Tuesday, April 10, 2012
Medical tests and treatment
My encounter with the medical profession has been, fortunately, only a few and far between; and always satisfactory, more or less, that is. I had a medical insurance for the entire family when I was younger, and had no occasion to claim even a few hundred rupees. So I decided to disregard medical insurance as one of my concerns. Occasional news of someone getting seriously hurt in an accident, a friend or relative being hospitalised for expensive treatment, etc., used to give me a momentary worry about my uninsured status. By the time I crossed sixty, the concern hardened and I also found that medical insurance at this stage involved cumbersome medical tests. I went through them, and was told that I had passed them all. I paid the rather hefty premium and waited for the policy document which did not come for a long time. The agent started avoiding my calls and told me after a couple of months that I had to go through more tests. Out of disgust I took the money back. Later, another insurance company happily covered my wife and me. We are yet to make any claims.
Before this happy ending, I went through some hellish moments. I slipped and fell on the terrace where I went to scrape off moss in a rainy July, and broke my wrist. I used to be scared even reading about somebody else suffering a bone fracture and here I was at the receiving end for the first time in life. The trauma was terrible. My friend took me to a hospital managed by our former classmates. I found myself in an Intensive Care Unit, and believe me, heard doctors asking about my chest-pain. I said there was some misunderstanding, there was no chest pain. There was this monitor there, showing my heartbeats faster than normal. I was told my blood pressure was very low when I was brought in. When the senior orthopaedic came, I told him that I had no history of angina, no issue with my BP, and possibly the dangerous ‘numbers’ came from trauma. He agreed, fixed the time for my ‘procedure’ the next day, took me out of the ICU and allotted a room where I rested two more days after the cast and sling were put in place.
Next came two serious accidents, one involving my wife which destroyed our car and put her in the ICCU for over five weeks. It cost us Rs.6 lakhs in all. A few months later the car my daughter was travelling from Pune to Mumbai hit the median somewhere on the Express Way killing the driver on the spot, and injuring a friend, my daughter and her 9-month old daughter. They had come to visit us soon after we took residence in Pune. My daughter had her femur and nasal bone broken, lacerations on her face; the child had a fore-arm and a femur broken, and our friend had her hip joint, and femur broken and three fractures on the arm. Our friend had a medical insurance though it was inadequate to cover the treatment. My son-in-law had this family health scheme in which his employer pays eighty per cent of the costs.
Apart from the traumatic situation, I was getting first-hand experience in paying medical bills, the main subject of this article. The hospital that took care of my people who suffered in the car accident was meant for highway accident cases. It was very efficient, well-equipped and well-staffed. It was also moderately-priced; but it had no paediatric ICU, mandatory for admitting a child involved in an accident. So my little grand daughter had to be taken to a super-speciality hospital run in the name of a big name in Indian industry. We realised from the grading of patients, the rental for the ICU, ward, and bystander accommodation, and the cost of tests and treatment that the hospital named after the late tycoon was no charitable hospice, but a ‘five-star hospital’ in common parlance. We had the comparative costs in the other place for every head of account!
And there was this condition in which you never ask questions. The life and limbs of your dear ones are in danger and you are also not really hard-up too. The latter aspect is a great boon from the Almighty who ordered the suffering for whatever reason, for sins of the previous life or whatever. I had occasion to sit next to people who worried like hell in conversation with others or on soliloquies how and from where the money for the medicines and the surgeries was going to come. One realises how fortunate one is, under the circumstances and thank God. However, I too had often wondered whether some departments in the moderately priced hospital were considering themselves as ‘profit centres’ and taking me for a ride. The radiography chap gave me so many bills for X-Rays that I never came across. Having paid in advance for an MRI scan, I was astonished to receive an instruction from him to pay Rs.2000 for “emergency” scanning. But the cashier raised some doubt, asked somebody-else’s concurrence and I obtained a 50% cut immediately. The pharmacist once told me the chief nurse in the ICU was asking me to pay for the ‘kit’ I had already replaced after the surgery, and he would handle it. He probably took pity on me in my unkempt appearance and worried look besides the amounts he was collecting himself, day-n and day-out.
