Doctors are increasingly prescribing tests to arrive at a diagnosis. Has this benefited medical practice or patients? Four experts debate
Medical tests: How necessary?
Over the past two decades, academicians and civil society have been expressing concern about over-medicalisation of clinical practice, with its growing dependence on diagnostics-tests, X-rays and scans. Advances in medical technology are certainly a boon, but their inappropriate and irrational use is a matter of concern. It is said that the clinical acumen of a physician should be primary and diagnostics should be a supportive tool. But the latter today is increasingly gaining the upper hand.
Several factors are responsible. These include the gradual decline in the quality of medical education, commercialisation of medical and diagnostic services and kickbacks and commissions by the diagnostic industry to individual doctors and physician associations.
The decline in the quality of medical education in government and private colleges is particularly a matter of concern. There are reports of theoretical and clinical training not getting its due in undergraduate and postgraduate studies. The Medical Council of India (MCI) had debated these issues after it was reconstituted in 2010 following the arrest of its president, Ketan Desai. The council’s Ethics Committee heard several cases of private medical colleges recruiting doctors from the public sector to get recognition from MCI. The committee took a serious note of the flouting of ethical norms. Its decisions are available for public scrutiny on the website of MCI.
The root of the problems lies in the commercialisation of medical services in India. A recent report of Transparency International confirms this trend. Harsh Vardhan, the Union health minister, has openly acknowledged that diagnostic centres pay commissions to doctors for referring patients.
In a deliberation of the Ethics Committee, of which I was a member two years ago, there was broad agreement that the regulation of diagnostic equipment and services, in terms of quality and cost, is extremely weak. A majority of the members believed this was an important ethical issue for MCI to regulate.
However, certain professionals within the committee resisted the idea.
There is need for reforms. MCI needs to be completely revamped to allow greater representation of persons from a non-medical background. The General Medical Council in the United Kingdom, for example, has more such persons than doctors. MCI should be open for public scrutiny and accountability. It must undertake curriculum reform in medical education that includes the importance of rational use of diagnostics in clinical practice. Institutionalisation of medical audits and reviews in hospitals is also critical for objective assessment of diagnostic use and misuse.
Here, it is important to talk about initiatives such as the Society for Less Investigative Medicine promoted by concerned physicians and specialists. In a recent interview to the magazine, Civil Society, BalramaBhargava, a cardiologist at AIIMS and one of the founders of the Society, points out the perils of the medical fraternity’s increasing obsession with investigative tests. He talks about how the benefits of certain routine tests that many physicians seem to be obsessed with today-a treadmill test or a coronary CT scan-have been overstated. He also reiterates the importance of self-regulation within the profession.
As concerned citizens, academics and clinicians, we need to highlight the importance of the rational use of diagnostics in medical practice.
A diagnosis is a must for good treatment. However, in recent times, concern has grown over the preponderance of medical tests. It is alleged that tests have taken over the diagnostic acumen of doctors, and commerce has played a big role in this development.
First things first. Most times, medical tests play an important role in making foolproof diagnosis. One cannot deny commercial considerations and the role of insurance companies in the practice. But all said and done, new forms of tests have improved diagnostics considerably.
These tests have proved beneficial for ayurvedic physicians as well. Ayurveda emphasises on diagnosis before treatment. Ashtvidhpareeksha (eight-way investigation) is the essence of diagnosis in ayurveda, although many other tests are described in ayurvedic texts.
Tests are evidence. Ayurveda was developed using parameters and protocols of the period when tools of modern sciences were not available. It was developed at a time when most rules of modern physics and chemistry were not known. It did not have the benefit of computing, electronics and statistics, so the recent advances are for the good of an ayurvedic physician. The modern-day investigations fall within the ambit of the ayurvedic principle of pramaan (evidence). Therefore, they should be respected.
Ayurveda has to combine its traditional wisdom with modern medicines. It has to maintain a balance between recent advances and traditional skills. I can vouch for the fact that Western diagnostics has helped me a lot. It has helped in the treatment of acute promyelocytic leukaemia, migraine, rhinitis, osteomyelitis, pancreatitis and other diseases. I make use of modern procedures both for diagnosis and to see the patients’ response to treatment.
There are always few people who will misuse a good thing for their own petty interest. That should be discouraged. We already have laws for that purpose.
Fifty years ago, in 90 per cent of the patients diagnosis was done on the basis of physical examination, but correct diagnosis eluded even the best of physicians in 20-30 per cent of the cases. When I was a medical graduate in the 1980s, diagnosis was based on history and clinical examination in 60-70 per cent of the cases. These were coupled with conventional and latest tests—CT scan was installed at AIIMS in 1980, the first in India. Yet, we failed to diagnose nearly 10-15 per cent of the cases. Today, we fail to diagnose barely five per cent of the cases because of the advancements in technology.
