Replacing clinical with diagnostic medicine
‘Medical gatekeepers’ are given to vitiating healthcare. Fearing litigations against them, doctors have turned to practicing defensive medicine
Medicine is not a profession but a passion. The patient-doctor relationship is one of mutual trust based on doctors' devotion to the patient as a human being in totality. Doctor in the past was fully connected to the family of the patient and had continuous information about her/his health problems. In old days, when medicine was not as developed, clinicians (vaid) at the maximum would check the pulse and put a hand on the abdomen to form an opinion of the disease.
With the advent of modern medicine, certain protocol was prepared to treat the patient. The first step in that is to get the patient's history with relevant questions. By good history taking the doctor can extract the relevant information from the patient which many a time the patient does not feel as important. No doubt each and every patient wants that she/he be properly listened to by the doctor with empathy even though many a time the information being given may not be important to reach a clinical diagnosis. A few words of sympathy, encouragement through proper dialogue help the patient feel better most of the times.
History taking is followed by examination of various systems of the body as needed for the particular disease. These may be followed by investigations relevant to the case. The new investigative facilities have helped a lot in diagnosing and giving proper treatment, which was not possible till a few years back. This has also helped in prevention of complications from occurring. The investigations have supplemented the clinical knowledge of the doctor.
In the recent past, there has been a surge in the investigations ordered by the doctors. This has many times raised scepticism in the minds of the patient. There are, however, several reasons for the increasing tendency of ordering investigations for which the doctor alone cannot be blamed.
There has been an increase in violence against the doctors in the past. Therefore, no doctor wants to miss anything. It has been seen that the patient's relatives, who were earlier reluctant when it came to investigations, would in case of a mishap, start blaming the doctor and saying that they never objected to any investigations. Doctors also fear litigations against them. Therefore, they have started practicing defensive medicine.
But needless to say that there has been a techno-centric shift in medical practice. With the changes that have occurred in economic relations and government, healthcare is no more being viewed as a social issue. With the entry of the corporate sector in the health care system, the whole scenario has changed. For them, health is purely a business with little empathy for the patient. Doctors are under pressure to generate income. Diagnostic investigations became primary and clinical knowledge has taken a back seat. Many doctors, instead of spending time on history taking and examining the patient, just started ordering investigations.
The whole scenario has led to the development of unhealthy practices by some medical practitioners. There are reports of some doctors ordering investigations for the purpose of getting cuts and commissions. This is not only unethical and illegal but also a sin. Charging money from a suffering person for the service which one has not provided is unacceptable. It is unfortunate that there have cropped up some 'medical gatekeepers' whose only job is to bring patients to the doctors and charge referral fee whether for diagnostic or for clinical treatment purpose. Such practices have to be checked by the appropriate authorities, medical bodies and society through dialogue.
(Dr. Arun Mitra is Senior Vice President, Indian Doctors for Peace and Development. The views expressed are strictly personal)
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