Waiting time in clinics – what’s the way out

I came across a tweet by someone disappointed with waiting time in a doctor’s clinic in Mumbai. The tweet had touched a raw nerve among both patients and doctors. Patients find it hard to believe that an appointment at 6PM can mean anything from 6 PM to 8 PM and doctors find it hard to stick to appointment times.

Some patients are even willing to pay for zero wait times, priority slots etc – at least in Mumbai. So I ran a series of twitter polls to understand the issue better.

Here are the results and my interpretation. (Yours might vary – feel free to post in the comments)

Disclaimer: The Twitter poll is not “scientific”, but serves as a starting point for discussion

Patient’s perspective

Nearly 60% of patients are willing to pay more for shorter wait times. Most of them are willing to pay 25 -50 % extra. So if the consulting fee is 500, they might pay Rs.625.

Doctor’s perspective

Most doctors are wary of express/priority pass as they think it will lead to negative PR and alienation of existing clientele. However, they are open to investing in technical solutions to the problem and are willing to pay anywhere between Rs.5000 per year (some are willing pay more too).

Insights

So is an express ticket a good idea because patients don’t mind? Probably it’s not as much taboo as doctors think it is, however it is unlikely to solve the problem. Most people are willing to pay 25 % extra because they think that is what it will take to get immediate appointments. However a 25% hike can be easily afforded by many people and the “special queue” will get almost as big as the “normal queue”.

“Smart scheduling” solutions can potentially adapt to the moving queue and update the waiting patient in real time, the status of the queue, how fast it is moving and whether their 6 PM appointment is indeed possible at 6 PM or only at 7 PM. For this to happen

1. Such a product should exist
2. Doctors should be willing to pay the asking price for that product

Q1 I am not sure. Q2 is roughly Rs 5000 to 10000. Given that there are thousands of clinics in India, it is upto the software makers to do a market research and find out if this a viable solution.

This is an opportunity for tech companies – or indie developer teams.

B complex – a tribute

The humble B complex tablet, is a fascinating portal into the practice of medicine. It’s one of those drugs that can be easy to start, but hard to stop – because people tend to get used to it, especially when it is free. It is remarkably safe and if the patient takes one tablet too many, it just comes out in the urine – the worst thing that happens is usually costly urine. In medicine, we call such drugs to have a high therapeutic index.

Consequently it is prescribed right, left and center. The B complex prescription industry is worth billions of rupees in India. It’s the safest cash cow available. Given the strong love for B complex among patients, it is also a holy cow. Because holy cows are hard to talk about, an aspiring doctor might give a “”treatmill test” for his/her communication skills by trying to wean off a patient from B complex.

Unlike most other modern medicines, B complex contains many things – vitamins for example. It’s not called as such, but is perhaps the most commonly used polypill. Since only a fraction of the patients who take B complex are actually deficient in vitamins, one wonders how the practice of widespread prescription of B complex came into effect.

One of the reasons is the weaponisation of language – B complex et al is called “சத்து மாத்திரை” (strength tablet) in Tamil. Similar terms probably exist in other languages. The idea is simple – take B complex and it gives you Thor like power. After decades of calling a tablet as strength / power tablet , it becomes a self validating prophecy. People wonder, if it doesn’t give strength, why would they call it strength tablet? Duh.

Another reason is the lack of placebo. Sometimes , a patient needs just reassurance – but like other things in life, dose matters.

The time needed to reassure a patient is directly proportional to the number of unexplained complaints they have.

It’s much easier to prescribe a B complex tablet, saying it will fix everything, than devote so much time.

B complex is often used as a polite way of saying “Shut up”

Of course, the prescription of placebo doesn’t always stem from cynicism. A doctor might continue to give B complex, because there is nothing else to give. Or perhaps the B complex may be the only ray of light in an ocean of poverty and darkness. The false hope it gives may be the only hope – after all, the only kind of hope available.
Depending on context, a B complex prescription can be a symbol of love or cynicism. Of hope or despair.

