RATIONAL HEALTH CARE

Prof. K.R.Sethuraman, AIMST University, Bedong. 08100. Malaysia

"The physician who fails to enter the body of the patient with the lamp of knowledge and understanding can never treat diseases rationally" - Charaka (120-162 AD)

Irrational Prescribing

WHO has defined irrational prescribing as use of a therapeutic agent when the expected benefit is negligible or nil or when its usage is not worth the potential harm or the cost (1985 draft).

Irrational drug prescribing can occur when the medication prescribed is incorrect, inappropriate, excessive, unnecessary or inadequate (WHO Draft, 1985). Accordingly, the types of Irrational Prescribing are:

1. Incorrect prescribing

2. Inappropriate prescribing

3. Over prescribing

4. Multiple prescribing

5. Under prescribing

Irrational Use Of Diagnostics

Using WHO definition of irrational drug therapy as the basis, irrational use of diagnostics may be defined thus: "a diagnostic test is irrationally used when the expected benefit is negligible or nil or when it is not worth the potential harm or the cost."

It is indeed strange that while so much has been written about irrational drug usage, not enough attention has been focused on irrational use of diagnostics. If one realises that an irrational CT-Scan is equivalent to about 100 bottles of an irrational �tonic', then the importance of rational use of diagnostics will be apparent.

One reason for this neglect may be that most medical professionals are not aware of the need to selectively and critically use the diagnostic tests and avoid the �tar baby syndrome�.

�Tar Baby Syndrome"- a Gold Mine for the Industry

All enlightened health care providers and seekers must be aware of the �tar-baby syndrome�. Mold JM and Stein HF first discussed this phenomenon (NEJM 1986; 314: 512-514). They described a cascading process that, after a triggering event, progresses inexorably to its inescapable conclusion, much like an avalanche. Dr. Patrick Ober related this to the Uncle Remus story of "Brer Rabbit and the Tar Baby" (Am J Med 1987; 82: 1009-1013). One could also give the example of Don Quixote chasing windmills.

The Story : One day Brer Fox got hold of some tar and made a Tar Baby. He put a hat on it and set it in the middle of the road. Then he hid behind a bush to see what would happen. Presently, along came Brer Rabbit. He politely wished the Tar Baby good morning. When it did not respond, he wished it again and then yet again. Finally, thinking the tar baby was being deliberately rude, he punched it in the face and of course, his hand got stuck in the tar. He punched it with the other hand and that hand too got stuck. When he tried kicking it, his legs got stuck. He could not free himself.

How does a clinical cascade begin?

A physician or at times, a patient, may be goaded by anxiety and frustration, the same stimuli that provoked Brer Rabbit to kick the tar baby and Don Quixote to chase windmills. Desire to allay anxiety, to feel in control and to overcome uncertainty prompt the order of some tests - a seemingly benign and safe action. However it may turn out to be a misstep that sets in motion a cascade of chain reactions that get progressively more risky and more expensive.

The myth of "laboratory proof" has to be realised by all, especially the professionals. Most doctors unfortunately use laboratory tests for support rather than illumination. Very few tests can make or break a diagnosis by giving absolute proof that a disease is present or absent. Most tests only affect the probability of a disease being present or absent (the likelihood ratio).

Typically 95% of normal people will conform to the range of "normal value" of a test because that is how "normal range" is defined when the test was designed. It also means that 5% of normal population will have values beyond what is considered normal for a test. They are "false positive" cases. If a disease is so rare as to affect one in a million of the population, blind screening for the disease using such a test will pick up 5000 normal persons (5% of one million) as false positives for every single case detected! That is a real-life needle-in-the-haystack situation!

Mindless screening tests thus initiate clinical cascades. It has been estimated that a battery of 12 biochemical tests done by auto-analyser will produce at least one false positive "abnormal" result in 46% of healthy persons. A 20-test battery will produce abnormal (false positive) results in about 64% of healthy persons; this will lead to further tests to clarify the issue. It is good for health care industry but may be risky or ruinous for the patients.

The plain truth is that clinical practice is a treacherous pathway lined with potential tar babies. It is indeed quite easy to "kick the tar baby" and initiate a clinical cascade of further tests (Ann Int Med 1981; 94: 553-600). Beware of "tar baby syndrome" whenever you go for a battery of diagnostic tests. With clinical testing, more is not necessarily better.

