to whether this was good advise.

Please read the report carefully again. Don't worry about the gobbledygook or the medical jargon. My point is that medical scan reports are often deliberately full of this, in order to worry patients and send them scurrying to their doctors. The cyst is about 10 mm in size - this means it's only about 1 cm ! It's extremely small - and the only reason it can be detected is because the ultrasound machines today are high resolution machines, on which the images can be zoomed, till normal anatomical structures can be interpreted as "lesions" which need treatment ! Unfortunately, most people are innumerate ; and not sophisticated in enough to interpret the report. Others trust their doctor blindly - and expect him to do what is needed. This is why George Bernard Shaw said that all professions are a conspiracy against the laity !

The beauty of this scan is that the doctor has done everything by the book ! He has simply reported everything he saw - in excruciating ( and unnecessary ) detail ! So why am I finding fault with him ?

Many reasons ! For one, this report is "pseudo-accurate" ! It's simply impossible to measure structures in terms of 0.1 mm ! While it's possible to position electronic calipers and read off their readout, this simply shows that the doctor is not applying his mind ! This is false accuracy and precision which misleads the patient.

Secondly, the interpretation is highly suspect. The ovary is normally a cystic structure, and this tiny "cyst" could just as well be a normal ovarian follicle, which contains a mature egg , rather than a "lesion".

Thirdly, he has deliberately reported his measurements in mm rather than cm - thus making the "lesion" appear larger. This can mislead poorly informed patients !

So is the radiologist not very bright ? On the contrary - he is very smart - he is a willing accomplice in the game being played by the referring gynecologist !

Doctors often send patients for scans. This is often to rule out problems - and to show patients how careful and thorough they are. Most patients are happy do these scans - after all, what's the risk of doing just a test ?

The trick is that the radiologist then "finds abnormalities" - even though he knows they are of no importance, and may be just normal anatomic variants. The patient reads the report - and then worries because of all the abnormalities which have been picked up. Off he goes back to the gynecologist, for treatment. The doctor is happy to comply , because this means more follow up visits - and additional income !

It's possible to milk this for many months because the new ultrasound machines can pick up tiny fibroids and cysts for practically all women, because these are such common findings ! The woman has now been converted into a patient - and she is now stuck on a game which shuttles her back and forth from radiologist to gynecologist, and it's extremely hard to escape this.

The danger is not just that of the money being wasted on the overdiagnosis and overtreatment - or on the unnecessary anxiety which is created. The bigger risk is that sooner or later some trigger happy gynecologist will decide that the cyst is not responding to medical treatment - and needs to be removed surgically. This unnecessary surgery will actually reduce the woman's fertility - thus making her an infertile patient who will need to come and see me !

I have discussed gynecological scans in this post - but the tragedy is that this charade is played out in practically all fields today !

Why the consultant must take the patient's history himself

2009-07-01T21:21:00.000+05:30

It’s very common these days to find that busy consultants often do not take the patient’s history themselves. Because they are so busy and need to maximize their efficiency , usually the history is taken by an assistant or a nurse. This person has a standard preprinted form ; and asks questions mechanically to ensure that the form is completely filled. The patient then goes with this filled in form to see the consultant; who then proceeds to examine the patient and orders tests.

The advantage of this system is that is maximizes throughput for the consultant, who can then see about 10 patients in an hour. It also ensures that all the information in the form is completely and systematically filled out .

While many consultants will swear by this system because it's one they have used for many years, the sad truth is that this is not the best method for the patient. The quality of the patient's history depends to a large extent on the clinical expertise of the doctor asking the questions - and an experienced clinician is far better at this as compared to a junior doctor or a preprinted form. In fact I feel the distinguishing factor between an experienced doctor and a junior is that a good doctor knows how to take a history ; which questions to ask; and how to interpret these questions . Unfortunately , this is not something which can be taught easily ; and is not efficiently done with the check box system.

This is why in real life , when a patient is referred to a senior consultant, the one thing which this doctor will do ( which was often not done properly before ) is sit down and talk to the patient. Many more puzzling clinical problems are solved by a carefully taken history , rather than by ordering more lab tests or scans.

