Do No Harm

How much is too much: The case of the persistent MRI

Technology has made the practice of medicine easier, sometimes. We complicate it by irrational use.

Technology has made the practice of medicine easier, sometimes. We complicate it by irrational use.  


How much is too much? A CT scan, an endoscopy, a colonoscopy, an MRI, that extra course of antibiotics, why even, surgery? As lay people how do we judge if all this is warranted?

You go to the doctor because you have been having a dry throat during nights, and you come out perplexed. You have in your hand a prescription for, among other things, an MRI scan.

You are like, "Whoah! What just happened?" and it seems like the doctor has taken you for the longest ride of your life. And yet, you don't want to take the chance. "What if ?" you think, even as you fret and fume about how the medical community is out to get your money. Reluctantly, you pay up, a huge sum for you. Or you squirrel up cash, slowly until you have the money to do an MRI.

Have you been cheated? Is this a case of over diagnosis?

SCENE 1: Yes. You have been part of an intricate con job. All the doctor should have told you is to turn off the air conditioner at night. Or, ride the two wheeler with a nose mask on. Or avoid chocolates and sweets. OR plain, drink more water.

Then, why has your doctor written out that investigation sheet? He's probably new to the business, has set up clinic and has invested a lot into it. How does he make his money quickly? If he's willing, the laboratories will pay him good money, and fast. Kickbacks from laboratories, and scan centres, can be very substantial. This is just like the pharma-doctor nexus, but it can be even more viscious.

All he has to do is to make referrals. That's when the doctor writes out MRIs for dry throats. If he's minimally genial, he'll tell you, "just to be on the safe side." If he ain't, he started scribbling furiously the moment he looked down your throat, whip out that sheet of paper like a knife and thrust it menacingly at you.

And inevitably, there is SCENE 2 as well.

The good doctor, having written that prescription out for you, swivels in his chair, looks you in the eye, and then goes on to explain, in an even tone, what he suspects you might have: Obstructive Sleep Apnea.

Basically that means disruption of oxygen supply during sleep. Caused primarily by the loss of muscle tone, usually brought on by obesity, usually brought on by a sedentary lifestyle, OSA can even cause death by cutting off the O2 that drives your heart and brain. [No, the doctor din’t say that, it’s just a stage whisper.]

Among the side effects of this condition are a dry throat. Bingo. You also, he has discovered while he spent time peering into your throat, and later asking questions, have heroic snoring which keeps the entire apartment complex awake at night, and vivid dreams of choking.

He pauses, peers over his half moon spectacles, and gently tells you that it is a condition that needs attention. You need to improve muscle tone, and the best way to do this will be to pump irons, but since the muscle, by now used to its laxity, will take up to a year or more to perk up, we need to investigate, he says. Turns out that MRI is a sleep MRI, the endoscopy is to see where in the windpipe the problem occurs.

The Doubting Thomases in you are nearly assuaged now. You like logic. You like to know why you have to pay.

Of course. You’d rather be in Scene 2. Actually, you would preferably not be in either scene, but if you must, it’s the latter. You’d like a little declaration of honest intent, an explanation approximating to layman’s use of language.

Indeed, there might be a genuine reason the doctor would like to see evidence from a machine before he narrows in on a diagnosis. Imaging systems today are so advanced, we’re catching all that we missed earlier. “If imaging can improve diagnosis, or clarify things for me, as a physician, then why not?” a surgeon-friend once said during a discussion that involved some fist-shaking at scan centres. But he admits, “Clearly, there are few doctors who choose to be outside of the diagnostics kickbacks scheme. If joined the race, I’d be making five times what I do now in private practice.”

The lure of lucre. We’re not against hardworking folks making some money, but is that lab sheet you just filled out justifiable. Not to speak of unnecessarily putting people through exposure to radiation, some amount of uncomfortable internal poking and prodding. Must you use a device, just because it exists. Even if you don’t have to?

To gyp a person who not only puts himself in your hands with trust, but also lacks the training to judge for himself, now, that is criminal. Above all, remember what you swore, as you tossed up your graduation hat: To do no harm?

“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”

Remember that? Now, here’s the last line of the Hippocratic oath you may not recollect as easily:

"If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.”

Indeed. May the reverse be thy life.

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Printable version | Jan 25, 2020 10:43:09 PM |

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