People unlike us

There are two kinds of people I meet through my day. Doctors and patients. Rather, healthcare workers like us who administer care and those who receive this care. Being married to a doctor, this universe extends even at home. This would happen in all professions when you work long enough, one would think. But doctors have it different.
In a reunion of schoolmates, I became painfully aware of the fact that I was sticking out like a sore thumb.Unlike my loquacious self, I was tongue tied and looking around desperately to join a conversation.I realized that my sense of humor was full of medical terminologies which the layperson could not 'get' and most of our funny anecdotes about idiosyncrasies around our jobs fell flat in a mixed gathering. Meanwhile a patient called me to inform that she had started her periods and as I was talking to her in one corner of the party about how many pads she was soaking today, I turned around to find a classmate aghast and shocked. So, I stood, nursing my Coke, till I was saved. Three of my classmates purposefully strode to my corner and started asking me about their 'gynec problems'. They appeared God send to me. I recovered my lost confidence and launched into a detailed treatise of how they should prevent and treat these problems. Rest of the party went smoothly as I advised anyone and everyone about their medical ills, real and imagined.
Another such opportunity presented itself soon. I was invited to a dinner by a neighbor. The other invitees were not doctors. I felt that knot in my tummy as the D day approached. I thought of declining ( doctors have the luxury of emergencies which can come up last minute). Then I prayed that someone would have some medical query which I could address and bid my time.
Strangely, the three hours passed quickly and effortlessly. There was hardly any discussion on medicine, but I found myself drawn into conversations. It was a refreshing change to talk to intelligent achievers, administrators and homemakers. We made small talk, but conversation flowed effortlessly and easily. And, at the end of it, I wished I knew each of them a little more, a little better.
It is easy to get caught in our web of diseases and maladies. Easy to restrict ourselves socially to our own kind. But it is refreshing to see the world sometimes from undiseased eyes.
People unlike us, sometimes are eminently likeable.

Assembly line

Medicine. Its exciting at first. After our preclinical classes, when we are ushered into the wards, to see real patients, all of us have felt thrilled. Then, as we climb up the ladder, pass exams, acquire skills and degrees, the excitement wears off.
We choose one specialty: specialize into one branch. And then , some of us, choose an even narrower sub speciality, a smaller cubbyhole. And spend rest of our lives in that small space of one organ or system or problem. We learn all there is about that subspeciality, painstakingly acquire all skills required, and ultimately after a long journey of fifteen years or so, start our practice.
In a few years, medicine becomes a rut.
Day in and day out: same old cases, same old surgeries.
And slowly, the sense of 'wonder' wears off. It is replaced by an assembly line approach.
The patient is no more a 43 year old banker who is finding it tough to control her weight, but ' that hypothyroid lady'. In the wards, we find ourselves looking not for Mrs Aparna, the schoolteacher who was operated yesterday, but 'that day 2 postop hysterectomy'. Slowly, the person/patient is seen as the disease and called by not their names, but their conditions.
Slowly, our increasing expertise means that we arrive at the diagnosis within seconds and spend less and less time with the patient in OPD consultation. Any queries , and they are shunted to the assistant for explanation.
The queues grow. The practice expands.
Slowly, we feel less like a healer. More like an assembly line worker.
I read Atul Gawande's book 'Better' last week. In his last chapter, he writes about asking unscripted questions to our patients..
' On the surface, this seems easy enough. The , your new patient arrives. You still have three others to see and two pages to return, and the hour is getting late. In that instant, all you want to proceed with the matter at hand. Where's the pain, the lump, whatever the trouble is? How long has it been there? Does anything make it better or worse? What are person's past medical problems? Everyone knows the drill.
But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question: " Where did you grow up?" or: 'What made you move to Boston".....
..... You don't have to come up with a deep or important question,just one that lets you make a human connection.'
Some of us might argue that patients come to us for our technical skills, for our diagnosis and treatment. Not for connecting with us as human beings.
But I still sorely remember my consultation with a Dermatologist some time ago. The gentleman did not look me in the eye throughout the ten minute consult. I came out feeling cheated and angry. I felt like a disease and not a person.
Wiser after that encounter, I have always been enriched by my patients and the lives they lead. The anxious 40 year old tubal factor infertility is a Principle of three schools and runs a charity for homeless street kids. The mother of two kids who is repenting her abortion and wants one more kid to get over the guilt of terminating that pregnancy. The couple who failed cycles of IVF with us, and call me every year for their adopted child's birthday.
Asking unscripted questions, delving into lives and not just diseases, makes our lives much more fulfilling. Diseases and their treatments are finite. But human life, with its vagaries and varieties, is infinite.
Connecting with our patients, not as diseases they happen to harbor but as people: mortal, sometimes flawed, eminently human and infinitely interesting, is the most satisfying part of medicine. Everybody can treat, but few can heal. And so, we need to connect.Not only to heal the patient, but to heal ourselves.