Not only will taking the history personally improve the care the patient gets, this history taking session is a great opportunity for the consultant to establish rapport with the patient and build trust and confidence in the doctor’s skills. It also gives the clinician a chance to connect with the patient and display empathy and compassion. This can be hard to do nowadays, when clinic visits have to be compressed within 10 minutes. Unfortunately , by not giving patients the time and respect that they deserve, we end up doing everyone a disservice.

Want A Baby? India Beckons by Taru Bahl

2009-06-30T19:41:00.000+05:30

Want A Baby? India Beckons by Taru Bahl: "Audrey and Derek are one of the many childless couples who come to India with the hope of going back home with their very own bundle of joy. Fertility tourism is big business now - the industry reportedly brings in hundreds of millions of dollars into the county. In fact, reports also suggest that the number of such cases has more than doubled in the last three years. The reasons: pocket-friendly treatment, world-class heath care facilities, a large base of English-speaking doctors, relatively fewer legal hurdles... the list is long."

Should doctors be frank and forthright ?

2009-06-29T21:30:00.003+05:30

Everyone agrees doctors need to be honest with their patients, but this is fine only in abstraction. The real question is - how brutally honest do you want your doctor to be when it's you are ill ? This can be a difficult question to answer, not only for patients, but for doctors as well ! Thoughtful doctors do their best to judge how much truth a patient can accept at a given time - and then provide the truth, in a form they feel will be palatable for the patient, in titrated doses.

Let's take a patient who is terminally ill.
When should the doctor tell him ? Tell his relatives ? How should he tell them ?

Good doctors learn how to tell bad news with grace - while others mess this up or delegate this job to their juniors, doing both their patients and themselves a major disservice.

Good doctors tell patients the truth because they respect them and they feel it's in the patient's best interests that he knows the truth. Others will simply follow a "tell the unvarnished truth policy" to protect themselves, because they need to protect themselves from a possible malpractice suit.

And it's not just when patients are terminally ill that doctors face these dilemmas. It can be a problem in all specialties, including IVF. For example, I saw a patient today who has testicular failure and who cannot have a baby with his own sperm. How do I break the news gently to him, without causing him harm or hurt ?
How much truth can he accept ? How do I judge this for each individual patient ?

I don't want to be cruel and take away his hope ? But don't I have a responsibility as a professional to tell him the unvarnished truth ? If I don't he may end up wasting time and money pursuing ineffective treatment from quacks. I agree having to deal with a hopeless situation can be cruel - but false hope can be even crueller. Often it's better to know the truth no matter how bitter it is, so patients can deal with it and move on with their lives. Many of them are much stronger than they realise - and a crisis can be a challenge and an opportunity as well !

My experience with my doctors - a patient's frank and forthright opinion

2009-06-27T20:56:00.001+05:30

This is a guest blog entry from one of my insightful patients. Intelligent feedback like this can help doctors to improve their skills !

My Pulmonologist 1 -
o Non stop talking
o No interest in listening to the patient
o Pre determined on the prescription
o Talking too much medical jargon
o Scaring the patients - if u don’t do as I say “bla bla“
o No greeting/No smile
o As if taking out all his frustrations on the patient
o Over medication for a temporary allergy, sneezing and breathing problem
• My Pulmonologist 2-
o Very good communication, empathetic listening, considering patient history, current ailments and treatments
o Stage by stage treatment according to the severity
o Invest time to listen to patients very cordially and collects all possible information for the treatment.
• My Gynecologist 1
o One of the well knwon consultants
o Consulted with lot of hope
o Never could meet the main Doctor during my 7 visits
o Very rude attitude of the hospital staff and doctors
o Too many people, no communication, no apparent linkage of consultations with the different doctors
o The staff expects the people to know everything from medical terminology to process to procedures
o No language/cultural sensitivity to communicate.
o Important decision without consulting the patient’s opinion
o Unhygienic clinics and scanning centre; scanning is a must every time

