FEATURE

Sickness Care or Corporate Monstrosity?

Prof. B. M. Hegde,

hegdebm@gmail.com

 Rather fail with honour than succeed by fraud.”       

                                                            -Sophocles

 In a book that is very well reviewed by the New York Times, an Indian born American doctor, Sandeep Jauhar “puts himself on the couch” pricked by his conscience. In his book “Doctored” Sandeep examines the broken system of medical practice in the USA. Thanks to the Indian Karma theory this young cardiologist who was the Director of a teaching hospital in New Jersey had eventually to leave his job as he refused to interfere where the patient did not need it. After being thrown out, he joined another practising cardiologist where again he found that ethical practice was given a go by. His boss told him that he also tried ethicalpractice and found himself in debts. Now he has joined the mainstream. Sandeep left that job also as he was asked to carry out all tests including angiography for all patients who came there!

This is exactly what we do in India now and even our politicians think that we have the best system in place. Our Union Health Minister wants AIIMS like hospitals in every state! In the west there is a cry for closing down such hospitals while we want to start more of them. No one seems to be bothered to audit the system to see what the AIIMS achieved during the time it existed and to what benefit to the common man? Such a study would be most appropriate to scientifically find out what to do for the future. An audit of 14 industrialised countries from USA to Japan showed that those countries with too many specialists and sub-specialists and very high doctor -patient ratio like the USA fared so badly that the system had completely broken down with highest disease, death and disability rates, while Japan with the very small doctor- patient ratio with majority of doctors being family physicians ranked first with increased longevity, decreased death, disease and disability rates!

When doctors went on strike in many countries in the last 25 years-Saskatchewan, Bogota, LosAngeles County, Dublin and recently in Israel- death rates almost plummeted to the bottom with disability rate reduced significantly in every place only to return to the original levels when doctors came back to work. It is reported that in Israel morticians had to bribe the government to give doctors higher pay for them to get back to work as morticians’ coffin business had almost shut down! This prompted the British Medical Journal to comment in an article that “doctors going on strike will improve society’s health”.The French government started a Chinese medical hospital with one hundred beds in Paris while their western medical system had become prohibitively expensive. The new hospital had brought down the medical expense to the government very significantly. Nobel Laureate Professor Bernard Lown, one of world’s best cardiologists from Harvard felt in his research article in the JAMA that unless we ban coronary angiograms for diagnosis of coronary artery disease patients will suffer unnecessarily. Professor Tom Treasure, a cardiac surgeon, pleaded with the British Government through The Lancet that they should drastically reduce cardiac surgical centres in Britain to stop wasting money on unnecessary tests.

Professor Harlan Krumholz, a Yale cardiologist, wrote an editorial in the (NEJM 1997; 336: 1523) about cardiac interventions: "cardiac procedures bring in billions of dollars in cash for doctors, hospitals and the instrument manufacturers, in addition to television interviews. The procedures are done mainly to get those benefits and not to help patients in the USA.” Let me conclude this by quoting a patient that I saw yesterday who had a very sordid story. A very healthy 63 year old man who is also a good writer in Kannada had mild elevation of his blood sugar for the last 6months which he had very well controlled with exercise and diet control. On an average he walks ten kilometres a day including a steep incline up a hill to reach his temple. He was feeling fit as a fiddle.

His publisher and a dear friend, an Ayurvedic physician, who, for some unexplained reason, has a fascination for western medicine, almost forced him to have a “check-up” since he has been a “diabetic”! He took him in his own car to a “special centre” in an upcoming District headquarters nearby. The doctor had also told him to have enough money should he need any interventions. As soon as they went in thepatient was asked by the cardiologist to have his ECG done which unfortunately turned out to be normal. But he was told that he needed an exercise test to see if there is any fault. Before that he had an echo test which showed a normal heart with very good ejection fraction (good function). Still the cardiologist insisted that he should have the TMT. No one had either talked to him or listened to him or even touched him leave alone physically examine him. Doing TMT on a healthy man who walks daily ten kilometres up a hill with ease is a business. Scientifically TMT has no value as that test has its sensitivity and specificity less than 50% which means whether it is positive or negative it means nothing. More over the test results depend on the disease prevalence in society which we do not know for India! Professor Perloff of Washington University had designed a Hyperbole which should be used to plot the results to get a semblance of value for the test. The only value of TMT is the fall of blood pressure during exercise. This denotes a bad heart muscle. In this hospital BP was never recorded during the TMT!

However, TMT was declared to be positive and the patient was almost forced to have an angiogram in spite of his mild protests. Poor man still has a swollen left hand with blood leak outside the artery and inflammation from the catheter! He was then told that he needs either an angioplasty or bypass surgery ASAP. At this stage he smelt a rat and paid their bill and walked out of the hospital. Interestingly, the discharge note has the following diagnosis for an apparently healthy man who NEVER ever had chest pain. Chronic Stable Angina with three vesseldisease and diabetes Mellitus type II. The angiogram, in fact, showed some small peripheral blocks in the epidcardial vessels.

The man came to see me walking slowly (he was asked not to walk till he has the interventions) and talking in whispers- a really sickly pathetic picture. It took me nearly an hour to make hima MAN again and send him back asking him to go back to get his eight tablets prescription also gradually reduced lest he should bleed seriously from the gut or inside the brain for no fault of his. He was on two blood thinners, beta-blockers, ACE inhibitors, long acting nitrates (which get tachyphylaxis soon and become useless), and some other fancy drugs. All the man needed was change of his mode of living with some minimal drugs for him to get off the high horse of the rat race that he was running which put him in the fight-flight-freight mode always. Medication could be an added boost.

God save our hapless patients from this corporate monstrosity.

“There are three things in the world that deserve no mercy, hypocrisy, fraud, and tyranny.”

                                                                                                                                 -Frederick William