Wednesday, May 25, 2016

Announcement not Advertisement- A call to change the Medical Code of Ethics

The Medical council of Tamil Nadu recently forbade doctors from having websites saying it was ‘unethical and amounts to advertisement’.
As India moves towards becoming Digital India, as Justice Lodha frames new rules for the Medical Council of India, isn’t it time we revisited the principles governing the practice of Medicine in India?

It’s a small world
We’re going global. The world wants to come to India for Medical treatment because Indian doctors are knowledgeable, experienced and healthcare in India is reasonably priced. How can doctors announce themselves to the world without even a website? Patients never go to hospitals. They go to a particular doctor. Websites for doctors are a must in today’s world.

Double role
Doctors are not merely medicine men or women. Or surgeons. They may be owners of a clinic, a nursing home or a hospital. They may have invested in real estate and equipment. They employ other doctors, nursing staff, paramedical workers, receptionists, managers, and even cooks and cleaners. They pay commercial prices in rent, electricity and water supply. They have to maintain everything in pristine condition since it is lives they deal with. They pay insurance and for various permissions. How do they keep all this going without at least announcing their presence and services offered by them in the form of a hoarding, a website, or a ‘yellow page listing’? The moment they do this, they get slapped with notices from their Medical Councils that it’s unethical to advertise. But if a non medico or a non allopathic doctor owns a hospital, [they can advertise because the Medical Councils can only suspend licences of allopathic doctors] that's okay. Many societies where our clinics are located don’t allow even a decent sized board visible from the street. How will people know we are there to look after them? Please give the poor MBBS a break.

Piece of the pie
Another of our PM Modi’s plans for India is to curb the parallel economy. How does a doctor fill his or her hospital if they can’t announce themselves to the community? They resort to malpractices like ‘cuts’ or referral fees to other doctors who refer patients, even to Hospital receptionists, ward boys, cab drivers, ‘agents’ anybody who sends them patients. And from where does this money come? From hiding income and not paying tax. By forbidding websites and announcements in the press, the government is just  fueling the Black economy. Let patients directly find their doctors instead and do away with all middle men. This will also curb unindicated surgeries or tests.   

The privileged clubs
Who benefits from the ‘no advertisement’ clause? Corporate hospitals-because they can advertise. Clinic chains. Old established doctors because the competition gets no mileage-they are the ones on all committees and councils and very keen on this rule. The American Medical association has done away with this rule for this very reason. In today’s world where people settle wherever their job takes them, patients need the digital world to find a good doctor. The good old family doctor cannot advise you on who is best. A corporate hospital or clinic chain may have really young and raw doctors to attend to you or a doctor who knows the owner or is politically connected to get the attachment- not necessarily the best doctor for the job.

We don’t want to make tall claims or quote false results. We just want to be allowed to inform the public at large that here is a doctor with these degrees who can treat you for these conditions at this price. Or who has special expertise in a particular area. Or who offers extras like a weekend clinic or low priced clinic or all women staff or senior consultants or unique procedures. Nobody forces patients to a treatment. We want them to make an informed choice. And maybe talk to other patients of ours for a feedback.

Why me?
Miracle cures are announced by homeopaths, ayurveda practioners, gym owners, dieticians, fitness experts in all newspapers and magazines and on the net all the time. No action is taken against them. Why be so very strict with allopathic doctors who don’t want to make tall claims, just to announce their existence on a street, an area, a city or a country? The Medical councils are welcome to issue strict warnings in case false claims are made or miracle cures announced. But to completely take away our right to put up signages or websites is extreme.

Dog eat dog 
In an intensely competitive world, often it’s the competition that complains about a doctor who has made any kind of announcement thereby threatening the existing kings or queens. News paper interviews are given or such complaints ‘leaked’ to newspapers to demean the doctor and ruin his or her reputation and practice –benefitting the one who complained. By all means take action against offenders but let there be a law against vilification of doctors by other doctors or administrative officials or going to the press before a case is tried in court. Just as there is a law against physical abuse against doctors let there be a law against newspaper statements or cyber abuse.

