I was often fascinated by the brilliant maverick doctor (Hugh Laurie), in the TV series “House”, dealing with patients with mysterious problems, and invariably ending up with an extraordinary diagnosis and saving the patient’s life. Today, I believe that seems to happen more on television than in the real world.
Increasingly the disease burden across the globe has veered massively towards long term conditions, and it almost seems as if medicine today is no longer about curing at all. What better example than the U.S. health care crisis, where the primary aim of health-care reform now appears to be cost-cutting rather than improving coverage. Indeed, spending on doctors, hospitals, drugs, etc. now reportedly accounts for more than one out of every six dollars that Americans earn. The point here is not to judge the vision of Obamacare, as the phenomenon is not just limited to America but is rather becoming a global reality.
Too much medicine
Ivan Ilich opens his book “Limits of Medicine’ (1973) with a scorn. “The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic”.
While Ilich’s rhetoric is too hard to be missed, the undertones may actually be becoming relevant now, more than that at anytime in the past, and much faster than what we can appreciate at an individual level. According to a United States Department of Health and Human Services report, in a country of about three hundred million people, around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests are performed each year. Its no different in urban India and elsewhere, where the phenomenon of over-testing in clinical practice is disquieting. But does this represent an improved quality of care? Not sure!
Misdiagnosis or overdiagnosis
“Medicine is about ameliorating, palliating, listening, explaining, advising, and consoling. It’s not glamorous. It should also be about caring, but patients accept that doctors are “too busy” for that (sometimes, I fear, in pursuit of the mirage of diagnosing, treating, and curing).”
Atul Gawande, besides being an endocrine surgeon at the Brigham and Women’s hospital, and a professor of Health Policy and Management at the Harvard School of Public Health, is also the chairman of Lifebox, a nonprofit dedicated to reducing deaths in surgery globally. The celebrated author of the book “The Cost Conondrum” provides an interesting emic perspective on the US healthcare, from the eyes of an insider.
Perhaps more than the inherent risks associated with overzealous investigations (e.g., radiation hazards), excessive investigation affects the health care system in more ways than is commonly realized. Indeed, the value of an investigation often depends on the likelihood of the patient as having a significant problem in the first place. A crushing chest pain and dyspnea raises the spectre of a serious heart condition, that renders an ECG as an invaluable piece of evidence. But, in the absence of signs or symptoms, an ECG, more often than not, adds no useful information. How many times we see a heart tracing that doesn’t look quite right but usually ends up as noise. Millions of ECG are done each year in healthy people; chances are that a heart tracing which is not completely normal may prompt further investigation, e.g., a stress test, 24-hr holter monitoring and even cardiac catheterization. The collateral damage from this over-testing can be colossal; thousands of dollars in costs, denial of health care to genuinely needy, anxiety, work absenteeism and, indeed, physical risks.
Nearer home, a similar trend is becoming a norm. All too frequently, in my general practice, I encounter prescriptions which appear to be exotic shopping lists of investigations. While generalizing this impression would obviously be wrong, invariably, these turn out to be fishing expeditions; in any case, since no one is perfectly normal, there is likelihood of finding a lot of fish. Who doesn’t have a little nodule here that can’t be completely explained, a lab result that is a bit off or a heart tracing that doesn’t look quite right.
Overdiagnosis is certainly not the same as misdiagnosis—the erroneous diagnosis. This is the correct diagnosis of a disease; one that probably would have never bothered the patient in his lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, we can save lives in large numbers. While the rationale is compelling, it apparently, is not playing out that way in the real world. Cancer screening with mammography, ultrasound, and blood testing has dramatically increased cancer detection over the last 3 decades. Thousands of more people are being diagnosed with these diseases than ever before. Yet, there is no objective evidence of its benefit, as the fall in mortality is too tiny to be considered a major gain.
To a large extent, over-testing is a by-product of all the new technologies we have for peering into the human body. Why not take a look and see if anything is abnormal? The motivation for over-testing is not always pecuniary, it can become a habit, or even we may genuinely but incorrectly believe in it. With some exceptions, doctors are not scientists. The tenet of science involves posing a falsifiable hypotheses, designing experiments that are amenable to interpretation and measurement and to finally nullify the hypothesis. To me that’s not how doctors should work. And certainly not as scientists.
It is not uncommon for me to be asked by my patients as to which part of the body I treat. The super-specialism in medicine thrives on diagnosis. No wonder then that I go weeks without a diagnosis. But the patients seem to be happy and I find that gratifying. GPs I believe are supposed to make a physical, psychological and social diagnosis. But this was not really taught in the medical school. To me over-testing is driven by the quest for diagnosis; Its just that the concept of diagnosis today appears to have stretched to the point where, perhaps, it isn’t useful.