Prudent Use of Diagnostic Tests

Before requesting an investigation, the clinician should ask himself/herself the following queries:

1. Will the test result help me to -

a) Confirm/establish diagnosis,

b) Rule out a diagnosis,

c) Monitor therapy,

d) Estimate prognosis, or

e) Screen for and detect a disease?

2. Can the abnormality I seek in this case -

a) Exist without any clinical evidence of it?

b) Even if present, be in any way harmful to the patient?

c) Be treated or controlled? and

d) Be worth the cost and the risk for this patient?

3. Is there no safer and more economical alternative?

If, after careful thought, the answer to all these questions is a clear `No', then there is no need to do the test. If the answer to any one of them is �Yes', the test may need to be performed depending on its availability, predictive values and affordability.

Medical Fashion Erode Rationality

Health care providers, episodically push certain disease labels and treatments because everyone else is doing the same, and it would be unfashionable not to do so. Dr. Buram listed some examples of 1987 in the New England Journal of Medicine (317: 1220, 1987).

1. Past Fashions in medical science

Stress under many garbs

in 1930's as "fight or flight" response

in the 50's as Selye's "alarm reaction"

in the 70's as "type A personality" of Friedman

in the 80's as "Hot reactor" of Eliot

2. Disease of Fashion

Chronic fatigue syndrome which was known by many other names earlier.

3. Fashions in Surgery

Historically, tonsillectomy, stomach-freeze for peptic ulcer, gastric balloon inflation for obesity are some humbling examples of surgical fashions.

4. Treatments of fashion

The use of a fourth generation cephalosporin for community acquired pneumonia in rural India - an unwarranted and eco-unfriendly act.

The current craze for - and uncritical acceptance of - all complementary and alternate medical practices is an example of a fashion born of collective gullibility of the post-modern society. This too shall pass.

Rationality and Cost-Risk-Benefit Analysis

Any health care option can be analyzed in terms of benefits, risks and cost. Benefits have to be weighed against risks and against cost. An enlightened health care seeker can cope with difficult decision making process through analysis. Doctors should encourage such patients to take decisions instead of being paternalistic and talking down to them.

Cost-benefit and risk-benefit can be simplified into four categories:

Category 1: a) Low risk - Low benefit; b) Low cost - Low benefit

These are mostly rituals in health care that are routinely done. "Why not try it? After all there is no harm" or "It does not cost much" are some arguments put forth to promote these options.

Category 2: a) Low risk - High benefit b) Low cost - High benefit

These are ideal options to be avidly accepted. "It is safe and dramatically improves outcome" or "It is a steal" are some arguments put forth to promote these options.

Category 3: a) High risk - High benefit b) High cost - High benefit

Many modern miracles of health care belong to this category. Some examples are transplantation, assisted reproduction, foetal surgery and cancer chemotherapy. Quite often, the benefits are highlighted and the risks and costs are understated in the media and by health care providers. Care seekers may mistake these options to be of low risk or low cost. If they burn their fingers due to unaffordable cost or adverse outcome, they may react badly and seek redress.

Much health care litigation in court arises from mistaking a category 3 option as a category 2 option. Proper pre-treatment counselling is the only effective solution.

Category 4: a) High risk - Low benefit b) High cost - Low benefit

These options should be weeded out from rational health care. Some researchers wanting to be the first to prove a point pursue high risk-Low benefit options. High cost-low benefit options are pursued by `health industry' that looks for new ways of making profits.

T.S. Eliot has warned us against action taken �not for the good it will do but that nothing be left undone'. "What other chance do you have" is the question put to the care seeker to justify category 4 options. This pursuit of the margin of the impossible has become "technological brinkmanship" in health care (W.A. Silverman: Perspectives in Medicine and Biology, 1995; 38: 480-95). This leads to the offensive practice of the so-called �defensive medicine'. In the name of ruling out possibilities, a large number of tests are performed. Tests should be critically selected to �rule in' a disease rather than `rule out' all other possibilities.

Twelve Questions on Risk, Cost and Benefit

If you want to be an informed seeker of health care, discuss with the doctor the following points before agreeing to undergo any procedure.

