Friday, December 30, 2016
Healthcare 2017- Ditch Robots And Bring Back The Doctors
Healthcare 2017- Ditch Robots And Bring Back The Doctors
After yet another fruitful year of practicing what I preach, I thought it’s time to put up a post on my pet peeve, again. The said peeve being, the practice of medicine is slowly being changed into a robotic occupation, where a doctor is given a set of instructions and told to follow them to a “t”. But unfortunately the human body doesn’t not cooperate with this by the book approach as every individual is unique by himself and every disease affects a person differently. Given a set temple and asked to follow the protocols given is the surest way to prolong disease till the patient is deceased. And that’s the reason why I always take evidence based medicine with a pinch of salt.
Evidence based medicine to give its due, works in a fairly efficient way, in a limited spectrum. But given its limitations it is inefficient at best and dangerous at its worst. And why, I will explain now. For those not familiar with evidence based medicine- it’s a set of treatment protocols (usually developed in western countries) which says after checking these protocols this is the best treatment for this disease and hence, everyone worldwide needs to follow these protocols whenever/wherever they see this same disease.
The problems with this approach are manifold. Let me just discuss the top two. Firstly most if not all of these protocols were developed for simple diseases and straightforward diagnostics/treatment procedures. If you have any complicated disease requiring multiple procedures, you just cannot follow any protocol template, you have to diagnose and treat case by case using all your years of experience and intuition and hope for the best. Which in turn defeats the very purpose of evidence based medicine. You need best evidence protocols for the most difficult cases because these are the ones which test you to the limits and are prone to end up with the death of the patient and the doctor being blamed for inadequate/insufficient treatment. Where others who have the luxury of time, weeks and months to study the symptoms will second guess the decisions you make in seconds by the patient’s bedside as the patient lies gasping for air and fighting death minute by minute. What’s the evidence say? Did you follow the treatment protocol? These questions are very easy to ask in hindsight but doesn’t help at the moment when most required.
The second major disadvantage with this protocol based approach for treatment is that the template developed most often uses a particular procedure using a particular piece of equipment which study in turn is sponsored by that particular equipment manufacturer. You can’t blame them – for most of these studies are really expensive and require large scale funding which governments never do and hence the researchers raise money from private players who naturally have a vested interest in promoting their products. So even if there is a better or more simpler or more low cost way available to treat that particular disease it will never be accepted as mainstream – because no one does research on it and no one publishes it and no one by which I mean no respectable medical board or journal accepts it- which results in the low cost or simpler alternative having the status only of quack medicine. While the costlier company sponsored study gets accepted in prestigious journals and then becomes the accepted standard of care worldwide merely because there is no other alternative to it.
This grant of legitimacy to costly treatments in the absence of alternatives is the primary reason that doctors from developing countries hate evidence based medicine. It’s all very well to recommend protocols followed in Boston or the Massachusetts general hospital but not everyone is lucky to be practicing in Boston or Massachusetts. What about somebody practicing in Nigeria? Or Nellore? With no access to the level of diagnostic or treatment machinery as given in the protocol as per evidence based medicine? Is it fair to punish that doctor for treating that patient but not following the best established practice protocol? Whose fault is that and how can you apportion the blame?
This craze of getting more and more evidence based protocols also has the side effect of developing and insisting on more and more tests, more than 90% of which are unnecessary- like treadmill test, stress test, angiogram, CT slice- 64/128/216 machines – all of them being developed just to rule out any cardiac disease and your doctor has to prescribe these unnecessary tests every time you go for a simple muscle sprain or gastric distress and indigestion or any other condition which does not involve the heart. But because the best evidence based medicine protocol says you have to rule out heart disease in all cases, everyone gets to do a CT scan at the highest possible resolution beyond 64, beyond 128 beyond 216 slices- even if you are a healthy person with absolutely no evidence of any heart disease. But because the protocol formed in SanFrancisco or New York or London says so- you have to get that CT scan, every time you over eat samosas and have gas. If this wasn’t a waste of resources and such a tragedy it would be such an inside joke, but I can’t laugh at it now. And neither should the poor unfortunate patients who end up paying for all that waste of time.
So the best thing that you and I can hope for is that the government gets into the act and funds medical research in a big way so that individual researchers do not have to go begging bowl in hand to equipment companies who in turn dictate the treatments to be researched and published. And secondly the realization that data mining and rigid protocol’s don’t work for human beings. There is ample space in medicine for hard won experience and intuition based on it. Or otherwise we will continue to take angiograms for every patient who comes to the hospital with an acidity problem and advocate cardiac by-pass surgeries based on miniscule blockages seen in every minor blood vessel, whether they want to or not get a major heart surgery done. Why? Because the evidence says so, and you want to get the best possible treatment at international level don’t you?
I hope national governments realize the immense damage being caused to local healthcare managements by these artificially imposed from abroad protocols and either help in developing local protocols for local people or at least stop penalizing doctors for using years and years of experience to treat patients instead of following Boston rules. Support doctors not robots.