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Because doctors spend so many years mastering the technical minutiae of their speciality, they sometimes forget how to communicate with their patients.

Rather than think of themselves as being endocrinologists or diabetologists or radiologists or cardiologists, I wish all doctors would think of themselves as being patientologists first !

Traditionally, medical care was always provided face to face. If you had a medical problem, you went and saw your doctor for a consultation. He would take a history; examine you; and then decide on what treatment you needed.

This was and is still a good model, because it allows doctors to provide the "human touch" , which is often a key ingredient in providing good medical care. However, as time evolved, doctors realised that not all their patients needed to come and see them for each and every problem.

Many problems are self-limited and resolve on their own, so that they can be effectively managed by reassuring the patient; while others simply need a renewal of a prescription ( for example, for managing a stable patient with a chronic illness). This is why "telephone medicine" is an integral part of medical care today.

As technology has evolved, the internet provides a more efficient way of communicating with a doctor than the telephone, so that online consultations are now standard in many fields.

While there is no doubt that seeing a doctor is very important in a medical emergency; or when the diagnosis is unclear, it's also true that not all medical problems require you to visit your doctor.

There are many downsides to a doctor visit. Doctors are busy - and it can take 2-6 weeks to get an appointment to see a leading physician. Also, a visit to the clinic can be quite disruptive , and may need you take a day off because travelling to the clinic can be quite a time consuming chore. A doctor's clinic can be quite chaotic - and long wait times ( surrounded by sick patients) is hardly conducive to healing.

Also, many times patients know what their diagnosis is. They just need a second opinion; or need to find out the cost of a particular treatment option - information which they should be able to get without having to go through the inconvenience and expense of actually going to the doctor.

Online consultations offer a lot of benefits - and in fact, the quality of care can actually be better in some cases ! An online consultation allows you to get an opinion from a world-renowned expert, without having to travel half way across the world to meet him ! Because the doctor's opinion is based on a review of your medical records, you have to make sure all your tests and treatments are well documented - helping you to become better organised, and thus become a better-informed patient. Also, you do not need to waste time waiting for an open consultation slot , because the doctor's clinic timings are no longer a bottleneck, as a result of which the turnaround time can be much quicker.

When you email your questions, do not need to worry about the fact that the doctor is in a hurry and another 20 restive patients waiting in line to see him. It's possible to ask well-crafted questions to clarify your doubts , so that you have a clearer picture of your options. Often email consultations are more productive because you are not stressed out . When sitting in front of the doctor, many patients forget half their questions - and after the visit, many cannot remember half of what the doctor told them. This can cause of a lot of unhappiness for both doctors and patients. An emailed opinion is in black and while - and you can verify this advise with other specialists and your family doctor ; and also share it with your loved ones, to confirm that you are on the right track ! Finally, an online consultation can ensure you get a more objective honest opinion ! Since the doctor does not know you, he has no hidden agenda, and will not want to push you into doing surgery, for example !

Can online consultations have a downside ? Yes, of course ! There is no personal rapport; and the online " expert " may not be trustworthy or reliable. This is why you need to use this option intelligently ! Also, doctors may not be willing to offer this option, because they are not sure how to bill for their time ( though I am sure this will change, as patients are quite willing to pay for phone consultations and online consultations as well !)

In my opinion, it's very good for both doctors and patients that additional options are now available, thanks to the internet . This option is especially useful for getting a second opinion and we do this routinely at www.drmalpani.com !

It saves me a lot of time and energy; and keeps my patients happy, because they can tap into my expert knowledgebase, without having to come and see me !

Cuts and kickbacks have become the norm in medical practise in India today. In public forums, most doctors frown on this practise as being unethical and unprofessional ( even though they continue giving cuts in their own practise). This is hypocritical and just adds more dishonour to the medical profession.

Let's take a fresh look at the subject. The question we need to ask ourselves is - Is there anything wrong with doctors giving cuts ? Is this really such a bad thing ?

Cuts and kickbacks are pretty much standard practise in many areas of life today, such as politics and commerce. Greasing palms is considered established practise if you want your file to move in the government office , and if it's okay to give bribes and kickbacks in other fields, what's wrong when doctors do the same ?

Let's see why the practise evolved in the first place - after all, the fact that it has spread like a cancer means it must have some plus points ! Rather than turn a blind eye to these , let's look at some of the benefits this offers.

The advantages to the family physician ( primary care doctor ) are obvious ! It's a fact that family physicians are underpaid as compared to specialists. Doctors who do procedures command an unfair premium and these kickbacks helps to reduce the disparity in their incomes.