Multi headed hydra 
Okay. Today you forbid websites. And Facebook pages. Tomorrow Whatsapp accounts, yellow pages like Justdial, Practo, Sulekha, then Instagram, Snapchat, apps for doctors, google adverts, use of SEOs , PR firms, advertorials in short, wipe out a doctor's existence in print or the virtual world. For every head you cut, two will spring in its place. We don’t even know what new technology tomorrow will bring. How can Medical Councils keep tabs on everything and everyone? It’s time to get real and allow doctors a level playing field within reasonable boundaries of course. We don’t want to ‘solicit’ patients or ‘advertise’ or claim greatness. We just want to inform the public and announce our presence on the web and on the street where we work.

May the best get their due.

Wednesday, May 18, 2016

Cost of a Test tube baby

The Times they are changing
With increasing age of marriage in women , stress filled lifestyles and multiple pollutants, the number of both men and women facing fertility issues is rising. The WHO recently revised it's criteria for 'normal' semen parameters to lower sperm counts and motility. Many of these couples would benefit from simple measures. But for those who have extremely low sperm counts or absent sperms[ azoospermia] in semen [ necessitating extraction from the testes-TESA / PESA/ TESE] or for those women whose tubes are blocked or even those couples where all other treatments have failed, a 'test tube baby' is the right if not only option.

What is the real cost of a 'test tube  baby'
The actual process using even the best of internationally available media with the machines the clinical set up and staff salaries costs around 40-50,000 Indian rupees. The injections given to stimulate the ovaries cost from 40,000 to around 2,00,000 based on the woman's age, ovarian reserve and type of stimulation protocol used. Tests cost around 5,000-10,000. So the actual cost is from around 80,000 to 2,50,000.

Can the cost of a test tube baby be brought down?
Using the newer 'soft stimulation' protocols where fewer injections are given to patients, the cost of a cycle- including medications-can be brought down to as low as 80,000 rupees. These protocols suit the needs of most patient-s give excellent results in experienced hands- with very few really needing the conventional long protocols. All patients do not need a scopy  though it does increase chances of a pregnancy. A good sonography is sometimes good enough.

Why do doctors quote high charges for IVF?
Many factors can inflate the cost of a test tube baby treatment- who and where the clinic is located for one. Rents and real estate in a city can add to the cost.

Many doctors start IVF cycles [ injections] but send patients elsewhere for sonography and the actual IVF to another centre. Some batch patients and take them by the bus load or a team flies down for 4 days when the egg pick ups embrology and embryo transfers are done. This raises the cost since soft stimulation protocols cannot be used in batching patients. And more people are involved hiking costs.Some clinics call embryologists for ICSI -again raising costs. Some doctors call an endoscopic surgeon as they are not experienced in endoscopy. This further raises costs

Part of a whole
If the IVF centre is attached to a large hospital or is a chain of IVF clinics or has multiple owners, the costs of the cycle can go up since a larger staff, marketing teams, paying of specialised doctors and lab staff increases. A single owner can be flexible in charges and charge lower amounts.

Cost of complications
If hyperstimulation occurs- as in PCOS patients freezing embryos and transferring them later is standard practice now. This hikes costs. If too many embryos are formed, freezing them does add to costs.

Old is not gold
Women in their late thirties and forties or who have had surgery done on their ovaries or suffered a severe infection or have endometriosis have fewer eggs and a higher percentage of abnormal eggs giving fewer good quality embryos. They need high doses of the costly gonadotropins to get a reasonable chance of pregnancy. - thus increasing costs. Using soft stimulation , freezing embryos and accumulating and transferring the best ones after thawing is a better option -it costs nearly the same and yields more pregnancies. Using an egg donor is also sometimes better-cost and result wise.

The 'soil' factor
If the inner lining of the uterus doesn't grow, docs add injections or instill drugs to improve it -increasing costs of cycles

What's the good news?
Competition- so many IVF centres and media providers as well as pharma companies making gonadotropins have brought down the cost with many claiming to be 'Budget test tube baby' centres

Experience As doctors and embryologists grow in experience they can give pregnancies with very few eggs, so cost of injections and hence the cycles is getting reduced.

Two for the price of one?
While there are journal articles showing that pregnancy rates increase at the second attempt, you could end up paying double for nothing.

Last words
Think it out. Plan well. Choose well. Be informed. But don't spoil your chances by bargaining with your doctor or dictating your treatment. Sometimes trust is best.