Chapter 42
How to Find the Best Doctor

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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In a perfect world, you'd have the perfect doctor, who treats you as an intelligent couple, has plenty of time, infinite wisdom, low fees, is totally honest yet compassionate, has a conveniently located clinic and understands your emotional as well as medical problems. While you may never find such a doctor, you need to keep your picture of your ideal doctor in your mind when you are looking for the physician of your choice.

You can find a doctor through:

• Professional referral. Ask any doctor you know for suggestions.
• Friends, other infertile patients, and infertility support groups.
• The yellow pages can also serve as a useful source of possible names if you need to make a comprehensive list.

You can phone the doctors on your list. Although it may appear unorthodox, "telephone shopping" can provide you with a lot of useful information about an individual doctors practice, including details of clinic timings, fees, qualifications, hospital attachments, special interests. After all, if you are willing to research which travel agent will give you the best deal on a holiday trip, then isn't it worthwhile researching into whose hands you are going to put your life in? You can learn a good deal about the doctor and his practice, even before you actually meet him, by merely telephoning and asking the right questions.

While it is true that many mediocre doctors flaunt posh clinics, the setting in which the doctor functions can reveal a lot about him. Is the clinic located in a decent building? Is public access easy? Has the doctor bothered to provide the basic amenities you need ( e.g., drinking water, comfortable seating )? What kind of reading material is kept in the waiting area? (Old and torn magazines should qualify as a negative mark . Patient educational literature and current issues of health magazines indicate that the doctor respects your waiting time and wants to use it to educate you). Are the office staff member helpful? How do they answer the telephone? How do they treat other patients? you can learn a lot about a doctor and his practice from the personality of his employees: remember that efficient, caring physicians tend to hire competent, friendly personnel!

While selecting a suitable doctor can be difficult, try to find answers to the following questions.

• Credentials - training and qualifications
• Skill and experience
• Accessibility ( locations; clinic timings)
• Affordability ( fees)
• Professionalism

• Does he prepare for your appointment?
• Explain records and test results?
• Keeps appointments and values your time?
• Manage an efficient clinic?
• Review your status and progress periodically?

Personality and style:

• Does he talk to you? Take time to listen to what you have to say?
• Does he show empathy and compassion?

A good infertility doctor will usually:

• involve both husband and wife in consultations, discussions and planning
• offer recommendations and choices. Since there are no "right" answers, he should allow you to choose your own course of action.
• tailor testing and treatment to your emotional needs and budget
• have time to answer questions and offer support
• chalk out a treatment plan for you, with a discussion of rationale, alternatives, costs, time limits and expected success rates.

Many patients are still not very sophisticated when it comes to selecting their doctor . Most Indians follow a herd mentality, and believe that a busy doctor must be the best – after all, if so many patients go to him, he must be good. However, remember that you need to be more critical when making such a crucial decision – after all, you have to trust that your doctor's skills will provide you with the best treatment for your infertility . There is little point in going to a doctor who is so busy that he has no time to talk to you, or who cannot even remember your name!

Most gynecologists can provide basic infertility workup and testing - but you may prefer to look for a specialised infertility clinic which will provide all the services you need under one roof, especially if you have a complex problem. Many gynecologists are not really geared up to providing the care which an infertile couple needs, and it’s not much fun sitting in a room with pregnant women who have come for their obstetric care, if you are infertile.

The risks of going to a general gynecologist for treatment are:

1. They may not have the expertise or specialised knowledge to treat your problem, since they may not be aware of recent advances in this field.
    
2. They may not have access to the specialised tools needed to treat you, with the result that you may have to run around from the doctor to the lab to the ultrasound clinic for your treatment.
    
3. They may not have a special interest in treating infertility, so that you may end up getting "second class" treatment.
    
4. A common mistake many gynecologists make is that they keep on repeating the same treatment again and again – wasting valuable time and money in the process.

We often find that by the time patients come to us, they are so fed up and frustrated, since they have wasted so much time and money on repeating ineffective treatments, that they have lost confidence in doctors – and in themselves as well! Don’t let this happen to you! While going to an infertility specialist can help you to ensure you are on the right track, this does entail the risk of "overtreatment" as well. Unfortunately, many infertility clinics are happy to do IVF for all infertile patients who come to them, whether or not they really need this!

