Knocked Up Podcast: Choosing Your Doctor
I don’t know about you, but I have enough trouble trying a new hairdresser, let alone finding the doctor that’s gonna help me have a baby!
Jordi Morrison: Welcome to Knocked Up: The Podcast About Getting Pregnant with Dr Raelia Lew from Women’s Health Melbourne.
I don’t know about you, but I have enough trouble trying a new hairdresser, let alone finding the doctor that’s gonna help me have a baby! Today, we talk about what to look for and how to work with your doctor. We’ve talked in previous podcasts about how “the process” is quite intensive, there are medical procedures and some difficult conversations. It involves the man, it involves the woman. It’s not always fun. One question I ask myself is if I was going through this, how would I know which doctor to choose? It sounds like your doctor is a partner in the whole process. So, how do I know they’ve got the right qualifications?
Dr Raelia Lew: Most patients choose a doctor based on their GP’s recommendation. This is usually a good way to look for a doctor because a GP will have a lot more insight than the average patient.
Jordi: Is that only if you have a regular GP? What if you’re going to a bulk billing clinic and you don’t know better or have a history with someone. What kind of relationship do you need to have with your GP in order for them to refer you?
Dr Raelia Lew: That’s a good point. Ideally, it’s nice to have a GP who knows you and understands the medical basis of your situation because they’ve done some preliminary tests on your behalf. Some people don’t have that kind of GP or they might see a GP as a one-off. Another common way for a patient to be referred is searching on the internet. They chose their doctor, go to a GP and say they’d like a referral to a particular doctor.
Jordi: Is that a risk? Because we’re not meant to use Google to diagnose medical conditions. If we go on the internet, what should we be looking for?
Dr Raelia Lew: Unfortunately, there’s a lot of variation in the qualifications of doctors in the sphere of fertility. There are doctors who do a lot of treatment of fertility, but don’t have as high qualifications as others. When I first got interested in the field of infertility, I was quite young. I was a medical student and I went to an inspiring lecture and I thought this area of medicine is for me.
Jordi: So, when you become a doctor you finish school and get into medicine – obviously you’ve got to be pretty good to get into medicine, what’s the process of becoming a doctor and when do you specialise?
Dr Raelia Lew: It’s a fairly long process. It starts with medical school, which is usually post-graduate. When I did medicine (back in the day) I did an undergraduate degree. I studied medicine for six years at university to become a doctor, then when I graduated as a doctor my next role was in a public hospital as an intern and resident. Only once you’ve done a couple of years of general practical training do you start to specialise. General Practice is in itself a specialty – those early years can, to some degree, count towards your early GP training. I did some specialty training in Obstetrics and Gynaecology before I committed to that training program. I did an extra year as a resident called a streamed residency year where I just did Obstetrics and Gynaecology and a term of Neo-Natal ICU.
Jordi: Is that almost like a trial?
Dr Raelia Lew: Yes, it’s a bit of a trial for you to see if it’s the right field for you, if it’s a good fit and if it’s really what you expected. But it’s also a trial for the teams who are going write references to recommend you to a training program. They’re trying you out to see if you’re any good!
Jordi: That’s good. To make sure that the match is right before you start the next process which takes how many years?
Dr Raelia Lew: Yes, so it take and extra six years to just become an Obstetrician/Gynaecologist.
Jordi: We’re talking 13 years from when you finish school to becoming an Ob/Gyn?
Dr Raelia Lew: Yes. And many people who do practice in IVF have that qualification of FRANZCOG.
Jordi: What does that mean?
Dr Raelia Lew: Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. It’s a mouthful, but there is a is another level called the CREI.
Jordi: I’ve never heard of this, not many people have it?
Dr Raelia Lew: The CREI is quite elite. It’s an extra three years of training on top of your 6 years of specialty training.
Jordi: Now we’re at 16 years?
Dr Raelia Lew: That’s right, then you’re a sub-specialist. I often don’t like the word sub-specialist because it sounds like “less than specialist”
Jordi: Whereas you’ve done actually 16 years…
Dr Raelia Lew: Yes. To have the CREI you have to not only have done the extra time, but you also have to pass an extra set of pretty gruelling examinations both practical and also written so not everybody gets the CREI. Even if you start doing it. Then also you have to have done significant research which is another component of the CREI as well as 3 years extra time.
