Dr.Malpani's Blog

How Information Therapy can help patients to become experts !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 23 May 2012 03:12:00 +0000

Information Therapy - Helping Patients Play An Active Role In Their Treatment !

Traditionally, Indian patients were passive and were quite happy to leave all medicaldecisions to the doctor.

However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor.
This is a huge challenge -- and a great opportunity as well. We feel patients are the largest untapped healthcare resource and that Information Therapy is Powerful Medicine !

Using Information Therapy to create patient delight !

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 22 May 2012 03:11:00 +0000

Information Therapy - Dr.Do'Little' v/s Dr.Do'More'

Information Therapy - makes all the difference... between an ordinary practice and a thriving practice !

Traditionally, Indian patients were passive and were quite happy to leave all medicaldecisions to the doctor.

However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor.
This is a huge challenge -- and a great opportunity as well. We feel patients are the largest untapped healthcare resource and that Information Therapy is Powerful Medicine !

How Information Therapy can help you make sense of health news

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 21 May 2012 03:10:00 +0000

Information Therapy - Senseless Sensationalism

Information Therapy - Helping people make sense of sensationalism !

Traditionally, Indian patients were passive and were quite happy to leave all medicaldecisions to the doctor.

However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor.

This is a huge challenge -- and a great opportunity as well. We feel patients are the largest untapped healthcare resource and that Information Therapy is Powerful Medicine !

Information Therapy for the GP

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 19 May 2012 03:09:00 +0000

Information Therapy - General Practioner

Feel the need to refer every patient to specialists ? Information Therapy helps doctors enhance their medical knowledge !

Traditionally, Indian patients were passive and were quite happy to leave all medical decisions to the doctor.

However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor.

This is a huge challenge -- and a great opportunity as well. We feel patients are the largest untapped healthcare resource and that Information Therapy is Powerful Medicine !

WHO Bulletin on E-health

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 18 May 2012 03:05:00 +0000

The newest issue of the WHO Bulletin is on e-health. This is an interesting issue , but what I found very disappointing is that there was not one single article written by a patient !

E-health , if used properly, can allow us to put patients first – and this is the major reason why I am so hopeful about it. Top-down approaches are doomed to fail - and while there are a lot of pilot projects which do well, the key is to get them to scale up and become sustainable.

This is where entrepreneurship comes into play. Clever Indian entrepreneurs will start companies which develop products for patients and doctors. Those which are useful will grow and multiply – while the others will die.

Innovation will be the key to success here. We need to change the entire ecosystem – and the key is to get doctors online. Once the doctors come online, everyone else will follow !

It’s hard to get doctors to change, so the key is to give them their own personal website. Because this is useful for them , doctors will be happy to make the shift to a digital e-practise !

This is the big picture , as I see it.

1. Every patient will have their own PHR ( personal health url) on the cloud and on their Aadhar UID.They will do this because their doctor prescribes it !

2. Their doctor will prescribe a PHR because it makes him more productive ( and increases his efficiency and income) . PHRs will be an integral part of the doctor's website's patient portal.

3. Information therapy can then be tailored to the patient’s needs , based on his PHR

4. Patients can interact online, using social media

Who will provide all the pieces of the puzzle ? Startups ? Tomorrow’s googles ? Today’s facebooks ? Health insurance companies ? The government ? I think all of these have a role to play – but only time will tell how this will play out.

The major advantage India has is that we have no legacy issues, so we can leapfrog and beat the rest of the world. We are renowned for our frugality and our IT expertise – and we can leverage these to come up with clever solutions !

Why do I fire patients ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 17 May 2012 02:58:00 +0000

I enjoy taking care of patients and do my best in order to help them to have a baby. However, there are times when I will criticize my patients. Now I know that this is not something which many doctors commonly do and I would like to explain why I do this.

Whenever I see a patient for the first time, I ask them to interpret their own reports. This gives me a good sense of how much the patient understands about their medical problem and the treatment options. However, many times patients look completely blank and are not able to provide a satisfactory answer. In fact, some of them are completely nonplussed as to why a doctor should be asking the patient these questions. After all , isn't it the doctor’s job to interpret the test reports? Why should a patient be doing this? Are patients even allowed to be doing this ? And does the fact that the doctor is asking the patient to interpret his reports mean that the doctor is clueless and does not know how to do this himself? Could this possibly be the sign of an incompetent doctor ?

