Some responses to the article, “Do doctors listen to Patients or computers” (Open Page, The Hindu, January 15, 2012), suggest a perception that the author was decrying the use of technology and quality control tools. Nothing can be farther from the truth. What is required today are not incremental changes, but is a radical transformation of healthcare, and to achieve this, state-of-the-art, cutting-edge technology needs to be deployed.
The question is when, where, why, how and at what cost. This needs an in-depth technical knowledge and the ability to quantitatively measure the expected alterations in health outcome, deploying technology vis-à-vis the natural history without intervention: for example, a 2cm meningioma incidentally seen on a CT scan done for a head injury may not produce problems for many years.
Observation is certainly justified. However, most patients want a definitive treatment immediately and look askance when doctors decide against intervention. Sniggers ensue when a CT is not advised for an inconsequential head trauma. Reeling off voluminous statistically validated “double blind, randomised, controlled studies” that a CT will not alter the outcome is of no use. A specialist opining that nothing need be done is unacceptable.
How many patients are satisfied when antibiotics are not prescribed for fever, cough? When a patient is told, after a thorough clinical history and physical examination, that anticonvulsants are not always indicated for one single seizure, he goes in utter disgust to a street-smart doctor, who gets an MRI done, reassuring the patient that it is normal!
Mahatma Gandhi once remarked that a customer is the most important visitor on our premises. He is not dependent on us. We are dependent on him. In the real world, whose bread you eat, his song you sing. The science of healthcare is different from the art of healthcare. Efficient healthcare requires informed doctors and informed patients. Is a patient also the problem? By promoting health literacy better care could be ensured at reduced costs. Patients today are often uninformed, anxious and non-compliant with healthy lifestyles. The word “trust” is slowly disappearing from the vocabulary of both patients and doctors. This sometimes translates into unnecessary investigations.
Ten million post-hysterectomy American women had pap smears as part of screening for cervical cancer! The uninformed patient is a universal phenomenon. A study of 10,228 people from nine European countries revealed that 89% of men and 92% of women overestimated the benefit of PSA (Prostate Specific Antigen levels for detecting prostate cancer) and mammography screening hundredfold. Why don't people know or want to know, particularly when Dr Google is available? Infant mortality reduces with the mother's educational status.
Patients also need to take responsibility for their health. DIY (Do it Yourself) has become commonplace. Do we not do net banking and print our own train and air tickets? Why can't we be more proactive in looking after our own health? Why not wear helmets, instead of complaining that ICU management for head trauma is expensive? Health care is more than diagnosis and treatment. Why are only doctors faulted always? Why not the entire health care-eco system?
Medicine is not mathematics. It is neither black nor white but shades of grey. Notwithstanding the hullabaloo about evidence-based medicine, the uncertainties offer scope for different treatment options. It is impossible to do away with a “conflict of internal interests” when there is a fee for service. Unconsciously, one will use arguments that would influence a patient to choose a proposal of benefit to the doctor. Studies have shown that worldwide, indications for surgery differ in the salaried group of surgeons! Practice variation in tonsillectomies, hysterectomies and prostatectomies is fifteenfold in the U.K. and the U.S. The Dartmouth Atlas of Health Care 2010 concluded that “Geography is Destiny.” Sir Muir Gray, Chief Knowledge Officer, NHS U.K., in a book, Better Doctors, Better Patients, Better Decisions, calls the 21st century the century of the patient, stressing that providing authenticated valid health information will create a well-informed knowledgeable empowered public.
Patients are also in a stage of transition — with easy access to information often associated with embellish ments and hyperboles, keeping up with the Joneses could be a status symbol. Unless the Right to Health becomes a fundamental right, there will always be bickering between the haves and the have-nots. Machiavelli said in 1513: “Never waste the opportunities offered by a good crisis.” Challenging the status quo is mandatory. The 21st century problems cannot be solved with 20th century solutions. To achieve this paradigm shift, patients need to be as much part of the decision-making process, sharing accountability and responsibility.
(The writer is a Chennai- based neurosurgeon and telemedicine specialist, and is a past president of the Neurological Society of India and the Telemedicine Society of India. His email ID is: drganapathy @apollohospitals.com)