Tuesday, May 19, 2015

The corporatization of healthcare - a double-edged sword



There is a lot of distrust among the general public about doctors, hospitals and healthcare providers in general. A lot of this started after healthcare started getting 'corporatized'. It is a well-known fact that doctors get referral fees for most medical services - lab tests, pharmacy prescriptions, hospital admissions, ICU admissions etc. Many corporate hospitals also are known to set targets for their doctors for these services.

Across the world, this has led to an increased burden on the payers - whether they are insurance companies, governments or the patients. This cannot be good for anyone in the long run.

Atul Gawande (a surgeon of Indian origin in the US, author of bestsellers like Better and The Checklist Manifesto) wrote in an excellent article for The New Yorker, "An avalanche of unnecessary medical care is harming patients physically and financially."

Gawande writes, "The virtuous patient is up against long odds, however. One major problem is what economists call information asymmetry. .... Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations."

Another major problem, Gawande highlights, "... is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative."

The whole model of incentivising doctors for tests and procedures has just too many problems.

There are many doctors who have started resisting this model. There are some companies which are being formed that are changing the model to show that doctors can still make money (nothing wrong with that!) but by ensuring better care. The US's WellMed has a model where "if a doctor improved the quality of care, this would save on costs, and WellMed would share those savings with the doctor in the form of bonuses." This is where healthcare should be moving towards.

Doctors should be incentivised, no doubt. They should be allowed to make money. After all, they spend years learning medicine, spend lakhs of rupees getting their education. What is wrong in them trying to recover those costs and lead a comfortable life? Aren't they entitled to a good life as well? Of course! The only issue is that this should not be at the patient's expense. This should happen only if they ensure that their patients do well! Outcomes based incentives are the way to go.

Despite people cribbing about corporate hospitals, these hospitals are the ones that have brought quality healthcare to the Indian population. Walk into a government hospital today and you see the difference. Many of these hospitals are very badly run. They just do not have the infrastructure to cater to the large volume of patients. The only way patients have got access to quality is due to these corporate hospitals. There's no denying that the latest technology has been made accessible to the patients in India only due to the corporate hospitals.

Many doctors are also becoming increasingly frustrated with the system that accuses them of various unethical practices but glosses over the constraints they are operating under. This led to a doctor saying he would never advise his child to become a doctor in India.

What needs to be done is to turn the model on its head and make sure that corporate hospitals remain profitable, doctors continue to earn a decent income and yet patients don't have to undergo unnecessary procedures and tests. I'm sure the MBAs and consultants that are managing these hospitals can figure this out!

A great beginning has been made by the SLIM (Society for Less Investigative Medicine) initiative started by some Indian doctors. This society aims to reduce the number of investigations and interventions for patients. An article about the initiative says, "Doctors from across the country and non-medical professionals 'frustrated by the sheer avarice on display in the entire field of medicine' have expressed their desire to be part of the SLIM initiative."

One suggestion to SLIM - give people who are part of this initiative a certificate or a poster they can proudly display in their clinics and increase awareness about this initiative. When patients go to SLIM empanelled doctors they can be sure that they would not be subjected to unnecessary medical expenses.

Any system evolves. The Indian healthcare system must also evolve. Just like Rome, it cannot be built in a day. The good part about this is that people have started realising this and some action is already being seen. I only hope this continues and the system changes so that all can win - hospitals, doctors and most importantly, the patients.

Sunday, May 17, 2015

The perils of growing up



Summers are an interesting time for me.

I grew up with cousins around my age. We were brought up in similar circumstances. We were brought up by parents who had similar values and had similar means. We made life's decisions around the same time. Our paths diverged when I was diagnosed with kidney disease. They went on to get married and have kids, their lives being completely engulfed in the routine chores of looking after their families. The males among them made careers, the females were mostly home makers.

Summers are interesting because the cousins typically come to Hyderabad to meet their parents. They bring their kids along. I find it really intriguing to see how these kids are brought up in the age of the internet and Facebook.

I cannot help sniggering to myself when I see my cousins scolding their kids for craving colas and junk food. To me, it was just a few years back when we ourselves craved these unhealthy options. Oh, I say to myself, how the times have changed!

I have seen this happening all around me. Most of my friends are married and have kids. They all try to bring up their kids the 'right' way. Eat the right things. Study. Don't play too much. It just seems a little weird to me that our parents were saying this to us not so long ago. At least it seems not so long ago. :-)

The innocence of childhood is lost in stages. When you get married, you lose about a quarter of it. There is still three-quarters left and there is still some hope left. When you become a parent, that is it. You're done for good. You lose pretty much all of it. You don't find silly things funny. You get irritated when your kids do things even though you did them yourself.