Before I start advising my patients, I first need to understand exactly what they understand about their own problem , which is why I ask them these basic questions. However, when they are completely clueless, I do get a little upset because I am concerned that they have spent such little time and energy on trying to make sense of their own problem.

I don't think it's a good idea when patients refuse to apply their own intelligence to solving their own problem . I'm worried about patients who want to leave everything up to the doctor rather than provide intelligent personal inputs.

It is especially when patients justify their ignorance by telling me – “ But how am I supposed to know the answers to these questions “ or , equally commonly , “ My doctor is to blame because he never gave me any of the reports of my IVF treatment cycle “ that I get even more agitated. While it's true that if a patient who cannot understand his medical reports suggests a patient who has received poor medical care ( because his doctor has not bothered to explain the details to him ), it is also equally true that this reflects badly on the patient himself , because he has not taken the time and trouble to do his homework himself. In this day and age, there is no good excuse for an educated patient not to understand more about his medical treatment , because there is so much information online , which is reliable , updated and easy to understand.

When this happens the first time , I am critical, but I do explain to the patient why it's important that they take an active interest in their treatment. I tell them that it is in their best interests ( as well as mine ) , because this ensures they have realistic expectations of exactly what I can do for them.

Patients are not used to being criticized by their doctor on the first consultation, because the doctor is usually on his best behavior at this time, because he wants the patient to come to him for treatment. Intelligent patients understand that I'm doing this in their best interests , so that going forward, we can create a win-win partnership to maximize their chances of success. However, there are some patients who get quite irritated with my criticism and decide that I'm not the right doctor for them. These are patients who decide not to come to me , and find another doctor.

So if I know that my being critical will cause me to lose patients , am I being smart in continuing to do so? Aren’t I being stupid ? Isn’t it better for me to be sweet so that I can get more
patients ?

I think doctors get the patients they deserve and patients get the doctors they deserve as well. The chemistry between the doctor and the patient needs to be right , and I prefer treating patients who take an active interest in their treatment and are well-informed , rather than those who couldn't be bothered to do so . This allows me to focus my energies on patients who understand the importance of information therapy , and have the same philosophy as I have. Since I have the luxury of being able to pick and choose my patients, I feel this strategy works well !

Movie triggers spurts in sperm donors

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 16 May 2012 03:12:00 +0000

You have to admire how clever newspaper headline writers can be !

Times of India interview with Dr Malpani about donor sperm

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 15 May 2012 09:28:00 +0000

Information Therapy - Pampering Patients

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 15 May 2012 07:07:00 +0000

Information Therapy - Pampering Patients

Information Therapy - Helps put patients' doubts to rest...even before a consultation!

Traditionally, Indian patients were passive and were quite happy to leave all medicaldecisions to the doctor.

However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor.

This is a huge challenge -- and a great opportunity as well. We feel patients are the largest untapped healthcare resource and that Information Therapy is Powerful Medicine !

Article on sperm donation in Bombay Times

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 15 May 2012 03:14:00 +0000

Sperm donation - interview in the Hindustan Times

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 14 May 2012 03:10:00 +0000

Dropping sperm counts - Times of India article with Dr Anjali Malpani

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 12 May 2012 03:08:00 +0000

Times of India article - How advances in IVF have reduced the need for donor sperm

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 11 May 2012 03:03:00 +0000

This is an article from the Times of India, Crest edition, which has an interview with Dr Anjali Malpani.

The drugs scam in India - and how to fix the problem

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 10 May 2012 08:27:00 +0000

The Times of India front page article today describes the unholy nexus between the pharmaceutical industry and doctors in India.

This is an other nail in the coffin of the Indian medical profession. The reputation of doctors is now in tatters; and it's getting increasingly hard for patients to trust their doctors. It seems that all doctors are "on the take" - whether it's "gifts" from the pharmaceutical industry; or "kickbacks" from specialists, hospitals or diagnostic center for referring a patient to them.

It all seems to be gloom and doom right now. However, we do need to remember that this is a situation which is not unique to India. This kind of malpractise has been documented in the US for many years - and there have been some great books which have been written about this. One I particularly like is - On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health.