Placebo. Filler. Cash cow. Holy cow. A self fulfilling prophecy. A subtitute for love, attention, hope and everything in between. An inscrutable enigma.

It’s almost like a God.

To sum up, B complex is er… complex.

Am I responsible?

When things go wrong, we make sense of them with 3 possible explanations

• I am responsible
• Someone else is responsible
• No one is responsible

I have been brought up to believe that if something goes wrong with my life, then I am responsible – and I should try to fix what I can. In Tamil, this is captured by “தீதும் நன்றும் பிறர் தர வாரா”. Children, of course, are unable to take responsibility and always blame others for their problems.

This centripetal blaming – blaming self, before everyone else – has its pros. It propels you to do whatever you can, to change the current trajectory. However, it can be counterproductive in medicine.

I saw a patient today, who had brought her son for a hormonal problem. His voice has feminine, and he had no moustache. The mother was concerned, that somehow her brought up is to blame. She asked, “ Is there anything in the food that I gave him ? Could it be the snacks or the phone ? “ I told her, there’s nothing she could have done to prevent the condition – a tumor in the pituitary. It wasn’t her fault or her son’s fault – no one knows why people develop pituitary tumors. They are like microscopic accidents in the DNA – one the tissue could not fix.

She was distraught, asking me repeatedly if the boy will be 100 % alright. I gave an evasive answer, smack in the middle of that gray zone between brutal truth and kind lie. The boy didn’t understand the gravity of the situation, he seemed non chalant. Ignorance is bliss after all.

As we grow older, we realize that the arrow of causality isn’t straight. It’s a veritable Gordian knot. There are many intersecting vectors – culminating in a problem – and tracing all to a single source is often impossible. Chaos doesn’t respect our need for explanation. Closure doesn’t come from explanation, but from acceptance of the fact that sometimes, there is no explanation.

Sometimes, no one is responsible.

The Noodles consultation & the ‘Google’ Patients

One of the common complaints among Indian patients is “the Doctor doesn’t spend much time with me”. An article published in BMJ claimed that the average time per patient was around 2 minutes !

Our consultations are like instant noodles , but a lot less enjoyable

This is particularly hard to stomach for the suave patient, who brings a ton of queries after a google search. For the rest of this article, I call them “Google” patients – which is only a short form, with no intended disrespect for their concerns. These are the patients who take to social media to vent their frustration with the system. Doctors in-turn are wary of these ‘difficult’ patients – not only are they more demanding, but they cause ‘perceived loss’.

Why do doctors have trouble with the ‘Google’ patients ?

The answer has both an intuitive well known part and less well known part.

1. Busy doctors have little control over consultation time in busy OPDs –  if they spend more time with a patient, then the other patients can’t get their consultations done on time. This is only partly related to doctor scarcity. The  patient flow to the doctors in a city /town is  skewed. It’s like Pareto principle on steroids. 5 to 10 % of “top” doctors see more than the bottom 50 % – and everyone, including the Google patients wants to go to these doctors.
2. Busy doctors can’t afford the Google patients

Why would a doctor not be able to afford ‘Google’ patients ?

For the most part, private practice in India is a volume business, not value business.

Because of the low consultation fee, the only way a doctor can earn a reasonable amount is to see as many patients as possible, while also balancing patient satisfaction. This   means the ‘low hanging fruits’  – easy problems, dominate the practice.

Those with complex problems, long list of queries demand more time . The same holds true for technology solutions which demand teaching.

If a consultation lasts 30 minutes, as opposed to the average 5 minutes, the patient cannot be charged 6x .

So if a doctor chooses to see 5 patients for 30 minutes each – he can see only 5 patients in 2 1/2 hours – as opposed to at least 15 patients per usual. This leads to a perceived loss of 10x the fixed consultation fee. All humans – including doctors have  loss aversion. The misery brought by a 10 dollar loss is more than the happiness brought by a 10 dollar gain.

