Today diagnosis has become a disease in itself. Patient anxiety, doctor worry and the corporate greed have all come together to over-investigate patients even for self-curing minor illnesses that affects the majority of patients
A recent editorial in the British Medical Journal (BMJ) last week (7 November 2014) talks about over treatment and over diagnosis and its dangerous fall out on patients. This is a topic very dear to my heart and I have been writing about it for decades even in the BMJ. Today, diagnosis has become a disease in itself. Doctors and their informed patients want to get a label for their illness. Doctors want to label their patients in this highly litigious society today to save their own skin against frivolous consumer claims. Patient anxiety, doctor worry and the corporate greed have all come together to over-investigate patients even with self-curing minor illness syndromes that form the bulk of patients.
A very interesting case comes to mind. I was once an arbitrator in a civil case between an insurance company and a large philanthropic institution that had insured a whole village in their area. A healthy farmer got a small skin tear in his feet while ploughing his field. He went to a nearby hospital. When they found out that he had insurance cover they immediately admitted him for investigations. They used all their technology to do all tests on him only to find that they were normal. They then told him that they were planning to do skin grafting for quick healing; the poor farmer believed them.
They got his pre-operative cardiac assessment, again using all their gadgets. Finally, they did a skin grafting and discharged him with a huge bill. The branch manager of the insurance company rejected the bill and wrote the rejection note on the case sheet in red ink that “skin grafting should not be done for a small fresh skin cut, as it is not indicated.”
I was pleasantly surprised at his note and summoned him to come to me. He was worried that he had committed a serious blunder for which I might reprimand him. When he hesitatingly entered my room, I made him comfortable and congratulated him profusely for his scientific medical knowledge to save his company. I was curious to know as to how a layman could have access to such accurate medical knowledge? He was hesitant to answer my question in the beginning but later opened up to say that he was a qualified veterinary surgeon but was a failure in his practice and got this well paid job in the insurance company!
This story tells us to what extent over-investigation and over diagnosis could go. Another area is cardiac revascularisation. Most, if not all, bypass and angioplasties are not indicated, but are done routinely. Anyone who goes for a cardiac check-up has a good chance of coming home, if he survives, with a stent in his heart!
“Over diagnosis of the well and under treatment of the sick are the conjoint twins of modern medicine." So writes Iona Heath in an essay this week (doi:10.1136/bmj.g6123). She articulates the fears that drive medical excess: our existential fear of dying, and the ever present fear that a serious diagnosis will be missed.
While striving for accurate diagnoses and appropriate treatment, Heath says that clinicians and patients need to acknowledge the limits of medicine and embrace the uncertainty that lies beyond. "Only because we do not understand everything and because we cannot control the future is it possible to live," she says. This is taken from last week’s BMJ editorial.
More than all these that Heath has written, corporate greed and consequent doctors’ greed drive over investigations and over diagnosis. In the area of cardiac revascularisation the culprit is the coronary angiogram which has NO PLACE in the diagnosis of coronary artery disease. (BM Hegde: Bull. Royal Coll of Physicians of Edinburgh 1995; 25: 421) In fact, large blocks never kill. “Less than 30% of the infarct related vessels are more than 50% blocked” wrote Valentine Fuster, a diligent research in this area.
Many other studies have together shown the following finding: “coronary arteries that became totally occluded and resulted in myocardial infarction (MI) had usually not been severely stenosed previously. The culprit artery in most cases had been less than 50% stenosed before the acute event. Several subsequent investigations confirmed that in the majority of patients with AMI, the culprit vessel had been only mildly stenosed before the acute coronary event. (J Am Coll Cardiol. 1999; 34(7):1854-1856)
Even young children have these coronary blocks all of which are intraluminal blocks (blocks inside the vessel lumen) (JAMA 1953; 152: 1090-1093).They are just “Band-Aids” to close the usual injuries to the intima of the coronary or any vessel wall. The killer plaques that attract a clot to produce an acute block (heart attack) in the vessel are inside the coronary vessel wall; the mural blocks, otherwise called the vulnerable plaque.
The latter can never be seen in an angiogram. Their diagnosis depends on blood tests to unravel inflammation there and angioscopy which looks inside the vessel. The ONLY role that the coronary angiogram plays is when one decides that a given patient, based purely on his clinical status, needs bypass surgery for his intractable chest pain relief (when it cannot be relieved otherwise), the operating surgeon needs to have to study the coronary anatomy to know where and how to plumb.
If we can put an end to coronary angiograms for the diagnosis of anginal pain millions will be saved from morbidity, adverse drug reactions (ADRs), and premature death. This was exactly the advice that my former chief, Nobel Laureate Bernard Lown, gave in his article in 1992 (JAMA 1992; 266: 754-757). Any re-vascularisation procedure demands lifelong blood thinner therapy.
In Indian context this could be one of the major risks. Even aspirin in small doses “might or might not reduce non-fatal heart attacks, but will certainly increase the incidence of fatal haemorrhagic stroke.” At the end of the day people who are destined to die will die. We doctors are good at changing the label in their death certificates, from heart attack to brain attack, but not it’s DATE!
Be that as it may, there are other compelling reasons why we should be avoiding over diagnosis and over treatment. Science is change and medical science has changed-naturally. With new physics we now know that the human mind is the human body. Our creating anxiety with a serious diagnosis is capable of advancing the death significantly.
In systems biology today human body is a closed system, where our interventions might interfere with the body’s innate capacity to heal itself with the help of the inner healer, the immune system. Placebo effect, the faith in the doctors’ kind words, is shown to have more power to heal than all the drugs and surgery put together (Sci Transl Med 16 February 2011; 3: 70).
For the benefit of our Resident Non-Indian (RNI) scholars, I have given below the latest thinking in this area by a good professor at Yale, Mary Tinnetti. She wrote: “The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities render medical care that is centred on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment.”
All potential patients should keep all these in mind when going for treatment. When you are healthy do not go for a check-up. The latter will for sure change your label from man/woman to a patient which might not change for ever. Beware!
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS. He is also Editor-in-Chief of the Journal of the Science of Healing Outcomes, chairman of the State Health Society's Expert Committee, Govt of Bihar, Patna. He is former Vice Chancellor of Manipal University at Mangalore and former professor for Cardiology of the Middlesex Hospital Medical School, University of London.)
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