Every crisis is actually an opportunity - and this is actually a great chance for doctors to cleanse the corruption and reinvent the medical profession. When a scam is unearthed, it's usually the doctors who suffer. The pharmaceutical company has deep pockets, and can hire the best lawyers to stay out of trouble. However, individual doctors are defenceless - and will often end up losing their reputation - and even their medical license to practise medicine.

While there are a number of guidelines and laws which are supposed to prevent pharmaceutical companies from providing gifts to doctors , the fact still remains that most of these are observed in the breach. This is an unhappy situation - and it's ultimately patients who will get hurt.

What can we do to fix the problem ? There's little point in moaning about falling ethical standards in society - we need to come up with concrete practical solutions. Pontificating will not help.

Let's start with the basics. The only reason doctors accept gifts from pharmaceutical companies is financial - doctors are human, just like the politicians and policemen who take bribes are . Just because doctors are professionals does not mean that they are "above it all". To expect them to behave as superhumans is unrealistic. The best solution is to make sure that doctors are remunerate adequately by their patients, so that they do not need to resort to accepting underhand payments.

Now I am not saying that we need to make sure that all doctors become millionaires All we need to do is to empower doctors with practise management solutions, so they can run their medical practise profitably . If they can do so, no doctor in their right mind will resort to dodgy means to make a living - doctors are smart enough to realise that there is too much at stake for them if they try to do so.

We need to make it easy for doctors to get patients directly, so they do not need to pay a middleman. Remember that it's only a hungry person who will steal food - a well-fed person will never feel the need to do so !

The best way to do so it to ensure that every doctor has their own website. There are millions of patients online, who are seeking medical care. If every doctor had their own website, it would make it much easier for patients to find them. Websites will encourage transparency and openness - thus benefitting doctors and patients.

These websites can be helpful for pharmaceutical companies as well . It would allow them to stay in touch with doctors electronically - and this is much less expensive that using medical representatives ! Even better, since all communication between the doctor and the pharmaceutical company is now documented, the scope for hanky-panky is considerably reduced !

Games gynecologists and infertility specialists play

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 10 May 2012 03:19:00 +0000

Ideally, the relationship between your gynecologist and infertility specialist should be a synergistic one. Your gynecologist should be your first point of contact ; and she should do your basic tests , so that she can establish a diagnosis and formulate a treatment plan . If it's a simple problem, she should be able to initiate treatment as well ; and make a decision as to when you need a referral to an infertility specialist.

The infertility specialist would treat you; and when you got pregnant , would refer you back to your gynecologist , who would provide you with antenatal care during your pregnancy. In an optimal world, this would be a well oiled machinery , where infertile patients with simple problems can be treated cost effectively by the gynecologist, without having to be referred to an infertility specialist; whereas those who had complicated problems would be referred on straightaway to a specialist, without having to waste time with potentially ineffective treatment with the gynecologist.

However the real world is much messier , and the problem can actually cut both ways. Sometimes gynecologists are reluctant to refer patients onto infertility specialists, because they do not want to lose their patients. This is because many infertility specialists will also deliver babies; and when their patients get pregnant, they will hold on to them and provide them with care during their pregnancy as well, rather than send them back to their gynecologist. This is not an optimal use of resources and medical expertise.

The flip side can be equally bad. Sometimes the relationship between the gynecologist and infertility specialist can get to be too cozy – especially when they work together in the same hospital. Each of them cross refers patients to each other , so that they both end up doing too many unnecessary procedures.

Thus , a lot of IVF specialists , before doing an IVF cycle , will routinely refer their patient to a gynecologist , and will ask them to do a hysteroscopy and/or laparoscopy for them. The purported reason for this is to optimize the endometrial cavity , in order to enhance embryo implantation. This is often done by doing a procedure called metroplasty, which is supposed to increase the capacity of the uterine cavity. This is a procedure which seems to be performed only in India ; and there is no evidence that it actually helps fertility rates at all. After all , the shape of the endometrial cavity has very little bearing on the fertility potential of the woman ; and there are a lot of normal anatomic variants within the fertile population as well. However, when an infertility specialist sees these normal anatomic variants in an infertile women, they tend to over treat them, and refer them to endoscopic surgeons to do procedures which not only are not helpful , but can actually be harmful . They may end up causing scarring and adhesions, and actually reduce the endometrial receptivity.

