By Dr Kamal Kumar Mahawar
If you live in Delhi and listen to the radio, you must have heard these adverts from a famous local diagnostic facility—how you must have a number of blood tests carried out every so often to maintain good health.
I am not sure if there is any scientific evidence behind this. One does wonder where the advertising regulator is and what rules apply to diagnostic facilities when they make such scientifically questionable claims.
India is perhaps unique, in that any individual can go to any diagnostic centre and get any test done. Some tests such as Xrays and CT scans may even have harmful physical consequences. Certain others like positive tests for HIV (AIDS virus) or cancers may have adverse psychological and social consequences.
Whether or not you as a patient can interpret a positive or a negative result, you are being encouraged to undergo whole body checks every now and then to ensure you stay fit!
Now, here is my opinion as a doctor, and one that I think most doctors in the world would endorse—you don’t need tests to stay fit. What you need is to follow a healthy lifestyle, live in a clean environment, take sensible precautions, and see your doctor when you have any problem. Not only can unnecessary tests cause direct financial, mental and physical damage, they can also lead to fraudulently wrong reports, unnecessary and sometimes dangerous treatment, and inevitable significant increases in health care costs.
The same is true of the custom of routine health checks being vigorously promoted by many corporate hospitals. As a patient, you will think this is a good idea. You go to a doctor. They examine you and conduct tests, diagnose disease at an early stage, and you stay healthy.
However, what you may not know is that the evidence for such routine health checks is not undisputed. Many of the diseases identified in these checks may never cause any significant harm to you whereas the adverse consequences of additional tests and treatment they inevitably demand are real. In addition to a significant financial burden on the health care systems and psychological distress to the individuals, routine health checks may not even translate into improved health outcomes.
Screening of asymptomatic individuals is a significant issue that policy makers and professionals need to examine in some depth. The purpose of all screening is to diagnose diseases at an early stage to improve treatment outcomes.
Though screening is routinely recommended for many diseases in Western countries, we lack studies establishing their benefits in the Indian context. This is one of those areas where data cannot be directly extrapolated (not that any data can ever be directly extrapolated across populations), as there are significant differences in lifespan of individuals, genetic makeup and ability of health care systems to cope.
There is a lot that India needs to fix in its health care scenario before we start screening normal individuals for diseases. Now, I am not suggesting a blanket ban on all screening in India. What I am trying to argue for is that we make a convincing case for any screening and also define the population to which it will be applicable.
The Indian population is a very heterogeneous mix and one of the responsibilities that fall to the planners and the professionals is to come up with different solutions that suit different groups. Moreover, health care resources are finite and societies must decide for themselves how they wish to use them.
Screening has significant cost implications for both publicly-funded and insurance-funded health care and usually ends up making health care more expensive for everyone. It may be that we recommend screening only for self-funded individuals who can bear the costs not just of the screening but also of the (usually negative) tests and treatments that follow. Such an approach will also act as a future cohort in studying the benefits of screening for the Indian population.
No two individuals are the same. This fact doesn’t prevent some doctors from treating accepted variations in physiological parameters as diseases. Prescriptions for tonics for thin individuals, nutritional supplements for tiredness, treatment of low blood pressure, medication for slightly high cholesterol—all fall in this category. What can be corrected with simple dietary advice is often treated with a tablet.
If you have some cold and cough, irrespective of the fact that a vast majority of these are viral infections, a large number of doctors will prescribe antibiotics. Part of this comes down to patient psyche—some patients only value a doctor who prescribes a few tablets.
Medical advice itself often counts for nothing. The medical community has responded, not by launching mass health education campaigns, but by giving in to the public clamour for capsules. There is another angle to this debate.
Doctors are working in a market. If patients do not get quick relief, they will go to somebody else. Doctors often treat a number of conditions simultaneously, to avoid missing any. If you visit a doctor with fever, your doctor will often treat you for a number of common causes simultaneously.
Furthermore, many diseases are self limiting and don’t need any specific treatment. Doctors wouldn’t tell patients this for fear of losing business. Hence, they prescribe symptomatic treatment and proclaim a cure while nature takes care of the disease.
Practising systematic and evidence-based medicine, in absence of respected local guidelines that both patients and doctors can trust, is a luxury that very few doctors can afford. Here, if a patient is not cured in a couple of days, he changes the doctor, and doctors are continually worried about surviving in a tough marketplace rather than honing their professional and academic skills.
We must understand that medicine is both a science and an art. It often takes time to get to the correct diagnosis and doctors usually develop safe algorithms in their areas of practice. If you, the patient, don’t accept this, you will indirectly end up pressurizing your doctor to treat you for all possibilities. This causes real harm and inflates health care bills.
Nevertheless, patients are not entirely stupid and it is important to understand the rationale underlying observed patient behaviour.
In a country where it can be difficult to differentiate quacks from doctors; where fresh pass-out doctors are given the licence to practice without any further training; where unethical medical practices are rampant and the medical regulator itself stands accused of corruption, how can any patient really be sure that correct treatment is being given?
Trust lies at the rock bottom of the doctor–patient relationship and that is the fundamental issue in this analysis. A series of bold and determined initiatives will be required to restore that trust.
Excerpted with the permission of HarperCollinsPublishers India from the book “The Ethical Doctor” by Dr Kamal Kumar Mahawar.
You can buy the book here.