• My Gynecologist 2
o Very well behaved and empathetic
o Technical knowledge to use the modern methodologies was lacking and hence ended up in a hasty decision to do laparotomy ( surgery) for my ectopic
• My Gynecologist 3
o Well behaved and empathetic listener
o High use of medical jargon and expects patients to know those words
o No realistic answer to patient queries
o Very expensive
o Good medical staff and very supportive
o First attempt didn’t work out for me.
• My Gynecologist 4
o Well known and acclaimed doctor who is said to have God’s touch
o We went for medical advice and a second opinion before starting the next round of treatment
o Before seeing the doctor, we were advised to take a scan
o The assistant doctors were very rude and unkind and asking do you have “xyz” disease and shouting because I was ignorant about medical jargon
o There was a printed prescription waiting for us when we met the doctor who asked us to take the medicine and advised us to come back after 3 months, if I didn’t get pregnant.
o In our 5 minute consultation the Doctor spent more time making fun of my previous treatments and the procedures my earlier doctors had followed.
o Answers were very point blank and on all my queries, there was no answer except that – “ everything is possible”.
o To our surprise, a very expensive test was prescribed at the end of the consultation. The cost of this ran into 5 digits ! (The relevance of this was very suspicious , since we were told to return to the clinic only after 3 months)
o Patients are taken for granted and expected to obey everyone from staff to the main doctor
o End result : We never felt the need to go back to the clinic

How to be a Successful Doctor- a patient’s perspective

2009-06-26T23:30:00.001+05:30

A Successful Doctor- from a patient’s perspective
Smile
Costs nothing
Increases the emotional bank balance
Gives the care & warmth expected
Smile can cure the anxiety of the patient
Ray of hope radiates from the smile!
Communication Skills
• Effective communication
• Active Listening
• Cultural/Language Sensitivity
• No gender/social bias
• Empathize
• Entrust to speak
• Build the Trust
• Avoid Deliberate Critical Comments
• Be curious
• Avoid Peer criticism
• A good listener truly wants to know the speaker
Counsel
• Focus on mental health rather than just the physical ailment
• Counseling enhances the mental power
• Understand the social and mental stigma
• Do not undervalue the problem with a mechanical cause
• Biological or mechanical reasons are part of treatment procedure
• Counseling kills the ills without the pills
Data Collection
• Listen, listen and listen
• Note down the discussion
• Encourage to reveal rather than perceive
• Patient is the priority
• Do not use medical jargons
• Probe for past history
• Do not expect the patient to be medically savvy
• Every patient is different, only symptoms match
• Key to opening the magic box of information is with you !
What Next?
• Past is past, what is next?
• Prescribe for the patient and ailment
• Educate and explain
• Do not conceal, or presume
• Explain process and procedures
• Do’s and Do not’s in procedure
• Steps to follow
• Cost involved and payment options
• Clarity will make the patient follow your advice
Solution /Treatment
• Every step of treatment should increase the trust
• Treatment procedure and data available to all related staff to avoid misinterpretations
• Educate the team and staff on behavior
• For many patients, their doctor is a savior. Value this !
• Include the patient in major decision making
• Cure= medicine + trust
Be successful to triumph
Your designation doesn’t make you successful, how you follow it matters
Trustworthiness and capability make you a successful doctor
A successful doctor will have high social responsibility
Success is the measure of happy patients

Patient education - a new approach

2009-06-25T09:14:00.003+05:30

Traditionally, patient education has referred to the education of patients by doctors, nurses and other healthcare professionals. This is a a result of the paternalistic medical model in which the doctor was the expert and told the patient what to do. This kind of patient education remains extremely important today, because patients need to learn about their diseases, and doctors are professionals who are experts in anatomy, physiology, pathology and therapeutics.

However, I feel an increasingly important type of patient education will be education by patients, where patients educate doctors ( and other healthcare professsionals) about their illness.

While doctors are disease experts and a know a lot about pathology, the patient is the one who has the illness - and it's the patient who is an expert on himself ! Since he is the one who has to live with the disease 24/7, expert patients are treasure houses of information . In the past, grandmothers were the traditional dispensers of home medical remedies and the court of first resort when any one was sick. Unfortunately, most of this knowledge was either locked up in the expert, who had no effective way of sharing it with others ( except by word of mouth); or this wisdom was undervalued, because the patient was not a doctor and therefore not considered to be an expert.

