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We deal with a number of difficult patients who have failed multiple IVF cycles elsewhere. Many of these are poor ovarian responders and a common question is - How many follicles do you need to go ahead with the treatment ? Is there a number in your clinic below which you will cancel the cycle ?

These patients suffer from a lot of anxiety and apprehension during the superovulation, because they know they are not likely to grow many eggs. They have already had many of their cycles cancelled in the past - and this can be quite a cruel thing to do , because these are eggs which they have produced with a lot of effort ! Their eggs are precious - and represent their best chance of their having a baby with their own genes. This is why when the doctor cancels the cycle because they have not produced enough eggs, their heart breaks.

From the doctor's point of view, cancelling the cycle seems to be a very rational thing to do . Why make the patient spend so much money when the chances of success are so slim ?

What they forget is that the patient knew prior to starting the cycle that the chances of success were slim, so that the fact that she has grown few eggs has not really changed anything. If she's prepared to take that slim chance it can be cruel to deprive her of it

It's especially cruel when the real reason doctors cancel the cycle is because of "clinic policy" - because they do not want to mess up their success rate statistics !

These are challenging patients, and during superovulation, the major worry is - Will we reach the stage of egg colleection ?

Many doctors will cancel cycles if there are less than 4 follicles, because poor responders have a lower success rate and they do not want to harm their clinic IVF succcess rate. These are league table games clinics play, where they weed out the difficult patients to artificially elevate their published succcess rate figures.

We need just one follicle to go ahead, as long as the patient has realistic expectations and understands that there are still many more hurdles to be crossed after egg collection: there may be no egg; or the egg maybe immature; or it may not fertilise. We can be aggressive and are happy to do our best to help the patient to have a baby, but sometimes biology can be cruel !

With this approach , our patients have peace of mind they did their best ; that they explored all possible medical options and did not leave any stone unturned. With this approach, it's often easier for them to move on to Plan B ( adoption or donor eggs) because they know they've given it their best shot.

The outcome is always uncertain, and I do not want them to regret the fact that they did not try. We do our best to work with our patients - even if this brings down our success rates.

I am an IVF specialist, and know lots about IVF. I read all the medical journals and keep myself updated, so I can provide high quality medical care to my patients - after all, my professional knowledgebase is my major asset and I spend a lot of time on polishing my skills and keeping current with recent advances. Since IVF is such a specialised field, it's much easier for me to do so, as compared to a general physician, for example, who has a much broader area to cover.

However, no matter how good my intentions, the fact still remains that there will be areas in IVF in which I have blind spots. The good news is that my patients are getting smarter and are happy to help me fill in these blind spots. I have always respected my patients and I learn a lot from them all the time.

Medicine is a rapidly advancing field and doctors need to learn all the time. Our best source of information and knowledge is our patients - and rather than getting angry and upset when patients bring huge sheaves of internet printouts, we need to treat our patients are intelligent expert research assistants, who can help up to provide them with the best possible medical care by helping to keep us on our toes ! These expert patients can act as our eyes and ears - and explore areas we may not be aware of.

Not all these expeditions will be worthwhile or productive - but you never know what the next expert patient can help you to unearth !

Like all professionals, doctors have a certain image about themselves . Similarly, patients have expectations of their doctors and expect them to conform to their mental model of how a doctor should behave.

Life was much easier in the past when both patients and doctors expected doctors to behave as demi-Gods. The doctor was a shaman who was considered to be a healer who had been inspired by divine powers which he could use to help the sick to get better.

In modern society, however, things have changed considerably; and few patients will treat their doctors as God-like figures ( and I feel most doctors would also be very uncomfortable in this role !)

What roles do doctors adopt today ? These are primarily three, as articulated so well by the British economist, Julian Le Grand. We perceive doctors act as:
Knights ( when their major driving force is virtue);
Knaves ( when driven by rigid self-interest ; or as
Pawns ( when they feel they are just passive victims of their circumstances.

All doctors play all three roles at various times in their life – but your primary avatar will depend upon your life experiences and your self esteem. We are Knights as we care for our patients. Always acting in the best interest of our patients is our primary professional role, and society holds us in high esteem for that. However, many healthcare activists take perverse pleasure in painting doctors as being self-interested and greedy; and paint all doctors as having Knave-like qualities ( an unflattering image some doctors help to reinforce when their primary focus seems to be on grabbing money ). Finally, in this day and age of insurance paperwork and governmental regulation , many doctors have simply given up and play the role of a bitter passive victim who is overwhelmed by demanding patients and squeezed by corporate hospitals. However, society is not kind to Pawns !

If we as doctors want society to regard us with the respect which we feel is our due, we should be aware of societal perceptions and foster a regard of doctors as Knights, and not as either roguish Knaves or helpless Pawns. Remember that society will treat us the way we expect to be treated and we will get what we deserve !

So how do you behave as a Knight and get your patients to trust you ? By proving that you deserve their trust – and you need to earn this, by being generous with your knowledge; showing your patients that you care; respecting their time; and fulfilling your promises. The hallmark of doctors who have been elevated to the status of being treated as trusted advisors by their patients is that the doctor places a higher value on maintaining and preserving the doctor-patient relationship itself , rather than on the outcome of the current consultation.

Establishing a history of reliability is one way to build trust. For example, if you tell the patient you're going to call with lab results, make certain that you do just that. Doing this the first time will show your patients that they can count on you. Doing it again and again will build trust. To win your patient’s trust, you have to behave as a professional – someone who will place the patient’s interests before his own – so that both of you benefit in the long run ! This is why senior doctors valued their reputation so much – it was built on the foundation of a lifetime of hard work – and even though it is intangible, it represents the fact that patients have trust in you.

The Trust Equation , as defined by David Maister, is simple.

T = C + R + I/ S, where

T = Trustworthiness
C= Credibility
R= Reliability
I = Intimacy
S= Self-orientation

Credibility = can your patient trust what you say ?
Reliability = can he trust your actions, confident that you will act honorably ?
Intimacy = is he comfortable discussing his feelings and emotions with you ?
Self-orientation = can he trust your motives, knowing that you care about him, and will act in his best interests ?

Professionalism is one of our core competencies , and we need to encourage all doctors to behave as Knights in the care of patients. Being a physician is still one of the greatest privileges society offers anyone, and we should always remember how fortunate we are.