Getting a second opinion

Get a second opinion - this can never hurt and is always helpful. If you find two experts saying the same thing then you know you are on the right track! If on the other hand, they disagree, don't get upset - there are few black and white areas in infertility, and doctors often have different ways of treating a particular problem. Ask questions of both of them and then choose the method which appeals to you - it's finally your decision!

What if you don't understand what the doctor is saying and are getting confused? This is not your fault . If you do not understand anything the doctor says - ask questions! If you still do not understand the fault is his - he is not explaining in terms which you can follow. Find another doctor!

Remember that you need to ask questions to get answers - your doctor cannot read your mind! But also remember that your doctor does not have all the answers - after all, medicine is still an imperfect science, and your doctor is not a fortune-teller. If he does not know the answer, he should tell you this as well.

How do we do a consultation in our practise? We first ask the couple why they think they have not been able to conceive, and how they expect us to be able to help them . The answers give us a good idea of how much the couple understands about their problem. It’s often heartbreaking when we see couples who have been through 3 IVF cycles, and don’t even know how many eggs they grew or how many embryos were transferred each time – or even why the IVF was done in the first place . During a consultation, we first explain, using models, how babies are made. We then review the medical records, and explain to the patient what we feel their medical problem is. We then explain to them what the treatment options are, and tell them to think about these and then make up their mind. In our clinic, we do not charge for a repeat consultation, in order to encourage patients to ask questions, and to give them time to make up their own mind. We take pride in the fact that our patients have a good understanding of their medical problem, and realistic expectations of how we can help them!

Remember that the purpose of a consultation is to get information. If you do your homework before going, you will be able to make better use of your doctor’s time, since you can focus on the issues which are important to you. You then need to go home and process this information, so you can decide what to do. It’s very difficult to think straight when you are sitting in front of the doctor, so it’s usually a good idea to give yourself enough time to apply your mind and assimilate the information, before making a decision. There is usually no urgency, since infertility treatment is never an emergency. Beware of a doctor who wants you to decide on the spot – it’s hard to do so under pressure, and you may end up making a decision in haste, which you may then repent at leisure. In order to encourage patients to think for themselves, we request them to come back a second time a few days after the consultation. We do not charge for this repeat consultation, and we find this policy allows our patients to ask their questions and decide for themselves!

As an infertile patient, you are very liable to being exploited - and quacks in this field abound! Suspect your doctor's credentials when:

1. He promises too much.
2. He says things like - "that's my secret."
3. He doesn't explain clearly what he is doing during treatment.
4. He advises too many tests and surgical procedures repeatedly.

When to change doctors

Because infertility is often a long drawn-out process, anger is a natural result - and often this is transferred to your doctor. However, constantly changing doctors or doctor-shopping can be counterproductive! If the quality of care you are receiving is good, be cautious about changing doctors - a doctor who knows you and your infertility well can be of significant help to you.

Changing doctors is never easy, because, over a period of time you do build up a personal relationship with your doctor. However, you should consider changing doctors if you feel that:

• the doctor is incompetent (i.e., he has ignored obvious symptoms, missed a diagnosis, prescribed the wrong drug, or can't get to the bottom of your problem)
   
• the doctor does not communicate with you effectively ( i.e., his explanations are not in lay person's language or no time is given to you to ask questions and bring up related problems)
   
• the doctor does not pay attention to your needs and concern
   
• you have lost confidence in the doctor's skill and ability
   
• you find the doctor is too inconsiderate ( i.e., he makes you wait a long time for an appointment, he fails to return your phone calls, he does not provide clinic time during evening or weekend hours )
   
• your doctor is too expensive.

A common problem patients face is that when they go to a new doctor, he insists on repeating all the tests all over again. While this can be frustrating and expensive, it can be helpful as well, because it allows the doctor to reassess your problem with a fresh perspective. Please ask your doctor to explain why he needs to repeat the tests, and how this will help in your treatment. If tests have already been done, but are more than a year old, or if they have been done from an unreliable lab, you may need to repeat some of these again.

