Alexander the Great lamented on his death bed, ‘I am dying from the treatment of too many doctors’, and even Voltaire once quipped, ‘the art of medicine, like that of war, is murderous and conjectural’. Alexander and Voltaire might have been metaphorical in their musings, but lately we seem to have given literal meaning to their utterances.
We have been labelled “A Heartless Profession” (Times of India, 24th August, 2014), and the recent book by Sandeep Jauhar, ‘Doctored – the disillusionment of an American physician’ is a candid and detailed exposure of the sordid saga of modern medicine.
Even a study from Harvard Medical School in 2014 clearly showed that the patient care, as assessed by 30-day mortality rate, is better when senior and technically highly competent and qualified doctors go on to attend the two major cardiology meetings in USA viz. American College of Cardiology and American Heart Association scientific sessions in March and November each year.
Is Pharmageddon – the bleak prospect of a world in which medicine produces more ill health than health and when medical progress does more harm than good, thus a reality? Infact it is not a prospect, Pharmageddon is fully upon us. Its realization, and infact to some extent confirmation, is borne out by the currently rampaging and ravaging Corona epidemic.
All tertiary care departments in hospitals are running dry, beds are empty, intensive care units are under-utilized, and operation theatres virtually closed. Agreed, routine work and OPDs are suspended, but what about Emergencies! The average number of urgent admissions, especially at night, which is a true surrogate marker of an emergency, too have dropped dramatically to less than half… And its not just in India, its worldwide.
Does it mean we were making skewed decisions, if not outright fraudulent and unethical? Were we over-prescribing money-generating interventions? If Yes, was it with ill intent and conflicts of interest, and thus by design or was it unknowingly by default? Is there something more than what meets the eye?
Some of the sane elements in medicine have been talking of this over-use for quite some time now. Infact this was taken as a defensive plea by Dr. John McLean on being convicted for increased billing in US Courts, ‘Inappropriate usage (of stents) is widespread and that he was prosecuted for a behaviour that is the industry norm’. The whole phenomenon is not new.
Ival Illich in 1975 commented in Medical Genesis, ‘Societies with an excessive number of doctors will suffer from social, culture and physical iatrogenesis’. Doctors’ association with mortality has been well documented in the literature, in studies auditing data during doctors’ strike, demonstrating a reduction in mortality during the strike and the mortality getting restored when the doctors returned to work.
This was demonstrated in widely separated geographical areas like Saskatchewan in Canada, Bagota, Los Angeles County, Dublin and Israel prompting a cryptic editorial comment in the reputed British Medical Journal in June 2000, ‘Doctors going on strike will improve society’s health’.
By no means I am down-grading the importance of technological advancements and the efficacy of new techniques. To the very contrary, there is incontrovertible evidence supporting the use of stenting and bypass surgery for high-risk patients, including heart attacks and multiple blockages in the blood supplying arteries of the heart.
What I am trying to pin-point is that these technologies are wonderful, only if used for the right indication and at the right time, but are potentially disastrous when they are misused. The misuse is rampant, and more often than not, dictated either by commercial interests or personal ego – the mundane race of the number games for that ever elusive and profane one-upmanship.
In a small number of cases, this is condoned as ignorance, even which, in the current era, is an indefensible plea. Apple falling on a knife or vice-versa, it’s the apple which gets cut; Over-zealous medicine – by design or default, wittingly or unknowingly, it is the society which suffers.
What we therefore need is judicious application of these potentially disruptive technologies. It’s a common wisdom, a lot of people die in bed, but it doesn’t mean that bed killed them. A lot of us may die ‘with’ heart illnesses, but not necessarily ‘due’ to them! They may just be innocent by-standers. So just the presence of disease is not an indication for intervention.
Unfortunately, any dubious symptom, even remotely likely to be connected with heart, is labelled as unstable angina and made an indication for angiography and subsequent interventions. We therefore need to step back and have a good look at our practices, and all opinions and decisions must ultimately be centered on the patient and patient only.
Changing gears and playing a devil’s advocate, Corona, in its wake of ghoulish devastation, has also provided us with some collateral benefits and lessons, which we could not have achieved for eons with our epidemiology tools. Road side accidents have reduced, pollution levels have come down, people are living more organic life – eating sanely and stress free, all these factors may have helped our cause. Granted, but then, it does not take us away from where we started – Are we evil?
The answer still is a big ‘Yes’, its just that now the focus has moved from the medical profession to the society at large and to an individual. Does this not cajole us to the fact that we are leading an epicurean and consumptive life, which is not commensurate with positive health. We abuse ourselves for decades, not willing to shake ourself out of the ‘laissez-faire’ and then expect the doctors to fix the aftermath problems in one brush of the paint – Stenting or Heart Bypass surgery. Is that sensible, or more bluntly, is it not outright stupidity?
Bottom line – we need to change, and this is not platitude, it is imperative. Its high time that we ratiocinate and transmogrify from the ‘s’il vous plait’ inertia to mend our hedonistic and ’Joie de vivre’ ways – both the ‘Society’ and the ‘Medical Profession’.
Food for thought!
About the author
Dr. OP Yadava is the Chief Executive Officer & Chief Cardiac Surgeon, National Heart Institute, New Delhi. He completed his medical graduation and Master’s in Surgery from Maulana Azad Medical College and had joined Armed Forces as a Surgical Specialist. Dr. Yadav was honoured with Membership of the National Academy of Medical Sciences (MNAMS) in 1994; FICC in 2003, FIACS in 2005 & FCSI in 2012. He has as an experience of over 12,000 open heart surgical procedures and his special field of interest is coronary artery bypass surgery especially total arterial revascularisation & beating heart surgeries (Minimally Invasive).
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