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I just saw a patient who was at her wit's end. She had done 4 IVF cycles at the same clinic and had failed all of them. She was angry; and was complaining bitterly about how badly the doctor at the IVF clinic had treated her. " She would make us wait for hours - and we only got a chance to talk to her at the first consultation. After this, all the care was provided by her assistants, who refused to allow us to meet Madam ! "

I asked her some basic questions about her medical treatment. " I need more details about your prior IVF cycles . What were the medications which were used for superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? How many embryos were transferred ? What was the embryo quality ? Do you have photos of your embryos ? What was the endometrial thickness ?
Can you please send me the printed treatment summary from your IVF clinic ? "

She was completely clueless about these basics ! She had no idea about how many eggs were collected each time - or even how many embryos were transferred. All she had from the clinic were some prescription slips - but no medical details at all.

I asked her why she didn't have this and she replied - " The clinic keeps all the medical records for all the patients. They do not give us copies ! The doctor does not tell us anything; and does not answer any of our questions. If we ask the staff or the assistants, they just tell us - Talk to the doctor - but the doctor is never available ! She is too busy seeing new patients ! The doctor did not give us any papers even though I asked for them many times !"

She was feeling very sorry for herself that her doctor has been so unhelpful - but did not think she could have done anything about it. Her attitude was - " This is the way things are done ", so what can I do ? "

I agreed with her that her doctor seemed to have provided very poor quality care ! However, while she was not responsible for her doctor's actions, she was responsible for her own - and the fact that she had not been more assertive and proactive reflected poorly on her !

I can understand her feeling helpless in the first cycle - after all, she had no way of knowing how transparent her doctor would be. But to allow the same poor quality care to continue for 4 cycles meant that she continued to allow her doctor to provide poor quality treatment. She was as responsible for her poor care as her doctor was !

As the old saying goes - " Fool me once - shame on you; fool me twice - shame on me".

In fact, I would be much more critical of her than her doctor. I can understand why her doctor was not willing to talk to her - she was just behaving rationally and optimising her income by seeing more new patients, to improve her clinic turnover. However, why was the patient behaving like a passive victim ? She was paying big bucks for her treatment, and should have been more assertive and articulate ! There was no reason for her to continue going to the same doctor if she was unhappy after the first IVF cycle. There's no shortage of IVF clinics in India - and many doctors treat their patients with respect and provide a high quality service .

Part of the problem is that patients do not respect themselves enough ! Infertile patients are so desperate for a baby, that they just do not use their common sense when dealing with their doctor. They want a doctor who will solve all their problems and provide them with a baby, which is why they want to be able to blindly trust their doctor. They do not dare ask too many question because they are scared this may upset the doctor and rock the boat. They are happy to toe the line and be compliant - and they just do what all the other patients in the clinic are doing, since this seems to be the accepted norm.

Often, many of them do not even know that they have a right to their medical records - or that there is a better and more enlightened way of doing things. They underestimate their ability to understand and take charge of their treatment.

Sadly, it's not just doctors who do this - many other professionals do so as well. I remember my experience with a Senior Counsel who is one of India's leading lawyers. When I went to him for a consultation, he refused to talk to me and spoke only to my advocate. It seemed that it was beneath his dignity to discuss my case with me !

The good news is that I found another lawyer whose approach was refreshingly different ! He dictated the brief in front of me - and this inspired confidence in me that he knew all the facts of my case and the relevant law as well !

I behaved as a responsible consumer - and when I found the first lawyer's attitude unacceptable, I found another lawyer ( even though the first lawyer had much higher brand name recognition !)

I think patients also need to take a similar assertive approach. Not all doctors are the same - and many are proactive, respectful and thoughtful. If your doctor does not treat you with respect, then you should find another doctor. And if you are too scared or lazy to do so, then please do not complain about the care you receive !

A new set of interactive guidelines have been created to help clinicians more effectively communicate when they deliver bad news to patients.

COMFORT is an acronym that stands for Communication, Orientation, Mindfulness, Family, Ongoing, Reiterative, and Team.

Communication- Clinicians need to learn to how to use clear and familiar language
when breaking bad news. Patients are people and have the basic right of receiving information in a manner that makes sense to them. Communication between doctors and patients should strive to be person-centered and nonverbally direct.

Orientation- Low health literacy leaves most patients and their families with little choice
about their care. A patient receiving bad news will be overwhelmed, and will often respond to any clinician recommendations, even if they are ineffective. Treatment outcomes should be clearly articulated in language that is appropriate for both the age and education level of the patient.