The good news is that it's become much easier for expert patients to share their expertise. For one, doctors have learned to value the contribution of the patient and they respect the central role patients play in managing their own disease and in getting better. Equally importantly, the internet provides a great tool which allows patients to share their wisdom !

How can expert patients educate doctors ? Some steps are simple. They can provide feedback about the medical services and facilities on offer, so that doctors can improve their clinics. After all, how will doctors improve if patients don't tell them what they want ?

Patients can be one of the best sources of CME, or continuing medical education for the doctor. They can offer to share what they have learnt about their disease . Patients have a lot more time to research the internet about their medical problems; and with the help of a doctor, patients can often do a much better job in finding out about new advances. This could include locating clinical trials; experimental drugs; or getting in touch with the world authority on a particular medical topic.

Observant patients provide feedback about what the effects of the medical intervention have been. Medicine is an inexact science - and telling the doctor about what works and what does not is extremely valuable. It's only when an empathetic reseacher observed that patients who were enrolled in a clinical trial of viagra ( for treating their hair loss) refused to return their surplus medications that he realised that the viagra was helping them improve their sexual life - and a billion dollar block buster was born - thanks to observant patients - and an observant doctor !

Good doctors have always known that patients are their best teachers. Traditionally, expert doctors ( for example, professors in medical schools) learnt from their patients and then shared this knowledge with other doctors by publishing the results of their research ( in the form of case
studies or controlled trials) in medical journals. Even today, a good doctor knows that every patient has something valuable to teach. After all, biology is an inexact science, and life is full of surprises and twists. Senior doctors learn to value the exceptional patient and the unusual one, because of what they can learn from them.

Sadly, some doctors still feel threatened by the well-informed patient. These are typically doctors who have low self-esteem; or whose knowledgebase has become outdated because they do not have time to keep up with medical advances.

Good patients will not only spend time in educating their doctor, they will also spend a lot of time educating other patients. Patient education of patients by patients if often far more affective and useful, because it's peer to peer ! Patients speak the same language; share the same concerns; and establishing rapport is muc easier, because they have "been there, done that !"

All of us are going to be patients some day; and illness is a fact of life. We all learn to live with our illness - and the smarter and more enlightened amongst us realise that one of the best ways of coping with this crisis is by helping others. Expert patients are generous with their expertise and knowledge - and use this to help others. This could be simply by publishing a blog, to help others with practical tips ; and to provide emotional support, so that they know are not alone in their struggles. Other patients are more ambitious and will start support groups; or publish a book; or even raise funds for patient advocacy and medical research.

You cannot choose your illness. But how you battle it is in your hands ! Learn to share - this is good for you - and for others as well !

Communicating With Cancer Patients: When the News Is Bad

2009-06-24T20:25:00.000+05:30

Communicating With Cancer Patients: When the News Is Bad: "The SPIKES protocol represents a series of steps for giving bad news. They represent a consensus of what is in the literature with regard to best practices when one has to talk about a very, very difficult bad-news situation to a patient. It's more of a guideline for clinicians as to how they might proceed, in the same way doctors learn how to complete the necessary steps to do a spinal tap, for example, and do it correctly, and to complete it in a way that's safe for the patient. So SPIKES is a series of steps that represent one approach to giving bad news."

It's always hard to break bad news. This useful protocol helps doctors to prepare before talking to patients and their family - and helps them to do a good job !

Patient-Doctor Communication | ICARE Videos - MD Anderson Cancer Center

2009-06-24T20:21:00.000+05:30

Patient-Doctor Communication | ICARE Videos - MD Anderson Cancer Center: " Doctors need to learn how to talk to patients. This free Video Library of Clinical Communication Skills has videos designed to help you learn and teach communication skills. This section contains video scenarios of patient-doctor communication that demonstrate the use of basic principles and advanced communication strategies exemplified in a number of situations oncologists commonly encounter: telling a patient he or she has cancer, or that it has recurred, that a medical error has been made, that it's time to transition to supportive care...and more."