It was very heartening to read in the New York Times that several major physicians’ groups in the US have identified 45 tests and procedures (five for each specialty) that are commonly used but have no proven benefit for many patients and sometimes cause more harm than good. Dr. Howard Brody, Professor of Family Medicine and Director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston (US), published an article in The New England Journal of Medicine in sometime in 2010 in which he criticized the performance of medical groups, observing that they were too concerned about protecting medical professionals’ incomes while refusing to consider measures (apart from malpractice reform) to reduce health care costs. That article initiated a conscientious relook by American medical professionals at the procedures. It is hoped that in India also such an awakening will take place among the medical fraternity before too long. The tests and treatments that being questioned in the US include, for example, annual electrocardiograms for low-risk patients and routine chest X-rays for ambulatory patients in advance of surgery. Dr.Brody’s article had urged each specialty to develop “top five” lists of tests and treatments whose elimination for main categories of patients would cut medical expenses quickly without depriving any them of meaningful medical benefit. American Board of Internal Medicine established a foundation which financed a successful test of the scientific approach in three primary care specialties first and further encouraged a broad range of specialty groups to develop their own lists. The review by cardiology, oncology, radiology and primary care, prepared the “top five” and their list included cardiac stress tests for annual checkups in asymptomatic patients; brain imaging scans after fainting; antibiotics for ordinary sinus infections caused generally by viruses, imaging of the lower spine within the first six weeks after suffering back pain; and bone scans for early prostate and breast cancer patients at negligible risk of metastasis. Radiologists now admit they could limit various tests performed earlier and gastroenterologists are prepared to limit the frequency of colonoscopies.
I am told by a veteran Indian practitioner of medicine that our doctors order these un-necessary tests for one or all of the following three reasons in varying degree: 1 - Wanting to feel they are "doing something" concrete for their patient (often at the request of the patient or relative) 2 - Poor training; and/or 3 - Financial incentives. In the US, apart from the above three, there is a fourth and very important one which is professionally christened “defensive medicine”, which is the practice of diagnostic or therapeutic measures employed, not to ensure the health of the patient but primarily as a safeguard against possible malpractice liability. Fear of litigation is the driving force behind defensive medicine in the US is known to increase cost of medical treatment higher by 79%-93%, particularly in emergency medicine, obstetrics, and other high-risk specialties. According to surveys by Jackson Healthcare and Gallup, an estimated $650 million plus is the additional cost of "defensive medicine," on account of ordering more tests.
In India things are not that bad for the medical profession. A physician can be charged with criminal negligence when a patient dies from the effects of anaesthesia during, an operation or other kind of treatment, if malicious intention or gross negligence could be proved as cause of death of a patient. In such cases, a doctor has to prove that he used reasonable and ordinary care in the treatment of his patient to the best of his judgment. He has immunity for an error judgment. The law expects a qualified physician to use a degree of expertise and care which an average person of equivalent qualifications ought to have, and does not expect him/her to bring the highest possible degree of skill in the treatment of patients, or to be able to guarantee cures. Gross/total lack of competency or gross inattention, or wanton indifference to the safety of patients, arising from gross ignorance of the science of medicine and surgery or through gross negligence, either in the application of procedures, use of equipments, selection of remedies, and failure to give timely and adequate attention to the patient are a different issue. The Indian Courts have been wary of holding qualified physicians criminally liable for patients’ deaths on account of errors of judgment in the selection and application of remedies or in inadvertent deaths. So defence medicine is entirely rules out in our country.
Look at the other side: if nothing is found in the medical test report, it is deemed a waste of time and money. If there is something indeed that requires attention, then it was worth it. Isn’t it therefore true to assert that these decisions must be made on medical grounds, not economic? But then can we ignore there indeed was a time when doctors didn’t have the MRI, CT the colour Doppler/ultrasound, and the ultimate imaging tool was the scalpel/knife which however, was never used casually? The older generation among us remember those days nostalgically. They also observe that technology appears to have usurped the history-taking, physical examination and critical clinical thinking, for the worse, more often than not. I would add here that an important thing many of us over 50 or sixty ought to consider is having an attitude starting with age not being an illness, and exercise/diet being our core responsibility.
Doctors’ awareness and ethical conduct alone is unlikely to ease the situation whether in the US or in India. Patients have a responsibility understand that just because they can afford or because the health insurance scheme will bear the financial burden, they should not insist on or request for procedures that have little or no value. Their attitude is likely to decide the general cost of health care in the country as well. (Because lower costs of health care will immediately improve the availability of health care to the larger population as it becomes more affordable). Besides, there are serious health consequences resulting from unnecessary treatment, including excess radiation, adverse drug effects, and exposure to germs in medical institutions thanks to scans producing false positive resulting in exploratory surgery, biopsies and so on.