Also, primary care doctors play a very useful complementary role to the specialist, but this is often not explicitly acknowledged or reimbursed . They don't just refer the patient to the specialist and then walk off after collecting their commission ! They help to identify the "best specialist"; help the patient to get a timely appointment; counsel and handhold the patient
( something which most specialists just don't have the time or energy to do !) ; explain what the specialist is saying ; and demystify the medical journey for the family. They are always available for assistance ( for example , in the middle of the night, when the specialist has disappeared) ; and because they have an ongoing long-term relationship with the family, they are able to provide emotional support much more effectively than the specialist . Equally important, they are better at taking a holistic view of the medical problem, as compared to specialists, who have a very narrow viewpoint - and who may know a lot about the technical minutiae of their specialty , but know precious little about the person who has the disease !

Family physicians act as a useful bridge between the specialist and the patient - how are they going to reimbursed for their efforts in a fair fashion ? In my opinion, the cut which the specialist gives for the referral is their reimbursement. Taking a share of the spoils is the most effective way for them to earn money.

So it all hunky-dory ? No ! There are major disadvantages to this system ( which is why we do not give cuts in our private practise !). For one, this system increases the cost to the patient. It also promotes malpractise , because family physicians will often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done which are not always in the patient's best interests. Also, because this is unaccounted for black money , which is paid in cash, under the table, it encourages a parallel underground economy.

Because this practise is hidden, it's never discussed openly , and this creates a lot of resentment amongst patients. The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. This is one of the major reasons patients do not trust their doctors , and why the reputation of entire medical profession has taken such a beating in recent years.

So what's the solution ? Can we ban kickbacks ? While the Code of Medical Ethics explicitly bans cuts, unfortunately this does not work in real life. We need to find a realistic solution !

I feel the major danger with the kickback is the fact that is done in an underhand secretive fashion. Because the doctor hides the fact that he is giving a kickback to the referring family , he has to be dishonest - and this damages the doctor-patient relationship, which should ideally be based on trust !

Large corporate hospitals routinely give referral fees to doctors. This is considered to be part of the "cost of doing business" and is usually given as a cheque payment. If we accept this practise
( because a hospital is a business and needs to fill its bed), then why not level the playing field and allow doctors to give referring doctors a commission as well ( which can be claimed as a tax-deductible expense ? ) Similarly, doctors give referral / commission fees to medical tourism companies which refer patients to them. What's wrong if they give this to the family doctors who send patients to them ?

I feel it's far better to make this an open and transparent system, so the patient knows what the truth is ! The specialist can add a " surcharge" to his fees, and this can be paid to the family physician by cheque , as a "patient management fee" . This transparency will keep everyone honest and help to align the doctor's interests with that of the patient !

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I saw a patient who wanted a third opinion. She was completely confused. As part of her infertility workup, she had had a HSG ( hysterosalpingogram) done. The X-ray showed that her uterine cavity was normal; the dye filled the fallopian tubes , but the spill into the abdominal cavity was loculated.

When she saw her doctor with the report, he told her that this suggested that there were adhesions around the tubes, and she needed an operative laparoscopy to treat this. Another doctor, to whom she had gone for a second opinion advised her against the laparoscopy. He felt that since the tubes were open, her best option would be to do an IUI, to improves the chances of the eggs and sperm meeting. This patient then sought a third opinion, which is why she came to me !

The first thing I did was to ignore the earlier opinions, and asked to see a copy of the original HSG X-ray films, so I could make up my own mind . Unfortunately, there was only one film, and this was of poor quality . The radiologist had done a sub-optimal study, because he had not taken any delayed films ( perhaps to save some money ?), as a result of which it was hard to draw a firm conclusion based on the HSG films. This meant were now back to square one.

The choices were; repeat the HSG; do a laparoscopy; or assume the tubes were fine and proceed with treatment. Each has advantages and disadvantages, and patients need to think their way carefully through their choices, so they can make the right decision. Unfortunately, most patients are not used to making choices regarding their medical treatment. Even worse, most doctors are not comfortable offering these choices to their patients. "The doctor knows best" is the model most patients ( and doctors) are happy to adopt - which means that often the wrong decision is made ( and usually for the wrong reasons).

We could repeat the HSG in a better clinic and make sure that it was done under fluoroscopic guidance and that delayed films were taken. While this option would give a much better X-ray image of the tubes, she was understandably reluctant to repeat the HSG. This is quite a painful procedure - and few women have the courage to do it again !

Laparoscopy is a surgical procedure, which means it costs more; however, the quality of the documentation is much better, because the surgeon can take videos of the pelvic anatomy. However, it cannot provide information on tubal function - which is really the only thing the patient wants to know - are my tubes working properly or not ?

Doing a laparoscopy was an option - but this is an expensive surgical procedure - and while it provides useful diagnostic information, it often does not change treatment options , which is why we are very reluctant to perform this in our clinic. What's the point of doing a test if it does not impact treatment alternatives ?

So what are patients supposed to do when their doctors disagree ? Some of them get very angry and upset when doctors do not see eye to eye ! I actually feel it's good for patients when doctors disagree. Each doctor will present his point of view and justify why this is better than the alternative proposed by the other doctor . The patient gets to see the pros and cons of both options, so she can make a better-informed decision !