Mindfulness- Doctors need to learn to treat each patient interaction separately. When
delivering bad news, the patient should be at the center of the doctor’s attention.
Focusing on a patient’s individual experience requires doctors to avoid basic scripts and protocols.

Family- Families should be included in conversations when doctors break bad news
to patients, since families provide support to the patient. Families are also affected by illnesses, and clinicians need to address both the patient and their family.

Ongoing- Clinicians must emphasize that the patient will not be abandoned after a
diagnosis, or while they receive ongoing treatments. By continually communicating with patients, clinicians can provide more clarification about the diagnosis, especially if the recovery will not be quick.

Reiterative- When interacting with a patient, clinicians need to keep the meaning behind
their messages the same, even if the message delivery takes different forms over time. The message must always adapt to fit the needs of the patient.

Team-Patients receive care from a team of medical professionals, including physicians,
nurses, chaplains, psychologists, and social workers. Communicating as a team will help reassure patients and their families that they will be receiving proper care.

This study appears in Volume 59 of Communication Education, a publication of the National Communication Association. For more information about NCA or its journals, please visit www.natcom.org.

I was recently invited to give a talk to the Ahmedabad medical association on How to be a Successful Doctor. After my talk, I went to visit 2 private hospitals, to see how doctors in Ahmedabad delivered medical care.

This visit was quite an eye-opener. Bombay is widely accepted as the Medical Center of India - and Bombay doctors treat patients from all over the country, including lots of patients from Ahmedabad !

I saw two hospitals. One was an IVF center; and the other was a Urology clinic. Each of these was a stand-alone 4-floor purpose-built building , covering about 20000 square feet. In comparison, in Bombay, where real estate is about 10 times as expensive, the typical private nursing home or hospital is about one tenth the size !

Because there is no shortage of space in Ahmedabad, doctors can build large hospitals for themselves - something which is impossible in Bombay ! These doctors are hard working specialists in private practise. They have a very entrepreneurial bent of mind, since they run their own hospital . While it's true that their patients are not very well off, and do not pay too much ( which means they charge a fraction of what Bombay doctors do ), these doctors have a huge patient workload and a lot of clinical expertise .

The doctors I visited have invested lot of money in buying top quality high end medical equipment , imported from all over the world. They do not skimp on buying medical equipment when they feel this is cost effective and helps them to perform better. This is why they provide high quality care- at a fraction of the cost which doctors in Bombay do !

Travelling to Ahmedabad is easy and the infrastructure is improving dramatically. Accommodation for patients and their family members is cheap; and these doctors have developed lots of clever indigenous innovations to keep costs down ! These have been clinically proven to work well in practise , allowing them to offer low cost high quality care !

I feel doctors from Bombay - and in fact doctors from all over the world - can learn a lot from doctors practising in Tier 2 and 3 Indian cities such as Ahmedabad.

If this is true, then why don't they attract more patients ? And why did I have to make a trip Ahmedabad to learn about the work these doctors are doing ? Why don't patients know about them ? And why don't other doctors learn from them ?

I think the answer is simple and is two-fold. The first problem is a limited vision. While there are some notable exceptions, most of these doctors are quite contented taking care of local patients. The other major problem is poor marketing. They do have websites, but these are poorly maintained and are rarely updated. Because of limited English language skills, the websites are full of grammatical errors and typos - all of which create a poor impression.

Why don't they do a better job ? This is honestly a million-dollar question I cannot answer ! These are easy problems to fix ! They can easily start websites, and especially if they do these in local Indian languages, they will have practically no competition ! While the internet may be global, it's great for attracting local patients ! I think doctors still underestimate the power of the internet and do not realise how many patients use this these days to find the best medical care for themselves.

Some doctors are intimidated by the technological complexity which they think is involved in running a website; while others do not bother , because none of the other doctors in the town have one either. Others have tried, but were very disappointed with the results, because they had very unrealistic expectations. Digital marketing is inexpensive - but requires a lot of patience ! These doctors can easily use video to reach low literacy patients - and this will become increasingly important as internet penetration in India improves; and every one carries a smart phone.

These small doctor-owned hospitals are often far better than corporate hospitals , because they provide personalised care, at a lower cost. However, unless these doctors learn to use the internet to market their services, they will continue losing their well-off patients to doctors from Bombay ! They need to think of the future or they will remain stuck in the past !