Too much medicineMay 1, 2013, 7:58 pm
by Dr Upul Wijayawardhana
"Upul, I passed some blood in my urine. Need I worry?"
This was a distress call to me in UK, from a relation of mine, who works abroad but was on a week’s holiday in Sri Lanka. I needed more information before I could give any advice:
"Did you have any pain or a burning sensation when you passed urine"
"Not at all"
"You must see a Urologist (a specialist in Kidney and Bladder disease) immediately. You need to have a cystoscopy"
Though I am no specialist in that field, my advice that he should have a surgeon look inside his Urinary Bladder was based on the fact that painless ‘Haematuria’ (passing blood in urine) is sinister unlike passing blood in urine with pain, often due to stones or burning sensation, often due to an infection.
He consulted an Urologist who did an Ultrasound examination first. As it was normal a CT scan was done which was also negative. Finally, he had the cystoscopy which did not show any evidence of cancer, fortunately. The bleeding was attributed to Aspirin he was taking for heart disease.
Did he need all three investigations? Though one can argue that it is sensible to play safe, could not the same diagnosis have been made with two tests instead of three. They all have a cost not only monetary but also health costs like exposure to a high dose of radiation for the CT scan.
The time I practiced in Sri Lanka most of the specialists did not charge a consultation fee to see the reports but am told it is more the rule than the exception nowadays! Perhaps, I should have asked what happened in this instance from my relation but did not do so as I was aware that he was covered by insurance and would not have been of any concern to him. What about the people who pay on their own, often with great difficulty?
Overinvestigation and overtreatment, interestingly, are subjects much under the microscope at the moment as it is not something peculiar to Sri Lanka. It is a significant problem in USA but not so bad in UK, probably because of the NHS: we who work for the NHS have learned how to optimize in the face of dwindling resources! A fortnight ago, a Cardiologist practicing in New Jersey, USA admitted to ordering unnecessary tests and procedures on patients to the tune of USD 15 million and is awaiting sentencing. According to ‘theheart.org’ he faces between 57 and 87 months in prison!
The British Medical Journal drew attention to this problem over a decade ago by publishing a theme issue titled ‘Too much Medicine?’ in 2002 and, reassuringly, momentum has gathered since. In launching ‘Too much medicine’ (this time without the question mark) campaign, Fiona Godlee, editor, BMJ writes in her ‘Editor’s choice’ in the BMJ of 2nd March as follows:
‘There is a great deal to celebrate in medicine and healthcare, but it’s also possible to have too much of a good thing……….the evidence of medical excess in rich countries has grown with increasingly clear documentation of the harms and costs of unnecessary intervention. In the past few years the individuals and groups calling for moderation and skepticism have begun to coalesce into a loose movement, to which the BMJ is now signing up. Impressed by "Less is more" initiative at JAMA Internal Medicine, led by its editor Rita Redberg, and by the Choosing Wisely initiative set up by the American Board of Internal Medicine Foundation we want to explore the causes and potential remedies of overdiagnosis and overtreatment.’
What she overlooks is the fact that this is equally true for medicine in the private sector of developing countries too. Probably due to the influence of the Thatherite/Regan brand of extreme capitalism, medicine has metamorphosed to an industry from a service!
An accompanying editorial starts with the following paragraph:
‘Distinguishing the sick from the healthy has always been a fundamental challenge for medicine. A chief concern has been to guard against missing disease, with the focus on problems of underdiagnosis and undertreatment. Yet with the modern technological expansion of healthcare in rich developed nations, skeptical voices have long warned of the flipside- too much medicine. Mounting evidence about the threat to human health from overdiagnosis and the harms and waste from unnecessary tests and treatments, now demand that we meet one of this century’s key challenges: how to wind back medical excess, safely and fairly.
This thought provoking editorial ends with the following:
‘Like the movements of the previous decades that have advanced evidence based medicine and quality and safety in healthcare, the movement to combat medical excess in wealthier nations embodies a much older desire to avoid doing harm when we try to help or heal. Such efforts are made more urgent by escalating healthcare spending. Winding back unnecessary tests, diagnoses and treatments will not only protect individuals from harm, it will help society focus on the broader issues of health in ways that are economically sustainable.’
In Sri Lanka, my colleagues have no choice but to depend on private practice as they are not paid a livable salary whereas in UK, I was paid a salary with which I could live comfortably and acquire property too. However, should private practice be unregulated and at times allowed to be exploitative?
While admiring the vast majority of my colleagues who deliver excellent service to their patients with great devotion, still considering medicine a great service, I am disturbed by the alleged malpractices committed by a few. Whenever I visit Sri Lanka, which is frequent since retirement, next to the stories of corruption by politicians what I hear are the misdeeds of my colleagues which causes me great distress.
I was shocked to hear about ‘kick-backs’ offered by one private hospital for referrals for heart surgery. Such payments are illegal in most countries, I am pretty sure it is so in Sri Lanka too, and any doctor caught receiving such payments would not and should not be allowed to practice.
One of my relations, whose heart rate decreased to a very slow rate due to a drug (beta-blocker) she was taking for heart disease was recommended to have a permanent pacemaker in spite of the heart rate normalizing after the drug was stopped! Her husband, a successful lawyer, was requested to come to the Institute of Cardiology to meet the representative of the pacemaker manufacturer to pick the pacemaker that was to be implanted in a private hospital! They contacted me, as they were well aware that it was I who started permanent pacing in Sri Lanka. I advised them not to have it done and expressed my surprise at the way of choosing the pacemaker! I was contacted again, a year later, as the same Cardiologist had offered to implant a pacemaker free of charge at the Institute of Cardiology. I told them to go ahead though I felt that this probably was an attempt to justify the original recommendation!
Saddest is what happened to a good friend of mine who had Coronary by-pass grafting in a private hospital to die of Leukaemia a few weeks later. The surgeon was aware that he had Leukaemia, as he had told my friend and family that he has an abnormality in his blood which can be sorted out later, but went ahead with surgery in spite of knowing that he did not have long to live, obviously, for the financial gain! He died in vain and the family is still paying the debts!! How cruel!!
Perhaps, standards will improve if patients start suing doctors for malpractice but before this happens I wish an overarching organization like the Sri Lanka Medical Association, with the support of all the colleges, would take steps to draw up guidelines for private practice. Under his liberalization programme, JR introduced unregulated private practice allowing even doctors in training, interns, to do private practice even before registration!
I read with interest the articles ‘Doctors’ competency, unvoiced concern in health sector’ by Dr. Kasun Ratnayake, Dr. Samanthi Athukorale and Dr. Thishan Nallaperuma in the Island of 19th &20th April. The suggestions they make deserve serious consideration, if we are to improve the standards.
I agree with them that the most pressing issue that needs addressing is the lack of continuing medical education or better put, continuing professional development. Perhaps, this is an issue that should have been addressed to by the Postgraduate Institute of Medicine which decided, unfortunately, to concentrate only on training specialists.
I remember well a discussion I had with my friend, late Mr W M P B Menikdiwela, Secretary to President Jayewarclana, at the time of inception of the PGIM. When I pointed out to him that the PGIM should have a dual function, enabling all doctors to have continuing medical education in addition to formulating postgraduate training programmes, he inquired what my conditions would be to take over as the Director. I side stepped the issue by telling him that it is a job meant for someone more senior!
It can still be done if the political will is there. Perhaps, the GMOA can threaten with a strike! It definitely will be for a much nobler cause than many they have being striking for!!