Communist Medicine In A Capitalist World

Communist Medicine In A Capitalist World – The Evidence Based Medicine Conundrum

Any casual reader of history or anyone at all with any general knowledge know that the discredited philosophy of communism and its paramount creation the soviet empire were both destroyed because both economically and even with common sense it beggars belief that decisions can be made in central committees and by fiat be implemented in all places and in all situations without a single thought for local conditions or differences. Crops to be sown, fertilizers to be used and harvesting times were all imposed on farmers from afar by fat-cat bureaucrats sitting in distant Moscow committees who thought they knew better than the local farmers born and bred up on their lands for generations. The result was total collapse of the agriculture sector and widespread famines everywhere in Russia. Production quotas and processes to be implemented in factories led to so many shoddy products that anyone who was just anyone at all in Soviet Russia preferred to use imported products for everything from shavers to ovens.  Rule by distant committee was comprehensively proved to be the stupidest idea to have ever been invented by the human race and believe me we as a species have made many, many more such mistakes.

So if I now told you that the same discredited theory of communism is now being touted as the only way to practice medicine what would you say? I kid you not- search evidence based medicine on the internet and you would find plenty of laudatory articles as the way to go for practicing medicine as per modern protocols. But read past the platitudes and rule by central committee is exactly what you would find.  And just because the committee distributing it is the internet itself it finds its greatest advocates on the net who tout it as the only way to go and not as one more way as it really is. Now enough with all the historical references and let me start explaining what evidence based medicine really is all about.

Sometime in the last decade of the last century (the 1990’s anyone?) there arose a new system of medicine called evidence based medicine. As with everything else when it was first introduced the intentions were noble and its advocates were sincere and it was definitely a step forward to the future. Doctors everywhere welcomed it because it seemed to offer a way forward during those times when doctors most need help- decision time. Evidence based medicine involved putting up the results of large scale clinical trials on the net to help doctors everywhere follow those same guidelines in their treatment for their own patients. It showed what worked or what didn’t work to others who were hard pressed to make difficult clinical decisions in real time. As such it definitely was a step forward. It even helped simplify which drugs to prescribe or which not to. For instance many of the old time doctors used to rely heavily on antibiotics where were popular during their heydays often not realizing that such antibiotics were no longer active due to an effective resistance built up by bacteria continually exposed to the same drugs for so long. Hence evidence based medicine pushed the medical fraternity into discarding old, tried and tested beliefs and adopting newer treatments. And that’s when things started going wrong.

When the popularity of evidence based medicine picked up worldwide big pharma was as usual right there to swing things in their favor. They started sponsoring the large clinical trials needed to get their evidence – often using low cost outsourcing firms in under developed countries where patients signed up for medical trails for a pittance- and used the results of such biased trials to push heavily in favor of their own drugs which had been used in such trials. Other drugs, even tried and tested ones didn’t stand a chance because all the latest evidence (sponsored of course) freely available on the net pointed towards such and such drug – as the only one with enough evidence available to show it worked. If a doctor wished to use any other drug which he felt could be equally effective he stood in grave risk of being taken to court by the patient for not following “internationally accepted standards of care available on the net”. Which led to all the doctors falling in line cowed by threatened medical malpractice suits and patients reading up the results of such biased trials on the internet and demanding of their doctors the same treatment that dr.google recommends.

If to take an example you have constipation and I as your doctor want to recommend to you a single plantain (local banana) every night and you go on the net and read that florida oranges grown in glass rooms in chilly Alaska when given to 5000 people led to 4000 people rushing to their toilets every morning and you quote that study to me and demand that I prescribe only Florida oranges to you- imported straight from Alaska- then I have no choice except to write a prescription of the same. Because I or anyone else for that matter have no evidence at all that bananas work, forget the fact that every single individual we know all around us for thousands of years have used bananas to evacuate their bowels. There is no large clinical trial for local bananas- no one paid money to large groups of people to eat a banana and shit in the morning and hence no evidence for banana which makes it a false treatment under the evidence based medicine guidelines and if despite this I want you to eat a banana, god help me, I would end up losing my license for practicing medicine- for not asking you to eat imported Florida oranges which might beggar you with just one months treatment cost. And this is the literal truth and I am not exaggerating. The costliest drugs are the ones which drug companies prefer to send for large clinical trials by recruiting thousands of patients. Hence when the results come out its the same costly drugs which become the default treatment option worldwide and any doctor who differs is branded a witch doctor for not following the evidence. Individuality has been stamped out and creativity rooted out in the name of the evidence based medicine fad.

Just like communists used to prescribe their guidelines from a central committee for everything, evidence based medicine has a central treatment guideline which every doctor has to follow to save their own skins or woe to them. Such evidence gathered in distant populations does not take into account individuals or their idiosyncrasies. Medicine is not an exact science and most prescriptions are based on informed guesses but that doesn’t mean that in the name of standardization a one size fits all variety of medicine becomes the only way to practice. The evidence based medicine fad has been taken to such ridiculous levels that surgeons who often make small incremental advances in surgery by trying out newer and innovative surgical techniques on individual patients cannot publish their results anymore as case reports and case series- which are about smaller groups of patients – are increasingly being not published or downright derided in favor of larger clinical trials. Surgeons are being forced to fall in line with the same efficiency as robots and an individual surgical technique (even surgical flair) is being eliminated in favor of standardization.