Growing up is highly over-rated. People give and expect too much respect. Life becomes too formal, too suffocating. People are constantly on the watch. "What would the world think about me if I did this?" I generally detest Navjyot Singh Sidhu, the irritating ass who's always on a laughathon and is always hyperactive. But he did say something once that makes a lot of sense, "Duniya mein sabse bada rog, mere baare mein kya sochte hain log?!"

 Of course, there are exceptions. But the vast majority of the people are too busy trying to become successful. We need to let loose for a bit every now and then; be a child again. Life would be much more refreshing that way.

Wednesday, May 13, 2015

Postprandial hypotension in dialysis patients: feeling dizzy after a meal



For a long, long time, I have had a major problem. I feel dizzy after my breakfast. This lasts about an hour to two hours and I need to lie down to feel better. I always put this down to pulling off too much fluid during my nocturnal dialysis sessions.

This did not seem logical however. If it really was due to pulling off too much fluid, I should feel bad towards the end of the session or immediately after the session. But I feel totally fine immediately after the session. I actually have a 45-minute swim soon after. I feel totally ok during the swim. Only after I my breakfast do the symptoms start.

Many times, on work, I have to take an early morning flight. This is really horrible. I need to have my breakfast before I head to the airport. By the time I reach the airport, I am totally like a zombie. To make things worse, early mornings are the worst time to fly from Hyderabad. The Hyderabad airport check-in and security lines are really, really long and to wait in those lines with a dizzy head is just too much to take for me.

For the last few trips, I took the wheel-chair option! I was embarrassed and was worried someone would see me! "This is the guy who claims he leads a normal life despite being on dialysis and here he is - on a wheel chair!!!"

My brother Prasan, with a casual comment one morning on the way back from Govind's bandi caused an epiphany. I was feeling really dizzy after the sumptuous breakfast and he said that the body needs to do something to process all that food and that was the reason I was feeling dizzy. That may not have been an accurate description but it was the first time I realised that it was only after my breakfast that I felt dizzy.

I typed the phrase "feeling dizzy after a meal" on Google and I found what I was looking for! The condition even had a name - post-prandial hypotension and had some suggested solutions - eating light meals that are low on carbohydrates, having a glass of some fluid about 15 minutes before the meal etc. And what's more, it was a condition that was common in dialysis patients!

I tried the solutions. Some did not work. But the one that worked for me like a charm was eating a very small breakfast. These days, I have a very light breakfast and carry some breakfast to office where I have it after an hour or so of reaching. I also took the last couple of flights without any problem. I am really so happy and relieved. Thanks so much to my brother for that comment!

Friday, April 24, 2015

How much fluid weight do I gain between two dialysis sessions?



A great thinker had once said, “Never ask a lady her age and a dialysis patient his weight gain.”

I often get asked this question. Especially when people get to know that I dialyse every day. People who ask this are either nephrologists or people on dialysis themselves. You can’t blame them. Fluid weight gain is one of the biggest problems for people on dialysis and for people who treat people on dialysis.

My guess is people who dialyse thrice weekly and have no urine output would gain on an average two to three kgs between sessions. Unless they are very compliant - the ‘good boys’ in which case they would gain between 1 to 2 kgs or extremely non-compliant - the ‘bad boys’ in which case they would gain about 4-5 kgs.

I dialyse every day (pretty much) and I typically put on 3 kgs between sessions unless it is my day off, after which I am about 5-6 kgs above my dry weight. If I am travelling and have a day off, it could touch as much as 7 kgs.

There, I have said it. No, no, please don’t berate me. Don’t tell me about the dangers of the high gains. Don’t even ask me how I manage to put on so much.

I look at it this way. I take all the trouble of doing daily dialysis. I spend all the money on doing daily dialysis. I bear two big pricks on my arm almost every day of the week. All this for what? To deprive myself of the cola? To restrict myself from having the chilled aam panna? Why even bother with so much dialysis if I had to restrict myself so much?

Make no mistake, the biggest problem I have with kidney failure is the fluid restriction. If I did not have to restrict my fluid, I would not have any problems with kidney failure! Seriously!


So, now that I have answered the question, please don’t ask me this again and more importantly, those who deal with me on a daily basis, please, never ever, ever ever say something so ridiculous like “such a high weight gain” again.