IVF specialists will also often refer patients prior to IVF for laparoscopy procedures- for example , patients with endometriosis. The rationale for this is that endometriosis can interfere with embryo implantation and that therefore it's best removed prior to the IVF cycle. However, there is no evidence for this , and unnecessary surgical procedures can actually end up reducing ovarian reserve and causing a drop in the IVF success rates.

One of the reasons for this business of excessive referrals is that doctors will often want to maintain collegial relationships amongst each other - it's the “ you scratch my back and I'll scratch yours “ reciprocity principle in play. When an IVF specialist refers his patients to a gynecologist for endoscopy procedures , it's highly likely that this gynecologist will then in turn refer his complicated infertility problem patients back to the IVF specialist. While this back and forth referral will help to increase volumes for both of them, it is unfortunately not in the patient's best interests.

The only solution is that patients need to educate and inform themselves ; and if they immunize themselves with information therapy , they can ensure they are not subjected to unnecessary procedures.

When your gynecologist can be a threat to your infertility

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 09 May 2012 03:16:00 +0000

Gynecologists are trained to provide healthcare for women and are usually the primary care physicians for most women. When a couple has a fertility problem , it's usually the woman who seeks medical advice , and her first point of contact is usually her gynecologist. Gynecologists are trained to do a basic infertility workup and to treat simple infertility problems , so that they can make the right diagnosis and institute treatment is appropriate. While most gynecologists will do a good job with handling simple infertility problems, the truth is that sometimes your gynecologist can actually prove to be an impediment in your quest have a baby.

This is because gynecologists often do not have any special interest , training or experience in taking care of infertile women. This is why they often cannot provide a well-defined treatment protocol, as a result of which they often end up doing treatment on an ad hoc basis every month, which wastes a lot of time.

Thus, most gynecologists have no idea what to do in case the man has a problem. The knee-jerk response is to refer the man to an andrologist , but this then means that care starts getting fragmented, as a result of which the treatment of the infertile couple gets compromised.
Sadly, most gynecologists are not very efficient in taking care of the older infertile woman. Because they're so used to delivering babies , and since they see older women who get pregnant in their own bedroom all the time , they often do not realize the deleterious effect which the passage of time can have on the ovarian reserve of the older infertile woman . As a result of this blond spot, they will often Institute ineffective treatment options such as clomid for ovulation induction or IUI for older women, thus causing them to lose valuable time , which can never be replaced.

Some gynecologists are still quite reluctant to refer patients for IVF to infertility specialists because they want to retain control over the treatment of what they consider to be their patient. This is why they will often repeat the same treatment ad nauseum, even when these have no therapeutic benefit whatsoever. Many of them will insist that the patient remove small fibroids or small endometriotic cysts – even though this surgery does not improve fertility - and can actually reduce it, by creating adhesions and reducing ovarian reserve.

Few doctors today do D&Cs for infertile women - but older gynecologists still resort to obsolete procedures such as hydrotubation to “open blocked tubes”. This just wastes time ! Even worse, the patient starts losing confidence in doctors – and just gives up on infertility treatment all together , because they are fed up; and have run out of time, patience and money !

Even worse when a new patient comes to them, even if the patient has received treatment from another gynecologist , they will often end up repeating the laparoscopy or repeating the IUI treatments, even though there is no logical basis to doing so.

Gynecologists don't have a holistic perspective when dealing with the infertile couple. They don't have any training in handling the infertile man with an abnormal sperm count; and they tend to underestimate the emotional consequences of infertility. They will often adopt an ultra conservative approach to these women, which can end up harming their fertility potential.
This often means that the poor patient just gets plain fed up of the same tired ineffective treatment options - and will then seek out an IVF specialist, because she wants to move on with her treatment. However, the waste of time is irretrievable , and often results in older women losing their best shot at getting the right infertility treatment for themselves.

Overtesting and overtreatment by IVF specialists

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 08 May 2012 03:17:00 +0000

I just received this e-mail from patient. He was looking for IVF treatment, and had been requested to do the following panel of tests by another IVF clinic , before going for a consultation.

For your wife,
-AMH
-FSH done on day 1 or 2 of menses
-TSH
-Prolactin
-Thyroid peroxidase antibody
-Anti-thyroglobulin antibody
-Vit D 25 Dihydroxy
-Fasting and 2 hours post lunch blood sugar
-Karyotype
-Trans vaginal pelvic USG between day 10-14 of menses.