The day is not far off when patients can print off their own prescriptions off the internet from a published list of symptoms to treat themselves and a doctor (or a middleman) becomes superfluous to medicine. Is that a step forward? Or will it lead to more chaos? Based on the history of communism I am very skeptical of the future of evidence based medicine as it is now. But I can’t speculate on what the next medical fad will be. Will evidence based medicine escape the stranglehold of big pharma and sponsored clinical trials and evolve into something more inclusive and egalitarian taking into account individual knowledge. Or will it act the monolith and seem impregnable till it suddenly implodes on its own like communism did? Only time will tell.

Dodging a Bullet with My Name on It.

Dodging a Bullet with My Name on It.

Disclaimer: This is quite a morbid post and better avoided by those with a queasy stomach. It contains graphic descriptions of diseases and deaths and is not recommended for everyone.

I woke up sometime around four this morning with my mind all alert of a sudden. For a few minutes I lay there trying to calm myself of the sudden wave of anxiety that had woke me up and trying to recall what it was that was troubling me so much. And then it crashed on me like a wave. Oh god, how could I miss it? It was so much like an HIV case. And then it all came back. Yesterday, being an unusually busy  day with a long line of patients- each one crowding out the other like on an assembly line- I had seen a patient with certain unusual symptoms- a severe disease with no logical added reason like diabetes or some previous fevers or something which could explain the severity of her symptoms. And being such a busy morning with forty plus impatient patients waiting next-in-line I had asked her the mandatory questions, asked her to get the routine blood tests next time she came, did a minor procedure on her then and there and prescribed the usual medicines all the while functioning on my robo- doc mode. 

I know that my being tired and distracted with all the noise and clamor of those patients surrounding me doesn’t excuse me from not suspecting something amiss right then and there. But, i suppose my ever present vigilance slipped for a minute and i decided to treat it for then and there and reserve further inquiry for the next visit in three days. But somehow, somewhere in the back of my mind my subconscious was not satisfied with the mystery is what I think now. It must have been plugging away at it all day until in the middle of the night it made the right connections and it woke me up. I was lying there in a cold sweat while thinking how careless i had been in handling an HIV patient. What if, god forbid, I had been exposed too? Was it already too late for me? Am I going to get AIDS and die? Believe me these are morbid thought to think in the middle of the damn night. They don’t make for much pleasant sleep the rest of the night.

When we are students we are taught repeatedly how to protect ourselves. There is a reason that we are taught to take precautions as if every single patient is an HIV patient because you never know who can be one. They might know that they are hiv positive but conceal it and lie to the doctor so they wouldn't be treated differently- with extra safety measures. Or the poor patients might not themselves have known about it. Any which way if only we, I, had followed the proper procedure of doubting everyone- I wouldn't be here in the middle of the night shivering with fear. But complacency they say can kill even the best of them and as i had started to think myself as wise as Yoda the Jedi master, I had let down my guard and been as foolish as the newest apprentice.  

Of course the blame can also be shared by the authorities- they expect us doctors to do miracles with what we have while they support us only halfheartedly. If you want to give the best health care to the poor patients then you should be prepared to spend more money by hiring more doctors who can spend more time with each patient listening and diagnosing carefully. You can’t expect just a handful of doctors to cope with a hundred patients in five hours and still take a detailed look into everyone’s complaint and not make a single error. We are human too- a fact which the authorities conveniently forget all the time. I had been travelling all night that night, on a rickety government bus, perched on an uncomfortable seat trying to grab a few winks of sleep and as soon as I had landed in the city I had come straight to work after stopping to change at home. I was tired, sleepy and my alert levels were far below normal. Of course I made an error- but the bottom-line is I am in a profession where errors are inexcusable- they can either kill the patient or kill the doctor. No excuses allowed.

And to conclude this post, medicine is as a risky a profession (for doctors, I mean) as you can ever see in life. The chances of our errors killing us is almost as high for airline pilots - remember the Thai flight lost recently due to pilot error? Similarly, one mistake, one moment of carelessness and we doctors are dead- it’s an accepted hazard of the profession though no one talks about it much. If you think I am being paranoid let me explain that on a daily basis we doctors are exposed to far more life threatening diseases than anyone else - including those sick people who have that disease and only "that" disease. For example, I had spent a majority of last week at the fever ward- the place where severely infectious patients are admitted- because there has been a recent explosion of chicken pox cases in the city and everyone's been pitching in to help out to get over the staff shortages because of the summer hols.

I guess my blood by now is crawling with all sorts of viruses and bacteria after being exposed to the infectious diseases wards all week. I am a walking, talking bio-bomb, most likely. On the other hand the fact that I am still healthy and haven’t caught anything yet only points out the astonishing fact that my immune system is robust and copes with everything that’s thrown at it. Those little buggers, the white blood cells swimming down my arteries must be some helluva strong fellas right? And in the end - what doesn’t kill us only makes us stronger, in the immortal language of that awesomatic rapper 50-Cent. So, let’s see, my options are I can either keep worrying all day long about whether I have caught anything or just get on with life throwing it all to fate and that’s what I am prefer to do. Just get on with my life and hope for the best - like the light brigade- canons to the left of them, canons to the right, rode the six hundred and so will I.

P.S. Just now- this morning the patient has returned with her blood test results. She said she had been cured completely by whatever drugs I had given her earlier- all her symptoms had disappeared. And most importantly her blood test results came out clean- she was not HIV positive which means I was in no real danger whatsoever and had merely been frightened badly. I don’t know who was more relieved at the result - her or me. Somehow I seem to have dodged the bullet this time- but I have learnt my lesson. Eternal vigilance is the price to pay- to sleep well at night. No more excuses- of being tired or anything- nothing will be tolerated. I vow to keep awake, alert, all the time, so help me god. And I sincerely hope that the bullet which has my name on it will take some more time to arrive. I am not dying yet, I have work to do and a life to live and miles to go before I sleep.