1. What is actually wrong with me?

2. How serious is this disease/condition?

3. What may happen to me if I leave it untreated?

4. What kind of procedure are you planning to do?

5. Is the procedure done for diagnosis, for treatment or for both?

6. What are the risks of this procedure?

7. What are the chances that the proposed procedure will be successful in my case?

8. Will the success be a long term or short-term benefit?

9. What alternative procedures/treatments are available?

10. Of these, which do you think would be the best for me?

11. If your relative were in my position, what would you choose for him/her? (If there is a difference between 10 and 11), please explain why?

12. Could you suggest any source of information on this disease that I could read or watch?

Monetary Compulsion Erodes Rationality

The pressure to bring in income by unethical means is much higher in hospitals run for profit by non-technical financiers. Bernard Shaw had an uncanny insight into the working of doctors' minds when faced with the dilemma of choosing between ethics and monetary compulsions. He wrote thus in the preface to doctor's dilemma: "As to the honour and conscience of doctors, they have as much as any other class of men, no more and no less. And what other men dare pretend to be impartial when they have a strong pecuniary interest on one side?" "It is simply unscientific to allege or believe that doctors do not under existing circumstances perform unnecessary operations and manufacture and prolong lucrative illnesses." (Bernard Shaw, 1906)

A junior doctor, my former student, who worked in such a place, could not stand the commercial exploitation of human gullibility and fears. He said this about his hospital: "No mother had a chance of normal delivery during the second half of every month because money had to be generated to pay back the next monthly installment to the bank. Similarly, any one with a chest symptom will be put into the intensive care and kept for five days unless they run out of money and ask for discharge." When he raised ethical queries, he was simply told to �join in or get out'. He chose to get out.

I have debated this issue with my friends in private sector. They argue thus: "The patient is happy getting the maximum attention, we are happy collecting our fees and the health care industry is happy generating income and wealth for the shareholders. It is an all-win situation. Why are you alone unhappy?" This is a vicious argument and had me cornered for some time. Then I asked my friends, "A drug dealer or a pimp will also use the same logic and say it is an all-win situation. Can you or society accept it then?"

The harsh reality is that two-thirds of our rural families are in debt because of health care expenditure. If the chain of rural indebtedness has to be broken, planners and health activists have to squarely address this issue and find some lasting solutions.

Ethical Self Test - For the conscientious doctor, there is an ethical self test that can be used as a guide: "Would I like myself or my near and dear to be treated thus?"

Eight Tips to Detect an Uncaring Doctor

The following are some warning signs that indicate that your doctor may not be doing his/her best to help you. He/She:

Does not listen to what you are saying.

Does not probe into your symptoms and complaints.

Does not examine you completely or forgets to examine the organ or body system about which you have raised some doubts.

Seems to be forgetful and peculiar in behaviour, either smiles inappropriately or is short-tempered.

Acts in a paternalistic (fatherly) manner; is all-knowing and tells you "the only way" to manage your problem.

Does not educate you on the nature of illness and the rationale of tests ordered and treatment advised.

Does not discuss risks and benefits of the tests, procedures and medicines advised.

Gets upset or reacts defensively when you suggest seeking a second opinion. It is better to change to a more helpful doctor!

Case Dumping and Case Grabbing Erode Rationality

For-profit hospitals engage health care workers, transport workers and others as touts to fetch cases for surgery and other procedures. These touts can be spotted in and around other hospitals offering unsolicited �helpful advice� to prospective clients. My students who work in private sector say, "Cases admitted for surgery are discharged against medical advice and transferred to another hospital. Insiders are involved and get a good commission for doing this."

If case grabbing is rampant in private sector hospitals, case dumping is equally rampant into the public sector hospitals. In USA, over 250,000 emergencies were shifted from �for profit' hospitals to public hospitals because they cannot pay. About one in ten, i.e., 25,000 cases die, mostly due to delay in transit (Sibbison JB: Patient dumping. Lancet 1991; 337: 38). In India, the situation of patient dumping is far worse.

The release of Citizens Charter of Health Care rights in Government hospitals is a step in the right direction; but who will implement it? When?

