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Is the doctor a professional or a technician ?

Posted Mar 09 2011 11:26pm
I just saw a patient who was 40 years old; she had had 2 miscarriages; and she wanted me to do surrogacy for her. I spent a long time explaining to her why I did not think this was her best choice. Surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

Her reasoning was completely different. The fact I got pregnant means my eggs are OK ! The fact I miscarried means my uterus is defective because it could not hold the baby. This means that if use a surrogate uterus, I will have a baby !

The reality is completely different. The fact that she conceived means her uterus is fine because it allowed the embryo to implant ! However, because the embryo was genetically abnormal, it could not grow any further ! We know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. From a purely medical perspective, using donor eggs would be a much better option as it would give her a much better chance of having a baby ! This was my recommendation to her, which she found quite hard to accept.

Logically, it makes no sense for me to clear her misconceptions. After all, I should be quite happy to do surrogacy for her - this is what she wants and I can charge her much more for it ! However, I refused to treat her, and suggested she find another doctor.

I have observed that there are 2 kinds of patients. One group treats me as a professional. They are looking for medical advise and guidance; and want my professional inputs. They have an open mind, and are seeking to form a partnership with me. They want to tap into my professional knowledgebase, so they can make the right decision.

The other group treats me as a technician. They already know what they want - they just want me to do this for them. While this may not be great for my ego ( after all, doctors expect patients to do everything they tell them to !), I am mature enough not to get offended, and am happy to listen to my patients and weight their inputs.

Does this mean I am wishy-washy and will do everything my patients ask me to ? No !

I use a combination of rigidity and flexibility. I am happy to accept patient inputs and preferences and modify my protocols, as as long as they do not affect the outcome ! For example, if patients want us to use the long protocol rather than the short ( which we prefer because it needs fewer injections !)

Similarly, some patients want to use rec FSH for superovulation, instead of the urinary HMG we prefer ( because it's as good and much less expensive !) and I am happy to comply.

However, I will not allow them to do anything which I feel is not right ! I am a professional , and
the buck still stops with me. I will not let them make a wrong decision, no matter what. Thus, if a patient asks me to transfer 5 embryos , I will request them to find another doctor.

Many patients come to me with preconceived notions, especially if they have done IVF treatment elsewhere. Websites and Bulletin Boards are also powerful sources of information - both good and bad ! These patients can be quite a challenge for doctors . If they are well-informed, we can learn a lot from them - but if they are not, it can be quite frustrating to get them to separate facts from reality !
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