Why don't Indian doctors keep upto date ?

2009-06-24T13:42:00.002+05:30

Doctors need to remain uptodate with the medical literature. Their professional knowledgebase is their biggest asset, and as medical science advances, they need to keep up with these advances.

The sad truth is that most doctors know the most medical science when they sit for their postgraduate examinations. Once they start practise, their knowledge becomes outdated quickly because they just do not have the time to keep up. Their medical textbooks get outdated very quickly – and very few subscribe to medical journals, because these are so expensive !

Most depend upon colleagues and consultants for specialist advise when they encounter a patient with a rare or complex problem.Some attend medical conferences for CMEs ( continuing medical education), to overcome this lacuna. For the vast majority ( especially in smaller towns) , the only source of medical knowledge is the "friendly medical representative" . Sadly, all these are very unreliable means of remaining well-informed – as a result of which they often become outdated very soon.

While it's possible to practise medicine based on 10 year old medical text books, the quality of this practise leaves a lot to be desired. This is why many doctors are insecure; and they often end up losing their patients to well-equipped specialists in corporate hospitals.

Not only is this bad for a doctor’s self-esteem, this can prove to be embarrassing when patients with internet printouts know more about their disease than the doctor does !

Also, this failure of the doctor to update himself with the latest medical knowledge can result is lawsuits for medical negligence – the doctor’s biggest nightmare.

It's not that Indian doctors are lazy or don't want to keep up with recent advances - it's just that it's very hard for them to do so ! Not only are medical books and journals exorbitantly expensive, most of them simply do not have access to a well-equipped medical library.

While some doctors do try to use the internet to keep updated, the sad truth is there is very little high quality medical information available on the net !

The good news is that now for less than Rs 30 per day, Indian doctors can subscribe to the world's largest online medical library, at www.mdconsult.com ! MDConsult allows doctors to remain uptodate by providing online instant access to the FULL-TEXT of over 40 respected medical books and 50 prestigious medical journals which are constantly updated. This means they will never need to buy another medical book in their life !

MDConsult provides convenience and peace of mind – at the doctor’s desktop - for only Rs 9995 per year !

They can also try out a risk-free 30 day demo – free of charge !

To subscribe, please contact: HELP - Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400 001
Tel. No.: 65952393/ 65952394/22061101
helplib@vsnl.com
www.healthlibrary.com

Baby Chase - Chapter 2

2009-06-24T13:09:00.000+05:30

Open publication - Free publishing - More infertility

Baby Chase - Chapter 1

2009-06-20T17:42:00.001+05:30

This is the first chapter of our new comic book, Baby Chase, which is the story of a couple trying to have a baby. In Charles Dicken's style, we'll be uploading the book a chapter at a time - stay tuned ! Feedback is always welcome !

Open publication - Free publishing - More infertility

Physicians Practice Articles : Smart Patient ID Cards Could Save You Money

2009-06-20T17:41:00.000+05:30

Physicians Practice Articles : Smart Patient ID Cards Could Save You Money: " Would you like to get paid faster and devote less staff time to billing and collections? Both goals could be achieved if you had a better method of checking the insurance eligibility of patients and of estimating their financial responsibility. The key to doing that — and to eliminating repetitive, error-prone front-desk work — might be a “smart” patient ID card.

The Medical Group Management Association is promoting the use of these smart cards through its new Project SwipeIT. The association aims to persuade payers, software vendors, and practices to “initiate processes to adopt standardized, machine-readable patient ID cards by Jan. 1, 2010.”"

Egg donation vs Embryo adoption

2009-06-16T21:53:00.002+05:30

Thanks to recent advances in reproductive technology, infertile couples have many options to help them build their family. While it's great to have so many choices, the fact is that making a decision as to which choice is right for them can be challenging, and many couples get confused. The choices offered using third party reproduction are especially perplexing, partly because they involve questions of genetic continuity - an issue which can raise a lot of debate and soul-searching.

Patients with ovarian failure now have 2 options: donor egg IVF
( www.drmalpani.com/donoregg.htm) or
embryo adoption ( www.drmalpani.com/embryoadoption.htm).