Pandering to Myths Erodes Rationality

Offensive options of abusing modern science to cater to myths and superstitions. Hiccup is just one example. I have seen a number of gullible persons fall prey to doubts and fears raised by proverbs, house-lizards, black cats, astrologers, palmists and numerologists. They abuse modern medical science to ponder to their fears and phobias; many medical practitioners are only too happy to oblige them as �it is good for the business'

Informed and enlightened consumers should break the shackles of age-old myths and superstitions and become truly autonomous individuals.

Gullibility Promotes Quackery and Fraud

The dividing line between trust and gullibility is fine. When some one is ill, there is pressure to "do something" and it may be tempting to try unproven remedies. Health care quackery is big business even in the developed countries. Unethical advertising, uncritical media hype and human gullibility help propagate it. When the truth about "the miraculous cure" becomes apparent, the stakeholder shifts the focus to protect the health care business interests.

"The capacity of human beings for self-delusion should never be underestimated; conviction profoundly affects observation. If you think you are right and can convince the patient that you are right, then whether you are right or not makes very little difference" (R. Asher: Talking Sense. Pitman Medical Publishers, 1972).

Asher also made a telling comment on hope prevailing over reason. "It is better to believe in therapeutic nonsense than openly admit therapeutic bankruptcy." In the case of AIDS, during the 80's, modern medicine made the fatal error of admitting therapeutic bankruptcy. This led to mushrooming of quacks and charlatans in USA and Mexico who made wild claims of cure to make �quick bucks' and then vanish. D. Lapierre has chronicled it in detail (Beyond Love, Chapter 57: Japanese mushrooms and Chinese cucumbers for the desperate. Domnique Lapierre, 1990. Bombay: IBH, pp.359-362). Similar quackery is going on in India today in treating many viral diseases.

How do quacks succeed?

Over 90% of illness are self-limiting and the body heals itself. (Even 90% of snake bites are non-venomous and a quack can claim credit for its "cure" if he is smart enough to refer the minority with venomous bites).

Of the various factors that contribute to healing, only 20% is ascribed to rational treatment using medicines or surgery. The remaining 80% is divided among the following:

faith in a placebo (inactive substance or irrational procedures).

faith in a system, a facility or a professional (Hawthorne effect).

faith in self or in supernatural (spiritual factor or factor X).

If a clever quack learns to operate within these three faith-related areas and stay away from rational therapy that may have harmful side effects, he/she can be quite successful with majority of his clients. On the other hand, modern medical professionals tend to confine to the 20% rational healing and ignore the faith related healing. The disenchantment with the doctors of modern medicine may be largely related to this deficiency. They need to be trained to include faith-related placebo, Hawthorne and X-factors in their treatment options and not reject them as unwanted and unscientific trivia. How to incorporate these aspects of case management into medical curriculum is a big challenge but is of urgent need.

Health and consumer activists have another area that needs urgent intervention to prevent exploitation of the gullible. Some tips are listed below.

Ten Tips to Detect possible Quackery or Fraud in health care

Like politics, health care has also become the last refuge for many scoundrels. J.H. Young, a professor of history has compiled the following guidelines:

1. Exploitation of fear and phobias or of hope for a miracle.

2. Claims of miraculous scientific breakthrough

3. Promise of painless safe treatment with excellent chances of "cure".

4. Reliance on anecdotes and testimonials. They don't separate facts from opinions or cause and effect from a mere coincidence.

5. Heavy promotion by advertising.

6. Large sums of money payable by clients for achieving cure.

7. The use of Simpleton science (one-size-fits-all type of dogma): diseases have one basic cause and one way of treatment takes care of all diseases. For example, water is the basis of all diseases and hydrotherapy cures them.

8. The `victim of scientific establishment' theory: "the establishment is blind, I am far ahead of times and will be a hero to future generations".

9. Shifting theory to adjust to changing circumstances.

10. Distortion of "freedom of informed choice" to "freedom of choice" to end up with "freedom to be foolish".

Non-compliance Eclipses Rationality

Doctors tend to overestimate compliance of their patients (Norrel SE: Soc Sci Med 1981; 15E: 57-61). They often presume that all the patients diligently follow all their advice and do not even check. But patients may feel burdened by treatment advice especially the life style changes and unpleasant procedures or medications.