For yourself,
-Karyotype
-Semen analysis

Seeing this long list of tests made me cringe. Not only are some of these tests extremely expensive , a lot of them provide information which is of absolutely no use in diagnosing or treating infertile couples.

Unfortunately, this seems to have become the typical practice pattern for most medical specialists today. Rather than talking with the patient or using their clinical judgment, they prefer ordering a boatload of tests , and then start focusing their energies on treating the abnormalities these reports generate, rather than treating the patient.

All this over testing does not help with increasing success rates. Over testing just leads to overtreatment and a waste of time and money. It is a mathematical certainty that the more the tests you order, the more the abnormalities you are going to pick up. A lot of these abnormalities are incidental red herrings which have no bearing on the fertility potential of the couple , because they are found in normal fertile couples as well. However, once an abnormality is found , the doctor is forced to “ treat” it !

Few doctors will take the time or energy to explain to patients that an abnormal result could just be a statistical variant; is often of no clinical significance ; and can be happily ignored.
Unfortunately , patients also contribute to this epidemic of over testing. Many patients are very happy when doctors order lots of tests for them – and the more expensive they are, the better ! They feel that doctors who order lots of tests are much more thorough and complete – after all, someone who orders so many tests must be a real expert , because he's looking for problems which the earlier doctor missed completely , as a result of his ignorance !

Unfortunately, more is not better , and patients need to beware of doctors who mindlessly order panels of expensive tests for all their patients.

How to get a second opinion

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 07 May 2012 03:15:00 +0000

I often encourage my patients to get a second opinion when they are not sure as to what to do next. Sometimes , it's obvious they are not very happy with the advice which I give them , and it helps if they get a second perspective from an independent physician . I'm quite happy to suggest names of physicians whom I respect , so they can get a useful second opinion ; or I tell them that they can find someone on their own.

I make it a point to document all my findings and explain the rationale for my opinion , so that they can then have a more intelligent conversation with the next doctor , who can then give them a better and more thoughtful second opinion.

Asking for a second opinion doesn't mean that they don't trust me . It just means that they need to be sure that they've covered all their bases and have explored all their options , rather than prematurely pursuing the treatment which I suggest, when there may be other alternatives which may be better suited for them.

This is better for me as well , because I don't claim that I have a monopoly on wisdom. I am quite happy to work with my patients , in order to craft a treatment plan which is in my patient's best interests.

If the second opinion is very similar to mine, this leads to the patient having more confidence in my judgment, so that they are more willing to trust me. However, if they choose to go down a different treatment path , that's fine too. This allows me to learn ; and helps me to fill up gaps in my knowledge base.

It's important that patients trust their doctors, but doctors need to earn this trust. The rule is simple - you should trust your doctor , but you should also verify independently that what you doctor is telling you makes sense !

Medical Tourism in India - IVF Babies - Outlook magazine

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sun, 06 May 2012 02:51:00 +0000

Why don’t doctors share information with their patients ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Sat, 05 May 2012 03:13:00 +0000

One of the commonest complaints patients have about doctors is that they don't tell them anything about their medical condition . They feel doctors keep them in the dark ; tend to be brusque; and are not very forthcoming in general, when pressed for information . Patients often feel short changed ; and there is a general perception that doctors are not very good at answering patient's questions. Some patients can get quite paranoid about this – and some even believe that doctors hide stuff from them, so that they can keep patients in their place !

Patients are also reluctant to ask questions because they feel that some of their questions are stupid; and they should not be wasting the doctor’s precious time by expecting answers to all their trivial worries. Patients also feel that doctors get irritated if they ask them too many questions, which is why they are reluctant to do so. After all, no patients wants to rub their doctor on the wrong side - and even if they don’t understand what the doctor is saying, they will continue to nod their hands and pretend complete comprehension – which means that many doctors are completely in the dark about how much in the dark their patients are !

So, why don't doctors share more information? Why aren’t they more forthcoming? Is it just a problem with time constraints? Is it that doctors are so busy , that even though they would love to sit down and talk to their patients, they just don't have the time to be able to do so ? Or is it that most doctors suffer from poor bedside manners , and are just not very good at answering their patient's questions?
The answer is complex and multifactorial. There are some surgeons who feel that their talents are best used in the operation theater ; and they feel that sitting and answering patient's questions is just a waste of their time , which could be put to better use by opening up the patient and operating on him. Some doctors get visibly irritated when patients ask what they feel are silly questions.