Sunday, April 12, 2015

Ooty diary

Coimbattooor-Coimbattooor...

The NephroPlus founding team was to be honoured with the "Dynamic Indian of the Millenium" Award by K. G. Foundation Coimbatore! So, the three of us, Vikram, Sandeep and I planned to go to Coimbatore for the event on the 5th of April. We also thought a celebratory break of a day would be just right in the cool climes of Ooty after the event!

Ever had a song stick in your head with no hope of letting it go for many hours? Well, I had that happen to me many-a-time and a few days before the event, the song from the movie Padosan, Bhai baddur was stuck in my head except that my head, all excited about the trip, conveniently replaced the first two words with Coimbattooor-Coimbattooor! Here's the original for those inclined:



Dynamic Indian of the Millenium

The K. G. Foundation awards distinguished Indians who have made some impact on society every year with these awards and we were quite surprised that we were picked for the award this year! The foundation is headed by the dynamic Dr. G. Bhaktavatsalam, an extremely active doctor, who heads the K. G. Hospital of Coimbatore and is a Padma Shri himself. The organisation of the awards event was really amazing. All the finer details were taken care of. The award itself was a plaque, a shawl and a memento. After the awards were given to us, they were collected back and were sent to our car. By the next day, an album with pictures from the event that featured each of us separately was delivered to us! Truly remarkable!




Ooty -  a day in the hills

We had rooms booked in Club Mahindra Derby Green at Ooty. As soon as the K G Foundation event completed, we headed out in a cab for Ooty. The three and half hour drive that culminated at around 11 p.m. was quite tiring. As soon as we reached, we checked into our rooms. The resort was a three hundred year old property. The rooms were made out of fine wood and had an old-world charm about them.

The next morning we got up late and headed for the restaurant for breakfast. We had a Maruti van come and pick us up to take us to the restaurant. The resort is so vast that for people with creaky bones like me, just going about from place to place would be an arduous task!

We then got ready and decided to go around Ooty. We first went to the Ooty lake. Just outside the boat house, I chanced upon some lovely Tota-kairis and passion fruit. We had our fill of these fruits which were really delicious. We then took a pedal boat and took a half hour boat ride in the lake.



How not to market Tea!

We then went to the Government Tea Factory where they show you how tea is processed from the leaf that is picked from the gardens to the Cut-Tear-Curl process and the roasting to eventually give you the tea that you actually brew. There's a rather sad sampling that you are offered after which you could buy what you liked. To put it mildly, a much better job could have been done.

To me, tea is something that is almost divine. I enjoy my three cups of Darjeeling Orange Pekoe over my day with such relish that this came as quite a letdown. I was looking forward to an hour of fondness, it turned out to be an hour of disappointment!

Doddabetta Peak

The driver then told us about the Doddabetta Peak which was supposedly the highest peak of the Nilgiris. We drove down to the point where there is an entrance to the place. You had to walk about half a kilometer to the point where you could get a great view of the valley. I, with my creaking bones and Vikram and Manju with their year old daughter decided to give this a miss. The drive to the place however was truly amazing. The road to the point is quiet and quaint, with eucalyptus and teak trees on both sides growing wildly. We were quite happy to take the drive back to our hotel for a nice, short nap.



Winding up

The evening saw us getting massages at the hotel spa which relaxed and rejuvenated us. I went to the local market and bought some passion fruit and mangoes for my parents. We had dinner and turned in. We were back home the next afternoon.

Though this was a small trip, it served the purpose - that of a short break and an opportunity to recharge our batteries. In the modern day and age, where you get so tied down with your daily work, even a short trip like this can really help. Especially with work like ours in NephroPlus, where every day can bring on a new challenge, where every decision we take is critical and affects a lot of people, it is essential for our minds to be refreshed once in a way.

Sunday, March 29, 2015

Depression in Indian Dialysis Patients: a problem begging to be addressed



This morning, as I browsed through my Facebook wall, I was alarmed to see a friend's post that he was trying to enjoy the last few days of his life! This guy is on dialysis and has been on dialysis for a year. I was wondering what could have happened that he thought these were the last few days of his life?

I called him immediately and realised that he was thoroughly depressed. I tried to cheer him up and realised that many people on dialysis are very depressed.