Sure enough, medical practice isn’t always driven by pure pursuit of profits, but very few doctors can afford to lose that much on a regular basis. Similarly ,the junior doctors who have more time , less patients don’t always attract the ‘Google’ patients. This creates a Catch-22 situation

What can be done?

Several options exist for both doctors and patients , but chances of any of these working are slim. Most of these take the spontaneity out of the doctor-patient interaction and neither doctors nor patients are ready for that.

• Fair usage policy on doctor’s time
• Guaranteed minimum time for the patient
• Printed FAQs as a differentiator / value added service
• Counsellor to reduce the drag on doctor’s time – the counsellor can be paid a fixed monthly salary, split among the patients who need such services
• Separate ‘doubt clearing consultations’
• Patients can choose to forgo social approval/validation and seek a younger doctor who is less busy, but appropriately qualified
• A check-list of 2-3 questions which can be answered in a short time, in a chit.

I have seen many doctors, especially from my field, resort to virtue signaling and ridiculing the concerns of the doctors who aren’t comfortable with the ‘Google’ patients. Such demonising of doctors with genuine concerns is as bad as demonising patients with genuine concerns, for which they seek search engines. It sacrifices a necessary dialogue on the altar of likes and comments.

It’s time we had an honest dialogue on this important problem.

Fragmentation of care: could Concierge medicine help?

Recently I read an article by senior endocrinologist,Dr Mathew John about the fragmentation of care in medicine and endocrinology ,its causative factors and possible solutions. You can read the article here.

After reading the article, I had a few  thoughts – the foremost of which centered on the idea of “family doctor”. A family doctor of the not so distant past,  knew the patient and medicine.

As medicine became more and more complex  , the family doctor basically disappeared – replaced by ever growing specialization and fragmentation of care. 

It takes two to tango

A simplistic thought is to long wistfully for the days of family doctor -but those days won’t return, since patients themselves don’t want it. If they really did, the ‘family doctor’ wouldn’t have disappeared as easily as it did. While it is true that patients don’t have all the power to change the trajectory, it is naive to think that they are completely powerless.  It’s common for doctors to blame themselves for the fragmentation of care, and then suggest some technological solution – to the problem. However,  patients have a role to play too – as do other stakeholders. It takes two to tango.

The million dollar question(pun intended) is if patients value holistic care, as opposed to fragmented care, are they willing to pay for it? 

Voting with the wallet – Concierge medicine 

Assuming patients are willing to pay for better holistic care, how can they vote with their wallet if there’s no option in the medical ballot? One option that can approximate the family doctor of the past, by combining its best features with the advanced medical specialization available today. 

Let’s take a fictional medical practice by Dr Rahul called Orion and a patient named Raghav. Orion clinic sees about 40 patients per day, rushing them through the day, referring patients to other specialists whenever the need arises. The patient goes to the specialist, gets things done, but Raghav does it on his own. When Dr Rahul sees him again, Raghav has a bunch of reports and case notes – some typed, others written with the notorious handwriting of doctors. Now Dr Rahul, has time constraints, and does his part of the care well , but has no way to know if the others are doing the same. Even if all doctors did their part well, the end result can be less than the sum of the parts. 

One fine day, Dr Rahul gets tired of seeing so many patients and delivering suboptimal care. He changes from Orion clinic to Orion Concierge Services. Now, he is the fulcrum of care. He becomes his patient’s nodal point, care co-ordinator. He liaises with other specialists, takes their opinion, but implements the one he and his patient Raghav agree on. Because he sees fewer patients, he is able to spend more time, doing high quality holistic care. For this service, Orion concierge services charges a retainer or annual subscription. Dr Rahul is able to negotiate with nearby labs,imaging services etc and lower the cost of testing. Similarly he has struck a deal with the other doctors / specialists to give his patients preferential appointment and even multidisciplinary zoom meetings.