Medical tests are a means to diagnose and monitor, both of which have become necessary today. This is because we are confronted with new diseases now more than ever—avian influenza, for example. The burden of bacterial diseases is more than it was three decades ago. At the same time, diagnostic criteria and treatment have changed— in fact, they are continuously changing—requiring increasing biochemical tests.
Awareness about diseases has increased, so has the awareness about the tests conducted to ascertain these diseases. In the case of diabetes, for example, many tests—such as glycosylated haemoglobin and microalbuminuria—are mandatory for its diagnosis. A panel of tests, like liver panel and kidney panel, are prescribed to cover the functional biochemistry of that organ. Similarly, genetic tests, previously unheard of, are available today for the diagnosis of many diseases and to see the response of drugs. Having said that, let us try to understand why a doctor prescribes multiple tests:
Of course, there are pros and cons. Today, we are accurate and fast in diagnosis. We can diagnose and culture bacteria in difficult cases of tuberculosis mostly within 24 hours as against several days and weeks earlier, and treatment can begin early. It can also be monitored properly. A PET scan can indicate even a small strain of cancer, which can be destroyed with the correct drug. But many of these tests are expensive. A coronory CT angiogram, which gives a three-dimensional picture of heart arteries and clots blocking the arteries, costs nearly Rs 20,000. The flip side of diagnostics is unnecessary prescription of tests for financial gain. But only a few doctors resort to such practices. Repeated unnecessary tests are unethical and can harm the patient, such as repeated exposure to radiation from X-rays and CT scans.
Thirty years of medical practice in India and abroad has taught me a lesson: laboratory tests are not meant to hold my hand and lead me to diagnosis. Instead, I should be able to make a presumptive diagnosis by just holding the patient’s hand and then judiciously order laboratory tests. This mantra has never gone wrong. I do have my share of wrong diagnosis, but I have succeeded in making right diagnosis more often.
During his last visit to India, S Kumar, an eminent scientist in the US, was hospitalised because of excruciating back pain. After extensive poking and prodding, Kumar’s doctors still had no definitive diagnosis. He was told that very few treatments were available and the pain would probably disappear with time.
One physician even suggested that, “the pain must be in his head”. Months later, at a scientific meeting, Kumar told his story and said that, “there is no pain management in India”.
Historically, pain has been considered as only a symptom of an underlying injury or disease. However, its prevalence worldwide has finally made clinicians accept that pain is not merely the manifestation of the disease, but a primary pathology and thus, should be treated as such. In India, however, pain is still regarded as a symptom. This impairs diagnostic quality and consequently therapy.
Pain is a universal warning sign. It is the body’s way of communicating to the brain about a tissue injury that is occurring or likely to occur so that preventive action can be taken before damage is done. More than 100 million Indians suffer from acute pain (lasting hours or days) or chronic pain (lasting for weeks, months or years) resulting from arthritis, cancer, neuropathy, diabetes, headaches, injury or surgical operations, among others. This incidence is higher than that of cancer, HIV and diabetes combined. In addition, it is estimated that seven million Indians suffer from avoidable pain due to the lack of access to morphine and other prescription painkillers. Though physical pain is a growing burden on the healthcare system in India and abroad, emotional pain, resulting from affective disorders such as anxiety, mood swings and depression, also contributes to the need for both better diagnosis and novel therapies.
Pain is a personal and subjective experience. The diagnosis in the clinic must be based on careful evaluation of the pain intensity and location as well as stimuli that make the pain better or worse in order to pinpoint the causes and suggest a suitable treatment regimen.
In many parts of the world, pain research continues along with efforts to model human pain conditions in animals in order to improve diagnosis, screen for new medications and improve the efficacy of existing drugs.
Physical therapy, psychological counselling and support, medication management, interventional procedures, acupuncture and other alternative therapies can all be part of effective long-term pain management. A recent drug reform Act has been passed in India making pain-relieving medications such as morphine and opioid available to those suffering from pain. But therapy should be preceded by diagnosis. Clinicians developed the “pain scale” to get a more concrete sense of a person’s pain. This metric is noted along with other vital signs, such as body temperature, pulse rate, blood pressure and breathing rate. A patient’s psychological evaluation also contributes to the diagnostic process. Though regularly utilised in Western medicine, the incorporation of the pain scale into diagnosis in India is uncommon.
Pain treatment is guided by the patient’s history, the intensity and duration of the pain and aggravating and relieving conditions, but the ability to detect pain-causing conditions is still evolving. A lack of sophisticated diagnostic equipment restricts the ability of physicians to identify the causes of idiopathic pain.
For example, magnetic resonance imaging can be used to identify areas of damaged or pinched nerves, but the necessary equipment is not widely available or not used for this purpose in India.
The lack of doctors accredited by the Medical Council of India and the limited number of trained teaching faculty and specialised clinical professionals only make the scenario worse. However, while technological limitations and a lack of well-trained physicians contribute to the under-management of pain in India, there is a larger problem. Until physicians begin to treat pain as a disease in its own right, patients will continue to suffer.
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