Many patients find it difficult to decide between egg donation and embryo adoption. The treatment plan is similar and the pregnancy rate with both options is equally high - about 50% per cycle. However, each has its pros and cons.

Embryo adoption is less expensive ; and easier to do because we are using frozen embryos. There is no waiting list involved and the treatment can be done whenever you are ready. However, both the eggs and sperm will be coming from unknown young people, so you will be providing no genetic contribution to the baby.

Egg donation is more expensive; and it takes us 2-3 months to arrange this, as we need to find an egg donor for you; to synchronise her cycle with yours; and to superovulate her for you. With egg donation, the sperm used will be yours.

In summary, if providing your genetic contribution is important, then egg donation is a better idea. If not, then embryo adoption is better.

Tests prior to IVF

2009-06-16T17:41:00.002+05:30

If you need IVF treatment in order to get pregnant, we will need to do certain tests to determine:

1. If we can do IVF for you

2. What kind of IVF treatment would be best for you ( IVF ? ICSI ? ZIFT ? donor eggs ?)

3. What your chances of success will be

Many clinics order a huge battery of tests routinely before starting IVF treatment. They use a mindless checklist approach – which can drain quite a bit of blood – and money ! Many of these tests are pointless, because they provide little useful information. However, this seems to be the norm, especially in large IVF centers ( which are run as mills and employ a huge number of doctors); as well as in the US, where testing is often done for non-medical reasons.

We prefer taking a simplified, patient-friendly approach by focusing on what is medially important. We customize this testing, depending upon the patient. In order to do IVF, remember that we only need to check the following: eggs; sperm; uterus and tubes.

We usually do just the following simple medical tests before starting an IVF cycle. If the tests have been done in the past one year, there is no need to repeat them.

For the husband, all we need is a simple semen analysis ( www.drmalpani.com/semen-analysis.htm) , to check sperm count , motility and morphology.

a. If it’s normal, then we plan to do IVF.

b. If it’s abnormal, then we plan to do ICSI. If there is an element of doubt ( for example, if the counts vary a lot), then ICSI is a safer option, as fertilization is guaranteed

c. If it’s zero, then we need to consider sperm retrieval through TESE or PESA

The wife needs more extensive testing.

1. blood tests for the following reproductive hormones : FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of the eggs). This needs to be done from a reliable lab such as Specialty Ranbaxy ( www.srl.in). If these tests are normal, then the standard superovulation regimen can be followed . However, if there is a problem, then this will need to be corrected.

a. A high prolactin ( www.drmalpani.com/prolactin.htm) can be corrected by treatment with bromocriptine or cabergoline

b. Abnormal thyroid levels ( www.drmalpani.com/thyroid.htm) can be treated with medications

c. An abnormal LH:FSH ratio suggests PCOD. This may need to be corrected with metformin prior to starting IVF. Also, the superovulation will need to be gentler

d. A high FSH level or a high FSH:LH level suggests poor ovarian reserve. This means that the response to superovulation may be poor and reduces the success rate. Poor ovarian reserve ( www.drmalpani.com/oopause.htm) . Additional testing may be needed, such as a clomid challenge test; tests for AMH ( anti-mullerian hormone levels) and an antral follicle count. Options may include trying to improve ovarian reserve with empirical treatment and using more aggressive superovulation for IVF. An alternative would be to consider donor eggs or donor embryos

2 . a HSG ( hysterosalpingogram, X-ray of the uterus and tubes) on Day 8 of the cycle ( to confirm the uterine cavity is normal and the fallopian tubes are open. You can read about this at www.drmalpani.com/hsg.htm. An HSG can be painful and this is not always essential prior to doing IVF. However, it is a very good way of documenting that the uterine cavity is anatomically normal ( especially in towns with poor medical facilities). Alternatives to HSG include vaginal ultrasound scanning , but this should be high quality. If the HSG is normal and the fallopian tubes are normal, then an additional treatment option which can be offered is ZIFT ( www.drmalpani.com/zift.htm), where the embryos can be transferred directly into the fallopian tubes, instead of the uterine cavity, to improve the chances of implantation.