Jordi: Okay, that’s a lot that goes into this specialty when you decide that this is what you want to do.
Dr Raelia Lew: Yes. I would recommend that if you’re looking for somebody to look after you who’s really got the top qualifications in this arena, look for somebody who is got both a FRANZCOG, a specialty in Obstetrics and Gynaecology, and a CREI. People like myself, who are “gluttens for punishment” might also have a Master of Medicine in Reproductive Health and Human Genetics. I also did a PhD in Genetics which has got a lot of applications in fertility.
Jordi: So you’re an expert, which is why we’re talking to you today! Yes? Okay so obviously it is qualifications, and I think it’s really good to look for because it is a bit of a minefield how to know someone is qualified. The average person might think “they’re a doctor… this I what they do” and not really know what else is required. It’s a very personal process. For myself, I would want to play an important part. I’d need to be able to confide and trust my doctor and know they’re looking after me. How do you work that out?
Dr Raelia Lew: Look, it’s hard to work out because really you find that on a first impression and often that means you have a consultation. I have patients come to me for a second opinion when they’re seeing somebody else and they haven’t quite felt that it’s been a good match for them. That’s not uncommon. I think with personality it also depends on your personality, how you treat your patients with infertility. Some doctors like to outsource a lot of treatment and others who more value the interpersonal relationship with patients are more involved during treatments. I’ve always found that I enjoy not only solving the problem but I also enjoy being involved in that process because that’s when as a doctor you get the most gratification from you patients’ success and also as a control freak you get to ensure that every aspect of treatment is applied in the exact way you want it to be.
Jordi: Also, if there are problems you’ve known every step that’s happened and can talk to your patient about what’s happened and what will we do differently next time, or why the outcome is the outcome!
Dr Raelia Lew: Yes, exactly. The first IVF cycle it’s quite diagnostic as well as therapeutic. It’s a privilege to see what eggs and sperm do together. It’s a privilege to see how a patient responds to your treatment. You can take that information and apply it in their best interests if you make changes moving forward. Being involved in the process and monitoring and having that continuity of care as the only doctor looking after them, I find contributes to my patients having better success.
Jordi: That’s something most people don’t really think about, that often you need more than one cycle of IVF. We’ll talk about that in a different episode. Let’s say you’ve had a couple of cycles with a doctor, you’re not getting your result and not feeling comfortable, there might be other reasons maybe location, maybe you’ve moved. If you want to change doctors, what are the things you should be considering?
Dr Raelia Lew: If you want to change doctors or want a second opinion, it’s important to have a copy of all of your medical records. This includes any tests you’ve had done — always ask for a copy of your results. I always think it’s very useful to keep a folder and just have a copy of all your test results.
Jordi: Then you don’t have to get the test done again…
Dr Raelia Lew: Yes, exactly. Because one thing you don’t want to do if you’ve been through a fertility treatment journey that’s been unsuccessful to date is to duplicate the effort and burden of repeat investigations.
Jordi: More blood tests, more blood work…
Dr Raelia Lew: All tests. Some tests won’t change, for example, if you had a genetic assessment such as a chromosome map, that doesn’t change. You won’t have to repeat it. If you’ve had an ultrasound very recently, you don’t have to repeat it. So it’s good to have copies of those things. Every speciallist you see will need a GP referral letter, so you will have to go back to you GP and ask for a new referral to see an alternative doctor. And look: different doctors have different approaches. Some are more holistic whilst others have a protocolised approach. Someone who doesn’t have the CREI qualification and hasn’t done extra sub training in reproductive endocrinology and specific management of infertility is more likely to run you cycle on a protocol.
Jordi: So, more of a standardised approach…
Dr Raelia Lew: Yes, as opposed to a more personalised approach. It might be that if the standard option hasn’t worked for you, there are other options that could improve your outcome. Often I see patients starting off in low cost clinics where they is a very protocolsed approach, a very “production line” style of IVF.
Jordi: When you say “production line approach”…?
Dr Raelia Lew: Every patient has the same treatment and each time may see a different doctor. Same drugs, same days (for procedures). With a different doctor every time there is naturally little continuity of care.
Jordi: Yes
Dr Raelia Lew: I see these patients often – usually for a second opinion. If that hasn’t worked for them, they do need an next level of care. Often they change doctors at that point.
Jordi: When you talk about continuity of care, could you explain what that means in this process?