"You must take it. It is for your own good", is all that most doctors can say to coax their patients to comply with the treatment.

Over the years, I have come across the following reasons for non-compliance:

1. Misunderstanding of the nature of the disease: Patients with diabetes or high blood pressure may assume that one course of treatment will cure the disease. Many chronic health problems need life-long monitoring and follow up. Effective counselling on the nature of illness may reduce this form of non-compliance.

2. Wrong assumption that �control is cure": This is an extension of the previous fallacy. The patients take medicines till the blood pressure, blood sugar, etc., normalise. Then they stop all treatment thinking that the disease is cured. Proactive advice - "when values reach normalcy, you have to go on to maintenance therapy" - may help avoid such non-compliance.

3. Misunderstanding of drug name or its dosage or duration of treatment: Effective communication, especially when written in a language that the patient can read, reduces this form of non-compliance. Patients should not feel delicate to clarify all doubts regarding treatment.

4. Fear of "addiction" and fear of powerful drug: Media reports of the panic-mongering type are followed by an epidemic of this form of non-compliance! Patients must openly discuss their fears with their doctors and get clarified on risk-benefit, potential for addiction or adverse reactions.

5. Mistaking "illness" for "disease": Though the terms disease and illness are interchangeably used in the health profession, medical anthropologists make a clear distinction. Disease is what is diagnosed by the health professional. It is the abnormality (pathological state) of the body or mind. Illness is what the person with or without a disease perceives. It is subjective. In many diseases like high blood pressure, diabetes and early cancers, a patient may not feel ill at all. On the other hand, in benign conditions like tension headache and irritable bowel syndrome, the patients may perceive severe illness but their doctors may say, "You do not have any disease; all the tests are normal".

It is important that health care seekers and providers understand the concept of "illness-disease" and the possible paradoxical relationship between them. It is the only way to reduce non-compliance among those with a "chronic disease without illness". It is also the only way to reduce �doctor shopping' by those with a "chronic illness without disease". Health activists! This is an area for you to run a major campaign. It will empower care seekers.

6. Social-cultural-religious barriers: Social events disrupt the schedule of an otherwise compliant person. Happy events like a wedding as well as sad events like death of a near and dear result in temporary non-compliance because "taking treatment did not seem terribly important then".

I know of a Muslim diabetic who thought all insulin is extracted from pigs. He never verified this suspicion with any one else. After nearly two years of non-compliance, he finally confided in me. There are many such deep-rooted social, economic, cultural and religious barriers to compliance.

7. Non-compliance by denial: Denial is one of the coping mechanisms that results in non-compliance. This is the most difficult to manage. Unless the provider-client relationship is strong, mutually respectful, and is able to address deep most concerns of the client, the barrier of denial cannot be breached.

Holistic Care Promotes Rationality

"Holistic is a buzz-word today - different persons interpret it in different ways. It is not a mix and match of various systems of medicine as being interpreted now. Ancient physicians like Hippocrates and Charaka have advocated truly holistic perspective in medicine. Hippocrates said "I would like to know what kind of person has a disease rather than what disease that person has".

Just think about it! Even today, it is difficult to improve upon this simple and yet accurate view of holistic perspective. Con�sider the diseased person as a whole - his/her personality, attitude to life, knowledge, and socio-economic and cultural standing etc.- in order to understand the illness from a holistic viewpoint.

If Medicine had such a �holistic' view, then when and how did it degenerate to be a dehumanised profession? As medical sciences advanced, we could understand more and more about the causation of diseases - revolutionary discoveries and progress were made in the field of medicine and therapy.

Our attention shifted more and more to the biological sciences at the expense of behavioural sciences. In order to cope up with the advances, specialisation became order of the day. As a cynic had said it, "Specialist doctors learn more and more about less and less until they know everything about nothing". Dr. K. White has coined the term Ignorant Savant for this breed of specialist doctors who are well informed in their own limited fields but are ignorant of patients life-world. T.S. Eliot lamented thus: "Where is the knowledge we have lost in information? Where is the wisdom we have lost in knowledge?"

Primary Care Can Promote Holism

Just as stomach and bowels have a primary non-glamorous job of breaking down complex food, primary care provider has to have a holistic view of a patient's illness and sort out his/her various problems. Sorted out health problems have to be specifically referred for specialised treatment.