3. a vaginal ultrasound scan on Day 10 or 11 , which should check for the following.

a. ovarian volume

b. antral follicle count

c. uterus morphology

d. endometrial thickness and texture

Because ultrasound interpretation is so subjective, it’s important to do this at a good quality center. The better centers have digital ultrasound machines, which allow them to give you the scans as a jpeg file which you can save on a DVD or a flash drive.

In case there is an abnormality, then newer ultrasound techniques, such as 3-D vaginal ultrasound provide more information. If there is a polyp, then this will need to be removed by doing a hysteroscopy. Intramural fibroids ( in the wall of the uterus) do not need to be removed prior to IVF, as they do not affect embryo implantation. You can read more about this at http://www.drmalpani.com/fibroids-and-infertility.htm. Submucous fibroids ( which are in the uterine cavity) need to be removed. These can be best removed with an operative hysteroscopy ( www.drmalpani.com/hysteroscopy.htm).

You should always insist on a copy of all your medical records.

What other tests are needed ? All clinics will also test you for infectious diseases, such as HIV, Hep B and VDRL. Other tests include checking your rubella immunity, in case you have not been vaccinated against rubella. If the test show there is a problem, then this can be treated prior to starting IVF!

Other clinics will perform much more extensive testing. These include tests for esoteric conditions such as: immune testing; testing for TB ( including blood tests for TB antibodies and PCR on an endometrial biopsy) ; routine hysteroscopy to check the uterine cavity; and TORCH tests.

Many patients are very impressed by doctors who order so many tests. They feel these doctors are very careful and thorough ! However, the truth is that most of these tests are pointless and just waste time and money. Before doing all these tests, just ask your doctor one simple question – How will the results of this test change my IVF treatment ? Remember, that if the result of the test will not change your treatment, then there’s no point in doing the test !

A fun way to learn more about IVF ! The world's first e-learning course on IVF

2009-06-12T12:53:00.002+05:30

Patients know that knowledge is power - and this is especially true when you are infertile and are considering IVF treatment, which can be expensive and time consuming.

What are the risks of IVF ?
Is IVF the right option for you ?
Which is the best doctor ?

However, reading can be very boring - and many couples find it difficult to absorb and assimilate the information they are bombarded with.

We have developed an interesting way of learning everything you want to know about IVF at
http://www.ivfindia.com/IVF/IVF.htm. This is free.

This is the world's first e-learning course on IVF , and feedback is welcome, so we can improve it !

Become a well-informed patient, so you get the best possible medical care !

How smart patients use youtube

2009-06-09T21:26:00.003+05:30

I am always impressed by how clever patients can be when trying to solve their medical problems.

I recently received an email from a patient who had had a hysteroscopy. This is a procedure where the doctor inserts a fine telescope inside the uterine cavity, to confirm the uterine lining is normal. She was not happy with her doctor's interpretation of the findings, and wanted me to review the video. I was happy to do this - but she wasn't sure how to send the video file to me. It was too big for an email attachment - so she uploaded it to youtube , and sent me the link, so I could look at the video. I was happy to reassure her that the hysteroscopy confirmed her uterine lining was normal !

Minimally invasive surgery has changed the practise of medicine - and endoscopy is now routine is many fields of medicine. The findings are documented as digital videos, which doctors can review when creating a treatment plan. Youtube can be a great way for doctors and patients to share medical videos inexpensively and efficiently !

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

2009-06-08T00:02:00.000+05:30

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker: "The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine. This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse.

A few doctors took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."

Should doctors pay for patient referrals ?

2009-06-05T11:13:00.004+05:30

Reproductive tourism has become very popular, and lots of patients now travel to India for IVF treatment. This is a very competitive field, and there are many IVF clinics in India today.

In order to facilitate travel for patients who come from other countries to India, many medical tourism companies have been established. They help patients to identify a good clinic and assist them with their paperwork and travel. This is a useful service, as it helps patients who are not comfortable with travelling to India with a lot of peace of mind, as they have a "local person" they can talk to.