Egg donation in IVF

A common scene in IVF clinics is when we fertility doctors have to break the news to the couple that the lady has exhausted her own eggs and egg donation would be the best/only way to have a child. Unfortunately the threshold for using donated/shared eggs is reducing very rapidly.In some clinics the doctor has to only see the lady's age at 40 to solemnly nod her head and say a “NO” to IVF with her own gametes. While most women at or just above 40 do have a poor ovarian reserve, there are some who still have a few good ones left. Especially the women with a shorter duration of infertility like a 40 year old who is married only for a couple of years versus someone her age who has been trying for say 15 years.
Recently a lady41 year old who had been refused IVF with her own eggs at two clinics came to us for IVF. While the ovarian reserve was borderline, we took her up for IVF. Some tweaks in our usual protocol and we got 4 follicles which gave us 4 good quality oocytes. All four fertilized after Intracytoplasmic sperm injection and resulting four embryos were transferred to her uterus on day 2. The reason for transferring four embryos was her age (usually we transfer about two or three embryos). And on day 18 post egg pickup it was what patients call a “BFP”: a Big Fat Positive with beta HCG value of about 480 IU/ml.
A transvaginal scan done today showed a single gestational sac with a good embryo and steady embryonic heartbeat.
It is days like these which make the toil and tears worthwhile.
And reaffirms our belief that third party reproduction with donated gametes or surrogacy is always the LAST option.
So, if your doctor suggests that your best chance is with donated eggs, wait before you take the plunge. Take a second opinion, do your research and hunt for a clinic that respects your right to genetic procreation. Who knows, your own baby may be waiting for you at the end of that long dark tunnel.

Right to records

It baffles me to no end when patients who have done IVF cycles come without any records of the treatment.
All of us know that IVF is not successful 100% of the times. So any patient who has one cycle, is likely to need another one in future. Whenever we plan the first IVF cycle, the protocol chosen is an educated guess from the details like the cause of infertility, age, condition of the ovaries and the hormonal profile. What we always cannot predict accurately is how the patient will respond to the drugs, the quality of resulting eggs, number of fertilized embryos and their quality. In the second cycle, we know all these details from the previous cycle ( provided they are recorded and given to the patient by the clinic!).
I always compare the first cycle of IVF to choosing a dress of your size in a shop: you choose the closest fit: Small, medium or large and buy it. It might fit you very well, or might sag in some places. The second cycle can be tailor made exactly to your response: the dose, protocol, culture protocol all can be modified learning from the first cycle  to optimize the cycle so that it fits you like a glove.
As a doctor, it is our duty to give the details of the dose of medications, protocol, number and quality of eggs, hormonal levels during treatment, fertilization rate and embryo number and pictures to our patients. This information is priceless. God forbid if the treatment doesn't result in a pregnancy, this information can help us ( or another clinic, should they decide to switch doctors!) tailor anther ivf cycle much better.
As a patient, it is your right to receive all this information. Always ask before you start the treatment if the clinic parts with this information.
If not, maybe you are not seeing the right doctor. Know your rights to get it treatment right!