Test­ing times

Doc­tors are in­creas­ingly pre­scrib­ing tests to ar­rive at a di­ag­no­sis. Has this ben­e­fited med­i­cal prac­tice or pa­tients? Four ex­perts de­bate

Down to Earth - - CONTENTS - RAMA BARU is pro­fes­sor, Cen­tre for So­cial Medicine and Com­mu­nity Health, Jawa­har­lal Nehru Univer­sity, New Delhi

Physi­cians are in­creas­ingly rec­om­mend­ing med­i­cal tests to di­ag­nose dis­eases. Is this a healthy prac­tice?

"Di­ag­nos­tics is a means, not an end" Rama Baru

Opast two VER THE 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

"There are re­ports of the­o­ret­i­cal and clin­i­cal train­ing not get­ting its due in un­der­grad­u­ate and post­grad­u­ate stud­ies"

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, Bal­rama Bhar­gava, 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.

"Di­ag­nos­tics has helped ayurveda"

Bal­endu Prakash

A"Western di­ag­no­sis has helped treat leukaemia, mi­graine, pan­cre­ati­tis, rhini­tis and other dis­eases"

a must for DI­AG­NO­SIS IS 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. Ashtvidh pa­reek­sha (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.

"We can di­ag­nose cor­rectly and faster to­day"

Anoop Misra

Fago,in 90 per cent IFTY YEARS 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: To de­ter­mine the pres­ence or ab­sence of a dis­ease that of­ten does not have symp­toms, such as di­a­betes. In this case, mul­ti­ple tests are re­quired for pre­ven­tive screen­ing and choles­terol dis­or­ders. To di­ag­nose a com­pli­cated case, such as fever of un­known ori­gin. Such cases may re­quire 20 or more tests.

"Med­i­cal tests are nec­es­sary be­cause to­day we are con­fronted with new dis­eases"

Some­times, dif­fer­ent tests may be re­quired to di­ag­nose a sin­gle con­di­tion so that the doc­tor can be sure.For ex­am­ple, Mon­toux test, skin test, spu­tum test,c hest X-ray, pus cul­ture, tis­sue biopsy and CT scan may all be rec­om­mended to reach a de­fin­i­tive di­ag­no­sis of tu­ber­cu­lo­sis and its ex­tent. As­sess­ing the re­sponse to a drug or a med­i­cal pro­ce­dure, both pos­i­tive and ad­verse, re­quires mul­ti­ple follow-up tests. For ex­am­ple, stress test, lipid test and kid­ney func­tion tests are rec­om­mended after heart an­gio­plasty. A physi­cian may pre­scribe sev­eral tests to min­imise er­ror. This also guards against le­gal li­a­bil­ity. Tests are ob­jec­tive and recorded at sev­eral places, so they be­come le­gal doc­u­ments. A pa­tient’s his­tory and clin­i­cal ex­am­i­na­tion are sub­jec­tive and recorded only by doc­tors. They can be eas­ily con­tested in a court of law. 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 three­d­i­men­sional pic­ture of heart ar­ter­ies and clots block­ing the ar­ter­ies, costs nearly 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.

"Ur­gent need to di­ag­nose pain"

Biswanath Maity

Dlast visit to UR­ING HIS 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 pain-killers. 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

"The pain scale is not used for di­ag­no­sis in In­dia, where pain is treated as a symp­tom rather than a dis­ease"

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.

BAL­ENDU PRAKASH is an ayurvedic physi­cian in­volved in re­search and de­vel­op­ment of treat­ment pro­to­cols for var­i­ous forms of can­cer

ANOOP MISRA

is chair­per­son, For­tis C-DOC Hos­pi­tal

for Di­a­betes, Meta­bolic Dis­eases and En­docrinol­ogy, and di­rec­tor, Na­tional Di­a­betes, Obe­sity and Choles­terol

Foun­da­tion

BISWANATH

MAITY is re­search fel­low at the Carver Col­lege of Medicine & Holden

Com­pre­hen­sive Can­cer Cen­tre, USA

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