During the 70's and 80's, USA went for specialist treatment in a big way. It was a disease oriented, procedural, piece-meal approach that was ruinously expensive and soon controlled by insurance industry. Now the society has realised its folly and is reverting back to a primary care approach that is patient-oriented, holistic, continuous and comprehensive. Unfortunately, the third world countries are caught in this quick sand now. Empowering �just an MBBS doctor� to shed his/her diffidence and practice rational primary care will go a long way to rectify the depressing scenario.

Primary care physicians need to develop into "health care advocates" for their patients. They must reverse the current trend and help patients to avoid inappropriate entry to specialist care; not merely because it is costly, but because it wastes everybody's time, incurs unnecessary risks and diverts attention from rational, more appropriate and effective solution (Hart JT: Lancet 1992; 340: 772-775).

Synergy Fosters Rational Health Care

Health care providers, care seeking public, industry (diagnostic, therapeutic and insurance) media, activists and governmental machinery are all key players and stakeholders in health care delivery system. If they cooperate and stand together to achieve the goal of "ethical and effective health care for all", then the system will be strong and functional. But if each player sets his own agenda forgetting the common goal, then the system will be weak and dysfunctional. Some examples are:

Ignorant, unethical or corrupt health-care provider.

Foolish, non-compliant or deviant behaviour by the care seeker.

Exploitative health-care industry.

Biased media that glorifies or vilifies a health care issue.

Activist with one track mind resulting in a stand off among key players.

A government that puts profits before peoples welfare.

The bottom line is not profit or high technology but rational care based on provider-seeker trust. If the basic trust is undermined, as has happened in the USA, the health care system will be in jeopardy and every player will be a loser. Trust is the glue that keeps the system together. Without that, it will fall apart like Humpty Dumpty and we may not be able to put it together again.

Other Strategies to promote Rational Care

Many target groups need to be addressed and multi-pronged action is required. All bad practices and drugs need weeding out by the government while rational management practices are to be promoted by the health care providers, seekers and other stakeholders.

Governmental regulation could remove all irrational formulations and help curb exploitative health care. We need a strong drug-control authority with enough teeth to implement whatever policy they announce from time to time.

The health care and drug industry could be coaxed by pressure of the consumer groups and by the medical lobby. But the medical fraternity treads gently in this regard as "You do not bite the hand that feeds you".

The medical profession needs to reorient towards rational care at all levels. This means two things: periodic updates for those in practice and curricular reforms for those in the medical schools. Educators of Rational Drug Usage (ERDU-group) initiated by CI-ROAP, Penang is an example of this approach:

Rational Management in Medical Education -

A Lancet editorial lamented thus: "The treatment has deteriorated. In consequence of cramming science down men's throats, they had very little idea of GOOD practice". The year was not 1985 but 1885!

In real life situations, life is com�plex and rational decision making much more exacting. The doctor ought to know the social, cultural and anthropological reasons of the health seeking behaviour of the person sitting in his/her consultation room. Medical curricula have shown benign neglect of these "soft sciences", resulting in the training of �hard boiled' medicos bristling with scientific information but unable to apply it well. Later in their practice, things only get worse because, "One of the things the average doctor does not have time to do is catch up with the things he did not learn in school. If medicine is a mystery to the average man, nearly everything else is a mystery to the average doctor" (Milton Mayer).

Behavioural sciences module needs to be introduced in medical education, not as a transplant from the West, but evolved in the context of the realities of the third world.

Finally, consumer education and people mobilisation to in�sist on and get quality and rational health service as a matter of right. This will be the most effective socio-political strategy but the most difficult and daunting one too. PHA-2000 is an ambitious attempt in this direction. Now is the time for all those concerned with the current crisis in health care have to actively support its mission.

Come on, let us all act for the Common Good !

References

All the important references are mentioned in the text in parentheses.

This article is specially written for the preliminary meet of PHA-2000 and is extracted from my book: Trick or Treat - a survival guide to health care. Published by - Society of EQUIP, P.B. No 8, D-Nagar, Pondicherry. 605006 The permission of the publisher is gratefully acknowledged.