This reluctance on the doctor’s part to answer the patient's questions often leads to a breakdown in doctor-patient communication. This is why , if things go wrong, patients are often very resentful and angry ; and want to seek revenge , because they feel that their doctor was not forthright and transparent , and did not share information with them.

The reason for this misperception is manifold. Communication is a two-way street , and it's not always the doctors fault when this is poor . Sometimes patients keep on asking the same questions repeatedly, which will often upset and irritate doctors. Patients do this because they sometimes don't want to hear the truth, and they feel that by reframing the question , the doctor will give them an answer which is more to their liking. Sometimes the reason patients repeat their questions is because the doctors are not very clear . Doctors tend to use a lot of medical jargon and technical terms , as a result of which the patient is often more befuddled than before.

The solution for this problem needs to come from patients as well as doctors. Doctors will always be very busy and will never have enough time to be able to see all the possible patients who are waiting for them in a leisurely fashion. This is why a lot of their patient educational activities should be done online; and doctors can use clever technology such as online videos and patient educational brochures ( which they can publish on their website in the form of FAQs ) so that patients can get their questions answered without always having to talk to the doctor.

Patients also need to take some responsibility for making sure they're well informed. They can't afford to leave everything up to the doctor or expect the Doctor to answer all their questions for them. They need to spend some time and energy doing their homework , so that they can ask more intelligent questions of their doctor.

Always remember that the quality of the answer depends on the quality of the question - and the more intelligent your question , the more intelligently your doctor can answer it. Also, if you ask intelligent questions , your doctors are more likely to respect you and provide you with better medical care.

Why have IV Intralipids become so popular for IVF patients ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Fri, 04 May 2012 03:03:00 +0000

A number of clinics are now prescribing intravenous intralipids for patients who have failed an IVF cycle. The hypothesis is that intravenous intralipids will help to increase the chances of successful embryo implantation . Intralipids are said to suppress the activity of NK cells in the uterus , thus preventing rejection of the embryo.

This is yet another example of the large number of empirical treatment options which are being offered to patients who have failed IVF treatment cycles . Many of these fashions and come and go – and after practicing for over 20 years, I am quite skeptical about the value of most of these. It’s not that I am jaundiced – it’s just that a lot of these interventions which are tom-tommed and hyped when they are new will soon be proven to be ineffective and worthless. A handful of small isolated studies that cannot be duplicated on a large scale by other doctors/researchers means it doesn't work. That's where intralipids is right now. As a conservative doctor, I’d rather other clinics tried them out on their patients, rather than use my patients as guinea pigs.

This lack of agreement as regards the utility of some of these “treatments” just highlights the fact that we understand very little about why certain embryos implant , while others don't. While I think it's perfectly okay for patients to explore these therapeutic options, I'm very reluctant to prescribe these treatments unless they are low cost and low risk.

The fact remains that every IVF cycle is a lottery ; and that we really have no way of predicting which cycle will work and which will fail. This is hardly surprising , given the fact that we still understand so little about human reproduction in vivo , and cannot even predict when a fertile couple will get pregnant in their own bedroom.

Just like we don't know which couple will get pregnant in the bedroom, we don't know who will get pregnant in the IVF clinic either. Of course , when the patient does get pregnant after an IVF cycle , we very happy to take the credit, but there is no way of prospectively predicting which individual patient’s IVF cycle will fail - and which one's will succeed.

Doctors don't like displaying their ignorance to patients , which is why this is one of those dirty little secrets which IVF doctors will not talk about. Fortunately very few patients ask us, “Doctor , why did my IVF cycle succeed ?”, so we don't really need to worry too much about this particular question. However, the more closely we study our successes , the more likely we are going to be able to pinpoint exactly what we need to do to increasing the chances of success for all our patients.

So should you take intravenous intralipid if your earlier IVF cycles have failed and your doctor is advising this? I think this is a decision each patient has to make for themselves ; and depends to a large extent on what your worldview about medical therapy is. If you are an interventionist by nature , who wants to use whatever technology is available , whether or not it's experimental and unproven , then you might want to try it. However , if you believe that there is little we can do to alter the outcome of a biological processes , you might want to hold off until we have more clinical evidence.