Gourmet meal or fast food ?

Dr Rahul faces a problem – since he has to spend much more time with the patients and sees fewer patients, he has to make up for the loss by charging patients more for the enhanced services. Unfortunately such business model innovations are pretty risky, because there is no way to know if patients will be interested. Most doctors don’t know how to do WTP (willingness to pay) studies, since they have done MD,DM or MS, MCh not MBA. 

Is it possible to sell gourmet meal in a market that only wants cheap fast food ?

It is possible – however it is not possible to get gourmet meal at the cost of fast food. 

People don’t like to be reminded of the reality , but you get what you pay for. Even in healthcare. A holistic care model which includes state of the art advanced medicine is expensive.

Dr Rahul won’t be able to become a family doctor. Nor can he be omniscient. He can’t be a master, but a damn good jack of all trades. A medical James Bond, if you will – provided the Raghavs of the world really value holistic care and are willing to pay for it. 

MediLocker

Many patients lose past medical records. Some claim natural disasters destroyed their past records – floods, ravaging fires and so so on. One way to solve this is to upload copies of past records into a central cloud, whose storage is paid for by the taxpayer money. Let me call it MediLocker – just like the DigiLocker initiative by Govt of India.

How is MediLocker different from, scanning and uploading it to , say Dropbox or Google Drive ?

• Govt pays for storage space
• Hospitals / clinics upload the documents / reports – not patients
• Interoperability is not a concern as it is not EHR dependent
• Patients can simply share the permalink to their healthcare provider
• Can be Aadhar linked

Unlike having the same EHR across the country -this is a distal solution, where regardless of the EHR used, the final output is stored securely in a server and can be retrieved no matter where the patient goes, even outside India. Hospitals can be appropriately incentivized for such digital initiative. From a practical perspective, if the responsibility of data upload is with the hospital, the chances of a patient losing records will be minimised. It is also likely cost effective – as storage tends to get cheaper with time, unlike most other things.

There are significant challenges too

• Healthcare data is more sacrosanct than other forms and data security is a major concern
• Whether people will be comfortable with storing their data in a govt server, especially if they don’t trust the govt is a question mark
• Data ownership issues

TPO antibody test : what’s wrong and how can we make it right?

I am not a big fan of measuring TPO antibodies. For starters, we can’t treat it. Secondly, even if it can be used for prognostication – what good is knowing what will happen if we can’t do much about it? There is hardly any evidence to suggest there is a lead time advantage with measuring these antibodies.

On the other hand, increasingly endocrinologists have to interpret the anti TPO antibody levels, which they themselves didn’t advise. This is particularly common in young women, who are either planning pregnancy or are already pregnant.

The typical scenario is a patient who seems scared because – her anti TPO antibody level has been reported to be in hundreds. Say 800. Obviously they may not know the signficance of the test, but they can see the lab cut offs which are printed in the report. This is a much smaller number. Naturally they think something is very wrong with them, and they get scared.

This leads us to a fundamental question

Does reporting of anti TPO antibody test as a number offer any advantage over reporting it as positive/negative?

The answer can’t be universal. The number may be helpful if we suspect Hashimoto’s encephalopathy in a patient. It may not be very useful in a young anxious woman planning pregnancy.

Several options exist

1. Print a disclaimer that the number is nothing to be alarmed about. This is meant to reassure patients (and non-specialist doctors too)
2. Use branching logic to report

If patient pregnant –> check if antibody > predetermined cutoff –> if yes, report as positive. If not report as negative.

This leads us to another problem – what could be the predetermined cut off ?

These things are, in my opinion, duct-taping – trying kludgy solutions to solve a problem that shouldn’t exist in the first place

Prevention is better than cure. We need to educate doctors not to order tests unless there is a real need.

Can you become an Ambani with diabetes?