It is all too common to find that infertility clinics do not provide complete medical treatment details to their patients. They often do this in order to make sure that the patient remains with them, and does not go to another doctor. This is very unfair – remember that your medical records are your property, and you are entitled to a copy of them.

You may find that your new doctor criticises the treatment your previous doctor provided. Remember that doctors do have big egos, and they are often intensely competitive and critical of each other. This can upset you, because you may start feeling that you were given substandard medical care. As long as you have a clear understanding of what was done to you and why, you should ignore this criticism - don’t let it disturb you. Anyone can be wise with hindsight – and do remember that all doctors will try to do their best to help you to get pregnant!

Many doctors will repeat exactly the same treatment the previous doctor has administered – often because they have nothing better to offer! However, remember that even though you have changed your doctor, you have remained the same – and the purpose of changing doctors should be to allow you to progress further with your treatment.

Choosing an infertility clinic

Many couples ask us whether they should travel abroad for treatment. Fortunately, the quality of medical care available in leading IVF clinics in India today is easily on par with the world’s best clinics, since they use exactly the same equipment, and the same techniques. In fact, IVF treatment in India is an excellent bargain by international standards, since you are getting exactly the same quality of treatment you would get anywhere else in the world – at a fraction of the cost. This is why so many IVF clinics in India routinely treat infertile couples from overseas.

How does the quality of care in the smaller towns in India compare with that available in the metropolises? Do you always have to travel to a clinic in a large city for treatment? Since there are no standards or regulations (IVF clinics in India today do not need to meet any quality control criteria) you need to be an educated shopper! While the quality of care can be quite good in smaller towns, most of the reputed clinics are in the larger cities. These bigger programs are usually better, because they are busier, and more experienced, and busy IVF programs (which perform more than 150 treatment cycles per year) have been shown to have higher pregnancy rates. However, very busy clinics may not be able to provide you with the personalized care you need, and some can be quite uncaring, so that they make you feel that you are just a cog in a machine. For simpler treatment such as IUI, it is best to look for a good clinic in your own town. However, for advanced treatments, you may be better off going to an established clinic. While traveling can add to your stress and expense, many infertile couples actually prefer not having to take treatment in the city which they live, as they would like to protect their privacy.

The need for active participation

Remember, you are in charge of your own medical care! Medicine,as both a science and art, often requires choices and there no "right" answers - you need to make your own decisions. After all, it's your body and your life!

You have a vital interest in treatment decisions and outcomes but lack the medical knowledge and skill to decide alone. The concept of a team - the medical caregivers ( doctors, nurses, specialists) and you ( the couple), working together, allows each to contribute to a successful outcome and offers you a sense of control over your infertility care.

Your role on the medical team is multifaceted - you need to wear many hats when you are an infertile patient!

Medical Information Researcher: The more knowledgeable you are about your problem and its treatment, the better are your chances of getting pregnant. Educate yourself - you need to become an informed participant in your infertility care in order to ask the right questions and to participate in making decisions about your treatment. After all, what’s the point of being intelligent if you cannot use your intelligence to help solve your own problems? You will also need to be able to critically assess press and media reports about " new breakthroughs in infertility treatment" ; and whether these are relevant to your problem or not. An Infertility Support Group Reference Library can be very helpful. A friend who is a doctor can also help in separating the wheat from the chaff. While you do not need to become a doctor, you do need to become an expert on your own problem! You cannot afford to leave everything up to God – or up to the doctor!

Medical Team Manager: Remember - you are the one in charge! You will have to locate, choose, evaluate and sometimes fire members of the medical team. Treatment Decision Maker: Although your doctor may be better equipped technically to select treatments, the ultimate decision rests with you. Each new treatment phase requires new decisions - allow yourself time to choose and be comfortable before starting a new treatment.

Treatment Monitor: You are the "expert" on what is normal for you - so record and report reactions. Combining medical and patient information helps to improve the odds for successful treatment.

Medical Record Keeper: You must keep all your records - this can be very helpful if you need to change doctors or get a second opinion. File all records in reverse chronologic order and also prepare a one-page summary sheet of what you've been through.