Unfortunately , the doctor’s advice depends on what his worldview is – not yours ! This is why if both doctor and patient have the same philosophical approach towards medical intervention , they are likely to be quite happy with each other. This is why you need to find a doctor who thinks the way you do !

Health insurance companies and moments of truth

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Thu, 03 May 2012 03:10:00 +0000

Health insurance companies are service companies and what makes or breaks a service company are the customers’ perceptions when they interact with the company. These are called moments of truth. Today, the way the health insurance companies are set up, most of their interactions with their customers are designed to be negative , as a result of which most customers have unhappy memories of their moments of truth interactions with health insurance companies.

This is because most health insurance companies today primarily perform just two functions:
1. They collect your premium on your policy every year when this is due
2. They process your claim ( and hopefully pay your bills) when you fall sick.

Signing up a new customer for a new health insurance policy is hard work. This is quite a competitive market ; and no one wants to think about falling sick , which is why most customers are quite reluctant to spend money on an health insurance policy . Most of us think we are immortal , and refuse to think about illness when we are hale and hearty. Also, while we don't mind buying , we hate being sold to - and we often feel that health insurance company agents and distributors are snake oil salesmen , who just want to make a quick buck off their commissions. They seem to be more interested in looking after their best interests, rather than ours. This is why most of us will not trust health insurance companies or their salesman.

Things are equally bad at the time of renewal. If you've never had any reason to submit a claim against your health insurance policy-and that's true for most of us , because most of us will remain healthy - we feel that we have wasted our heard-earned money on the premium , and are quite reluctant to renew.

The only way for health insurance companies to fix this problem is to start creating more interactions with customers which are designed to create positive strokes , rather than the present negative ones. There are multiple opportunities for health insurance to do so , thanks to mobile phones and technology, it’s become quite inexpensive for them to do so.

Clever health insurance companies could send a friendly healthy message every day - by SMS or e-mail – to their customer, in order to educate and engage them. This will reinforce the message that health insurance companies are in the business of keeping their customers healthy, rather than simply paying for their care when they fall ill. Simple interventions like this can make a world of a difference in keeping customers loyal and healthy !

How much should we spend on healthcare ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Wed, 02 May 2012 02:59:00 +0000

I recently attended a conference on the healthcare insurance industry in India. Everyone agrees that this is an industry which is poised to grow rapidly over the next few years. One of the points every speaker emphasized is that while the US spends over 14 percent of its GDP on
healthcare , India spends only four percent, and that this gap suggests that there is a lot of room for healthcare expenditure to grow. While these are interesting numbers, one thing which still confuses me is what the optimal proportion of GDP spending on health care should be? Does a country which spends more on health care services care more for its citizens , because it wants to keep them healthy ? Is this therefore is a better government? Do countries which spend more on healthcare expenditure have healthier and therefore more productive citizens? Is increasing healthcare expenditure justified because it provides a better return of investment? Or is it that countries which spend more on healthcare find they are wasting a lot of their precious money on futile treatments , which do not serve any useful purpose?

How does one look at healthcare expenditure ? Is this expenditure a waste , because it consumes valuable resources ? Or is it something which is good , which we should be happy to be spending money on , because it helps our citizens to be healthier? What is the optimum proportion of GDP expenditure on healthcare? And how do we arrive at this particular figure?

One way of doing so would be to compare expenditure on health care with other sectors . If we spent 10 percent of our GDP on growing enough food for our citizens, are we better than a country with spends 20 percent of its GDP on the agricultural sector? If you need to spend only 10 percent , and still keep your citizens well fed , doesn’t this mean that you have a more efficient agricultural system ? Or should we aim to increase our expenditure to a hypothetical gold standard of 20 percent, because if we can produce more food , we will have happier citizens?
Healthcare is a service industry , and it might be useful to compare the proportion of GDP expenditure on healthcare with how much we spend on entertainment . Does a country with spends more on entertainment mean that its citizens have additional discretionary income , which they can choose to spend on keeping themselves entertained and happy ? Or is this a sign of decadence which signals that the society is headed towards doom , because it wastes precious resources on “ unproductive “ assets?