The famed story of Shri Dhirubhai Ambani is almost a folklore in India.He had humble beginnings and worked as a petrol pump attendant in Aden. He noticed that the coins had silver which were worth more than their face value when melted and cast as ingots – and he did just that.

Diabetes patients use glucose strips to check their blood glucose with a glucose meter. These strips have gold and palladium ! The catch is – the quantity is very low. The yield is about 0.009 gms of gold for 10 strips , although exact estimates are hard to come by. To complicate things, getting this gold out of glucose strips is not easy like just melting them – it is a more nuanced process.

All this might seem daunting, until we realise that type 1 diabetes patients (and many type 2 diabetes patients on insulin) test glucose thousands of times during their lifetime. They typically throw away the glucose strips. Instead of throwing away the glucose strips, if they collect it for several years, it is quite possible that they may be able to get one sovereign of gold ;-). Not bad, considering it is anyway wasted.

At the very least, they can make contemporary art from used glucose strips like Michael Natter or Agne Kisonaite !

Contemporary diabetes artwork from glucose strip – agneart.com

Self portrait with glucose strips – Michael Natter

Bottom line : You may not become Ambani or even become a glucose strip alchemist, but you can have a lot of fun.

TSH and fertility

Today I gave a talk on TSH and Fertility in the Indian Thyroid Update 2021. This is a pretty controversial topic, but the key points are

• High risk patients need screening
• Guidelines favour treatment in antibody positive women, even if the evidence that this improves outcomes is controversial
• “What is normal TSH” itself is controversial

You can view and download the presentation below.

TSH and infertility from Dr Karthik Balachandran

Green jackfruit flour and diabetes

Green jackfruit powder may help patients with diabetes – by having more fiber, reducing absorption of carbohydrates or mildly stimulating insulin release. It is apparently flavourless and tasteless, and contains fiber. It can be added to dosa batter or chappati flour .  There are recipes to make it interesting and even add to rice. Many states in India cultivate jackfruit .An interesting paper has been published in Nature Nutrition and Diabetes by an Indian startup – Jackfruit365 which makes greenjackfruit flour and sells it by the same name.

You can access it [here ](https://www.nature.com/articles/s41387-021-00161-4)

## What did they do and what did they find? 

It’s a small study of 40 people, 20 of whom were give 30 gm of green jackfruit flour per day (15 gm with breakfast and 15 gm with dinner) and 20 were given “placebo” flour – which contained 10 gm more carbohydrate. 10 gm of carbohydrate is roughly equal to one extra white bread per day.  There was a statistically significant reduction of HbA1c in the jacfruit flour group by 0.25%. No change in lipid parameters were noted.

## Limitations

The effect is modest. The sample size is small. While the control group took 10 gm of extra carbohydrate per day, it is unlikely to have influenced the results. The authors don’t mention whether the “taste” of the food was altered or whether the subjects had any GI side effects like bloating or flatulence. 

I checked out the pricing in Amazon. Assuming a patient takes 30 grams per day, as done in the study, he/she will need 30*30 =900 grams per month. The product costs Rs. 600 per kg. Though it’s not very expensive, there are several out of patent anti diabetic drugs which cost less than this while reducing HbA1c more. 

Nevertheless, the main advantage of Jackfruit flour is – it doesn’t sound like medicine. It sounds “natural” – something patients love. Many  Indian patients with diabetes wonder if they should give up on their favorite foods – like Dosa and Idly and eat chapati instead. In those people, adding green jackfruit flour to food may have modest benefit without burning a hole in the pocket.

**My take** : This flour is unlikely to be harmful. It’s not very expensive. A patient might try it for a few days – to see if the taste, flavor, texture of Dosa / Idli remains unchanged. If so, they can continue for 3 months and see the effect on HbA1c themselves. If they are satisfied, they can continue. 

Like any other non-pharmacological health intervention, the consumer will be the final judge