Financial Manager: Infertility treatment can be very expensive - and sometimes it seems to be an endless drain on your financial resources. You must be aware of the costs involved - and you need to decide if you can afford these.

Communicator: Because infertility involves such personal matters as reproduction and sexuality, people sometimes find it embarrassing to discuss their concerns. It is important that you be open and honest with your doctor. Ask questions, listen to the answers and take notes. It often helps to write down your questions before your appointment, so you do not forget important concerns in the stress of the consultation. Remember, the only stupid question is the one you don't ask - so don't hesitate to ask!

Your Rights

1. You have the right to be treated in a humane manner with care, consideration and dignity.
2. You should be given a clear, concise explanation in non medical terms of your problem by your doctor.
3. You should be given a clear, concise explanation of any treatment or investigation including whether such treatment is of an experimental nature.
4. You have the right to have your partner with you in the consulting room.
5. You are entitled to refuse an examination, a particular treatment, or an operation.
6. You have the right to ask for a second opinion. Ask the specialist you are seeing or ask your general practitioner to refer you to another specialist.
7. You have the right to see your medical records.

Your Responsibilities

1. Be assertive - ask, demand, tell, confront, book, change, refuse, persist, understand, question. You don't need to be aggressive - remember, the doctor is on your side!
2. Be well informed - join a self help group. Read the available literature about your particular problem.
3. Keep your own record of all tests, results, and treatments.
4. Make a list of questions before your doctor's appointment - and write down the answers. If you wish to tape the interview, ask the doctor's permission.
5. Book a long appointment if you feel you need more time with the doctor.
6. Inform the doctor or his receptionist if you are unable to attend a consultation.
7. Take your partner with you to the doctor - it can be mutually supportive
8. Defer any treatment you are unsure about .
9. Do not have unreasonable expectations about your doctor. Understand that he may be tired, rushed or sick at times.
10. If you cannot communicate with your doctor, it is in your interests to find someone you can talk to.
11. If you are dissatisfied with your treatment, try to discuss this with the doctor.
12. If you have unexplained infertility and all investigations and treatments have been tried, you may like to return to your doctor every two years to check on new developments in infertility treatment that may help you.

Emotional Care

When confronted by infertility, you need more than just medical care – and a good doctor will help to provide you with emotional support as well. Unfortunately, doctors often end up amplifying the stress infertile patients find themselves having to cope with. Many doctors make patients long hours, for no good reason; and others are often insensitive to their emotional needs. Others may be quite thoughtless, and instead of trying to provide special attention to the needs of infertile couples, make them wait with pregnant mothers in the clinic. A good clinic, on the other hand, can help to alleviate your stress, by recognizing it; teaching patients that this is normal; and showing them how to cope with it. A good doctor will be able to establish a relationship with the couple, based on understanding and respect, to help them maintain and rebuild their self-esteem.

Questions to Ask Your Doctor

• Do you have experience in fertility treatment? When do you consult with an infertility specialist?
• Will you refer me to an obstetrician when I get pregnant or will you deliver the baby?
• Will you send me to any other physicians or laboratories for treatments or tests?
• Will you treat my spouse? If not, who will?
• Do you arrange for adoptions?
• Do you document surgeries with photographs or videotapes so I can see your findings for myself or provide them to other doctors?
• Which hospital(s) do you use?

Questions to ask About Tests, Surgery, and Treatments

• What kind of procedure is it?
• What will the procedure tell you?
• What results do you expect?
• How long will it take?
• What will it cost? Does insurance cover it?
• Will it hurt? How will it make me feel afterward?
• Can you do it in your office? As a hospital outpatient?
• Will I be incapacitated? For how long? Will I miss work?
• Will my spouse be involved? How? Will he/she miss work?
• Will it interfere with our sex life? How?

Questions to ask About Medications

• How long will I take it?
• What will it cost? Does insurance cover it?
• Will it hurt or have side effects?
• Do I take it at home or at your office?

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Other IHR Web sites: 
Consumers: Infertility Resources
Professionals: InfertilityProfessionals.com
Professionals: InfertilityWebsites.com