The other way of looking at this is to compare a country with a family. Is a family with spends more money on keeping themselves healthy consider itself to be better off as compared to one which spends more of its money on entertainment or junk food?

If healthcare is considered to be good, then isn't it logical that one of the aims of the government should be to increase its proportion of healthcare spending? And that is the case then why is the US so worried that it spends 14 percent of its GDP on healthcare?

Exactly the same argument applies to the number of hospital beds per thousand patients. Is it better to have a lot of hospital beds , because this means that you have a lot of medical care facilities? Or is it actually a bad sign , because this means that a lot more of your citizens are ill and require medical care ? Isn’t it true that the more the hospital beds you have , the more doctors are likely to want to fill these hospital beds, resulting in inappropriate medical procedures and wasteful medical expenditure?

These are fascinating questions , and I'll be very happy to hear from readers as to how we can go about finding answers to these !

Why does health insurance in India come under the finance ministry ?

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Tue, 01 May 2012 04:58:00 +0000

Healthcare is regulated and controlled by the healthcare ministry in India. Healthcare insurance is an enabling tool which makes healthcare more affordable , so that when patients fall ill , they can get assistance in paying their bills , and do not need to worry about how they will be able to do so. Insurance is a risk management tool, which helps to blunt the financial hit patients take when seeking medical care. Thus, while it is true that health insurance is a financial tool, it is also equally true that it is an enabling tool , the purpose of which is to allow people to get the healthcare they need. If that's the case , the isn't it perfectly logical that healthcare insurance regulations should be framed and implemented by the healthcare ministry , rather than the finance ministry?

There's a lot of unhappiness and angst as regards health insurance in India today , and part of the problem is that a lot of the rules and regulations are being set by the finance department , which doesn't have enough healthcare expertise in order to understand the pain points with patient and healthcare providers encounter .

The worldview of someone working in the finance industry is completely different from someone who works in the healthcare industry ; and it is this difference in perspective which is one of the contributing factors to why we not been able to solve some of the sticky healthcare insurance issues in this country today.

Ensuring that Indian citizens remain healthy and productive is extremely important towards ensuring that we take advantage of the fortunate demographic dividend we find ourselves in. Healthcare insurance is an extremely powerful tool to ensure this ; and allowing people with expertise in healthcare to formulate the rules which govern healthcare insurance would go a long way towards achieving this laudable goal. Let’s not squander this opportunity !

A tip to help infertile patients make better decisions

noreply@blogger.com (Dr Aniruddha Malpani, MD) — Mon, 30 Apr 2012 03:01:00 +0000

When you are infertile, it can sometimes be very hard to make decisions as to what your next course of action should be , especially when your IVF cycle fails. There are always many options , but because this is such an emotionally charged issue, it becomes very difficult to think through this logically. Should you just repeat the IVF cycle again ? or should you change your doctor ? or consider using donor eggs ? or surrogacy ? Or should we just forget about all this , and adopt a baby instead ? Having so many choices often leads to paralysis by analysis. The problem becomes even more acute when the husband and wife don't see eye to eye , and would rather adopt different solutions , because they have differing worldviews.

When you're stuck and don't know what to do next, it can be helpful to find a counselor who can walk you through your options and help you come to the right decision for yourself. A good counselor will never tell you what to do – she will help you find the answer within your own heart.

However, finding skilled counselors can be extremely hard - and another way of addressing this problem is to treat it as a business problem. You need to step out of your own body and pretend that this is a problem which is affecting someone else - perhaps a friend , who is confused , and needs to know what to do next, and has come to you for advise. You can then stop using your heart and start using your head. You need to approach this dispassionately and objectively , as a business problem , for which you can create a decision matrix and order your choices so as to maximize your gains.

While it may seem extremely heartless to take this approach, this is actually a far more efficient way ; and will help you to make the right decision much faster.

Here's another tip which will help you listen to what your heart is telling you - try tossing a coin ! Now I'm not suggesting that you let the result of the coin toss determine your future course of action ! No – this is far too important a matter to be left up to such a random event. My point is that while the coin is in the air, you will find yourself hoping that it comes up heads , rather than tails – or vice versa ! If you find yourself clearly preferring one side to another, this clearly means that your heart knows what’s right for you. It is telling you what to do next – and this simple trick is a useful way of being able to listen to your gut feel !