Dr Raelia Lew: Continuity of care means looking after patients at every step of their treatment. When I look after patients, the buck stops with me. I am responsible for how that patient is treated during their IVF cycle. I decide on their medication which is a decision that we take together in the context of their history and then I monitor their treatment personally (while they’re going through treatment). Then when it comes time for them to have a procedure, I do the procedure myself. When the lab take instructions, they take it from me so I decide exactly what’s going to happen in the lab. Then when they do have an embryo transfer, I do that personally. That’s what I mean by continuity of care.
Jordi: It’s about having someone with you every step of the way explaining what happens and overseeing. Something else that I think would be important are facilities. How do I know that my doctor really has the best of what’s needed and what is the best?
Dr Raelia Lew: There is a big range of facilities available. Lower-cost models of IVF usually have a basic laboratory with the basics equipment. In terms of staff, you also can opt for premium service models where you have headhunting of the very best staff. For example, Melbourne IVF (where I take my patients for IVF treatment in the lab) invest in cutting edge of infrastructure, new scientific developments, every new piece of equipment and we headhunt the best staff from around the world. Professor David Gardner is our head of science in the laboratory. He is the guy who the grading system of blastocyst embryos and is named after and very famous in the world of IVF. Our laboratory manager has being brought in from a lab in America where the best success rates were achieved in the whole of the United States. Part of the cost of treatment in these facilities is paying for the best technology and the best people.
Jordi: You’ve mentioned working with Melbourne IVF. Could you explain to everyone why Melbourne IVF is a clinic in Melbourne that store the eggs? What else do they do and how do you work with them?
Dr Raelia Lew: I have a range of patients in my fertility practice. However, only a fraction of my patients need IVF treatment because as a CREI sub-specialist I perform a whole range of treatments to help couples conceive, some are completely separate from the need to use an IVF lab. I use Melbourne IVF as my lab when I take patients through an IVF cycle. I’m not employed by Melbourne IVF but I have a relationship with Melbourne IVF much like I have a relationship with a private hospital if I take one of my patients to have an operation in a private hospital. One of the reasons I chose Melbourne IVF as the lab I was going to collaborate with is Melbourne IVF is a premium service laboratory, it really does invest super heavily in technology, so I have the access to the very best equipment for my patients. In the lab I have access to the very best staff and a whole network of support.
Jordi: Passed onto your patients…
Dr Raelia Lew: Exactly. This is what my patients can access, including counsellors and nursing staff to support them. But also it means that I have the freedom to manage my patients in the model care that I want to. Melbourne IVF don’t prescribe the way that I manage my patients, I manage my patients as individuals. Melbourne IVF is a lab that allows me to do all of my procedures personally. Other labs you can affiliate with as a specialist might have a more protocalised approach. So you can make a plan, but you then surrender your patient to “the system” and you might not necessarily have very much to do with them during treatment. That’s not really the way I wanted to practice.
Jordi: Would most doctors in Australia be tied to somewhere like Melbourne IVF or a particular hospital?
Dr Raelia Lew: Yes, a laboratory. Melbourne IVF are selective in the doctors that they affiliate with. They protect their brand and their reputation Most doctors would affiliate with one lab to care for a one group of patients. The practicality of using multiple labs doesn’t make sense.
Jordi: Okay. As a quick summary, when we’re looking for a doctor, qualifications are the most important. Took a look at how qualified they are, what experience they have and their personality. What can we glean about their personality from what we see on the internet? What we see from maybe personal referral or GP referral, what support they have and what facilities are they able to offer.
Dr Raelia Lew: Yes, and of course location. Although it is sometimes worth traveling for a special doctor, location also plays an important part.
Jordi: Because ultimately there’s quite a few appointments and you need to be able to get to them.
Dr Raelia Lew: Yes, that’s right.
Jordi: For more information about Dr Raelia Lew and Fertility Services, visit the Women’s Health Melbourne website or find us on the socials under Women’s Health Melbourne. Thank you for joining us, see you next week!
Reviewed by Dr Raelia Lew
RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
Co-host of the Knocked Up Podcast, Co-founder of Lovers intimate wellness solutions. Raelia has a PhD in Preconception Health Promotion and Genetic Screening. Raelia is a leading Australian expert in IVF and egg freezing, pioneering a bespoke model of care.