Unfortunately, in a country like India, where there are hardly a thousand nephrologists for a population of more than a billion, doctors do not have enough time to spend with their patients and give them 'all-round' care. A dialysis patient has multiple problems - the basic issues around dialysis itself, diet problems, co-morbidities, psychological issues. There is just not enough bandwidth for a doctor to attempt to address all these problems!

The patients themselves find it hard to grapple with a multitude of problems. Add to that the horrible problem of paying for treating all this.

"Its all in the mind", goes the adage. Now, there's proof to back this. A paper in Nephrology, Dialysis, Transplantation states, "scores on the emotional components of (Quality of Life) questionnaires are in fact strong predictors of patient outcome." A study quoted in this paper actually found that "patients with scores of 0–37 have twice the relative risk of death than those patients with scores of 51 or higher".

In India, what can we do to address this very significant cause of patient mortality among the dialysis population?

First, we need to acknowledge that this problem exists. We need to at least start tracking depression among our patients. It is not very difficult. Standard questionnaires are available. A beginning can be made by administering this questionnaire to our patients and then figuring out the magnitude of the problem at hand in our country.

Subsequently, steps can be taken as arranging support systems for those affected. We, as a country, may not have the resources to treat every patient who is depressed. Let us at least make a beginning. Rome was not built in a day. Treating dialysis patients is honestly, a more arduous task.

The medical community owes this to the patients. Dr. Victor Gura said, in response to a question on how working on the WAK helps him:

"Why would somebody go to medical school for any reason except because you want to alleviate pain and suffering or save lives. If you go to medical school that's what you want. And I would be basically fulfilling my endeavors and my hopes of becoming a physician. Alleviate suffering, make life better and hopefully save a few lives."

Saturday, March 14, 2015

Improving outcomes and QoL in patients on long term dialysis: what is the secret?

I was recently a panelist on a discussion at the Indian Society of Hemodialysis Conference on the topic, "Improving outcomes and Quality of Life in patients on long term dialysis".



I have been on dialysis for almost eighteen years now. I lead an almost normal life. I swim every morning. I work full time. I travel regularly. If you asked me what the secret ingredient in this recipe is, I would unhesitatingly say, "hours, hours, hours". The number of hours you spend on the machine, in my mind, is the most important factor.

I could not make that point as forcefully as I would have liked to in the discussion. In any panel discussion, even without Arnab Goswami as the moderator, there is a limited amount of time that each panelist gets to make his or her point. With Arnab, you have a second or two before he would interject and then make your point for you even if it is not really your point!

But, I digress.

There are two things dialysis removes - fluid and toxins. You can use a better dialyzer to remove toxins in a better manner. However, for fluid removal, even the best dialyzer in the world is restricted by the physiology of the body. The human body can only handle about 400 ml/hour without any complications. Stretch this limit and you are setting yourself up for a variety of problems like cramps, low blood pressure and some heart issues like Myocardial Stunning.

More hours on the machine also means you have less time between treatments. This means lower inter-dialytic weight gains. The normal human body has about 5-6 liters of blood. When someone consumes about 2 liters of fluid without removing it, it means almost 40% extra fluid for the heart to pump. This puts a lot of load on the heart causing it to expand (Left Ventricular Hypertrophy) and eventually fail. That is why most dialysis patients die of Cardiac issues and many of them die during the 'long-gap' between sessions. For patients on thrice a week dialysis, this typically is the 'killer weekend' - the Sunday-Monday gap or the Saturday-Sunday gap.

So, how much dialysis should one get?

I would say, "however much you can practically get!" I get about seven hours each night, six nights a week. That's at least 42 hours per week! Compare this to those who get five hours, twice weekly or four hours, thrice weekly. I get a lot more. Yes, there are a large number of people who have survived for a lot longer than I have on these modalities. But we must not get swayed by a few odd cases. The vast majority of patients who get low hours per week have poor survivals and quality of life.

Even when it comes to toxins, middle molecules can only be removed by more hours on the machine. These are the silent killers when it comes to long term dialysis.

I strongly believe a lot more effort needs to be made by the Indian dialysis community in getting patients more hours on the machine. Yes, patients here have financial constraints. Yes, we have a resource crunch. But if we honestly ask ourselves the question, "Are we giving optimal (not just adequate) dialysis to every patient who can afford it?", I am sure the answer is a big "No".

Are we giving enough hours to patients covered by private insurance? No!

Are we giving enough hours to patients covered by Government reimbursement schemes? No!

Are we giving enough hours to patients to patients who can afford them? No!

Where is the financial constraint for patients here?

I rest my case.