Many of these companies approach us, and expect to be paid a commission for referring patients to us. This is not something I am comfortable doing, so we have refused to do so. While I am quite happy with their charging patients for the services they provide to them, I am not comfortable about their lack of transparency ; and that patients are not aware that these companies are taking a portion of the medical fees. Isn't this simliar to giving a cut or kickback ?

However, this means we are losing patients to competing IVF clinics who are happy to pay these commissions. Are we being stupid ? Is there anything wrong in giving these companies a
" service fee " or "facilitator fee" ?

Are Indians racist ?

2009-06-05T10:23:00.002+05:30

I think the answer to this question is - Yes ! It's not so much the negative racism which we read so much about in Australia ( where Indians are being beaten up because they are not white). It's a "reverse racism" where we look up to white-skinned people, because they are white - skinned . For example, Indian patients still feel the best medical care is available at Mayo Clinic because it is in the US ! Similarly, Indian doctors prefer publishing their articles in prestigious journals ( read - journals published in the West) as compared to Indian journals. I guess it takes a long time for centuries of colonial subjugation to get this out of our system !

Thousands of women leaving UK for fertility treatment | Society | The Guardian

2009-06-04T21:07:00.000+05:30

Thousands of women leaving UK for fertility treatment | Society | The Guardian: "Thousands of British women desperate to have a child are going abroad every year to have fertility treatment in order to avoid NHS waiting lists and a shortage of donated eggs.

The numbers are increasing because foreign clinics cost less than British ones, treatment is available within weeks and more older women are seeking to become mothers when their fertility is declining."

A comic book guide to How to get the best medical care -

2009-05-15T18:41:00.001+05:30

Open publication - Free publishing - More patient

The surrogacy racket

2009-05-07T11:29:00.002+05:30

It's amazingly easy to fool infertile couples - especially those who are
desperate , and are clutching at straws. An excellent example is what some IVF clinics in India who offer surrogacy do.

Even though these clinics know that there is no legal method of allowing the couple to take the baby after birth with them out of India ( because Indian law only recognises the birth mother, whose name must go on the child's birth certificate, which is a legal document), they use the garb of the " ICMR guidelines" ( which have no legal validity whatsoever) to put the intended parent's ( the infertile couple's) name on the child's birth certificate. While one may justify doing this for various reasons, the fact remains that the truth is being distorted out of shape - and once you are willing to do this, it's very easy to continue the distortion even further. This is why these clinics refuse to allow the surrogate to give interviews to the media .

So how come so many couples continue to come to India for surrogacy ? The fact is that infertile couples are desperate, and because surrogacy is so much cheaper in India, they are happy to be party to this deception . The problem is that if the doctor can put a false name on the birth certificate, he can also lie to the intended parents.

A common racket is to tell the infertile couple that the surrogate got pregnant after the embryo transfer ; to collect the fees; and then to tell the infertile couple ( who is most probably in the US or UK and has no method of monitoring the surrogate's pregnancy, which means they have to rely completely on the doctor's integrity) that she miscarried at 8 weeks !

Unfortunately, there's no way to track how many of these " surrogate pregnancies" miscarry - which means that infertile couples are completely at the doctor's mercy - and some doctors will take undue advantage of this trust.

It's hard to place your trust in someone whom you know is not being completely honest. If the doctor can put a false name on the birth certificate ( and thus lie to the Government), what's to stop him from lying to the infertile couple ?

Open-Source EHR Systems for Ambulatory Care: A Market Assessment - CHCF.org

2009-05-07T01:10:00.000+05:30

Open-Source EHR Systems for Ambulatory Care: A Market Assessment - CHCF.org: " Open-source electronic health record (EHR) systems have proliferated in recent years. This executive summary presents the findings from an evaluation designed to determine whether these systems, commonly referred to as free and open-source software (FOSS), are suitable for ambulatory EHRs.

The authors investigated a number of FOSS EHR projects to assess their organizational structures, development communities, functional capabilities, and available implementation and support services. The evaluation also analyzed the potential advantages of FOSS EHR systems for physician practices, as well as the limitations and general challenges of this alternative approach to acquiring clinical information technology."