Is it truly ‘test’ Worthy?

Sunil K Pandya, Department of Neurosurgery, Jaslok Hospital & Research Centre, Mumbai examines the factors driving unethical practices in healthcare, including prescription of unnecessary medical tests and gives insights on prevention of such malpractices

There is a public perception that the medical profession is growing increasingly avaricious and unscrupulous. The defendants of the profession take refuge in the explanation that medical doctors are merely reflecting social mores. As corruption worsens in the society at large, doctors find reasons to follow suit. A common argument put forward by doctors is: ‘When I search for a consulting room for my practice or a flat for my home, I have to pay a considerable sum as black money. Likewise, when I try and enroll my child in a reputable school, I need to pay a huge sum under the table. Where am I to get these sums? Willy-nilly, I too must use avenues to collect unaccountable funds.’

Such thought flies in the face of the fact that the doctor is a highly educated and privileged person who cannot and should not justify unethical and unscrupulous acts under any circumstances.

Discussions on this topic have been in progress over decades. Indian Journal of Medical Ethics, published from Mumbai, features several essays criticising current trends and suggesting corrective measures.

The topic of unethical practices in performing medical tests (among other instances of unethical behaviour) has been brought into international focus by an essay written by a gynaecologist Dr Arun Gadre from Pune and published in the British Medical Journal (BMJ) on February 24, 2015. Particular emphasis has been placed on the excessive use of expensive tests for pecuniary motives.

The role of tests

Tests are requested after the doctor has obtained a detailed account of the origin, duration and progress of the illness from patient and family. The recording of this history is followed by a careful, detailed clinical examination of the patient. On completing the examination and reviewing the findings in the light of the history, the physician arrives at one or more possible diagnoses. In many instances, where the diagnosis is unequivocal, the physician may not require any tests and may proceed to treatment.

When the diagnosis is not clear and may be one of several possibilities, the doctor requests tests that will eliminate the unlikely possibilities and focus attention on what ails the patient. These tests may be in the form of examination of the blood, urine, sputum or other body fluids or tissues or some form of imaging ranging from X-ray films to sonography, isotope scans, computed tomography (CT), magnetic resonance (MR) scans and positron emission tomography (PET) scans. Accurate and appropriate treatment can now be recommended. So far, so good.

Unethical practices

The problems under discussion arise from greed in the two parties – the doctor requesting the tests and those performing them. The latter individuals and groups, attempting to garner a greater share of the business, offer incentives – financial and otherwise – to the referring doctor for each test ordered.

The ethical doctor disregards such offers. The most effective and least expensive tests are requested from reputable centres near the patient’s residence or workplace.

However, those swayed by lucre, request as many tests as they can, concentrating on those that are the most expensive as these guarantee the maximal returns in terms of commissions from the laboratory or imaging centre.

Other compulsions may also play a part. Doctors who have secured appointments as consultants in reputed private hospitals are, at times, under pressure to boost the income of laboratories and imaging units in these hospitals by sending all their private patients there. Some hospitals monitor the income generated by each doctor for such departments periodically and penalise those not sending ‘adequate’ referrals for tests.

Why are these practices not in the interest of the patient?

• Unnecessary tests are a drain on the patient’s purse. Worse, they may result in a chain reaction that can, at times, be disastrous. For e.g. an unnecessary X-ray film of the chest may show a doubtful abnormal shadow near the heart. This shadow is in no way connected with the patient’s illness but since it has come to notice, it elicits a recommendation that a further test – angiography – be performed. This adds to the patient’s costs. Angiography involves threading a large artery in the thigh and the injection of a chemical that renders blood vessels in and around the heart opaque to X-rays and thus clearly visible on films. Angiography shows a variation of the normal that requires no treatment. Unfortunately, the patient suffers a complication at the site of arterial puncture in the thigh that results in blockage of the artery. An operation is required to restore the flow of blood through it. The patient undergoes physical hardship, inability to work for a fortnight and considerable additional and unnecessary expense.
• When incentives in the form of kickbacks from laboratories or imaging centres play an important part in the decision by the doctor to order tests, the temptation is to send the patient to the laboratory or imaging centre that offers the largest sums. These are usually not the most competent or reliable laboratories and imaging centres.
• The sum paid by the laboratory or imaging centre to the referring doctor is included in the charge levied on the patient. The patient is thus paying an added sum, unaware that he is rewarding the referring doctor.

How can patients avoid being victims of such unethical practice?

Since we are unaware of the extent to which such unethical practices are in vogue it is best to be on guard against them.

Tests ordered after a cursory recording of the history of the patient’s illness and physical examination are questionable. The doctor has not taken the pains to learn details of the evolution of the disease that has caused the patient’s illness or determine where it is located in the body. A battery of tests cannot compensate for a good clinical examination. Such tests can be compared to the use of a shotgun that fires innumerable pellets in different directions. Since they are not focused, they may miss the target and despite considerable expense, the patient may be none the wiser about the cause of his illness.

When you are told to get the test done only at a specific laboratory or imaging centre without being given a rational justification for this recommendation, your antennae should quiver. There are centres and laboratories with special expertise and referrals to them for specific tests are in the best interests of the patient but this must be explained to the patient. Most simple tests can be performed at a variety of labs or imaging centres without any dilution of the information elicited.

Likewise, when you are asked to get tests done at a particular private hospital to which your consultant is attached and he dissuades you from getting it done at a centre near your home even when getting it done at the hospital causes considerable inconvenience, you should question the choice of the laboratory or the imaging centre.

Why is the onus on avoiding such malpractices thrust on the patient? Beset with a multitude of anxieties – about the symptoms experienced, doubts of the gravity of the illness causing them, expenses that may have to be met, interruption of work at home or in office – why should the patient have to shoulder the additional responsibility of detecting and frustrating unethical doctors and centres?

As a nation, we are poor at enforcing ethical practices. Agencies such as the Medical Council of India and the state medical councils were created to maintain standards of ethical medical practice. They have dismally failed to do so. Several efforts have been made to ensure probity and accountability in their functioning but these have failed so far.

We lack accreditation agencies that study the performances of individual doctors, laboratories and imaging centres and rate them by excellence, ethical standards and other useful criteria. The lay individual is thus sailing in an uncharted sea.

Over the past few years, there are groups that claim to rate agencies. The little I know of them is not conducive to confidence in their ratings as they solicit doctors, laboratories and imaging centres and do not perform rigorous, independent assessments.

So, is the current situation hopeless? How can you make the best of this state of affairs?  Well, the following steps may help:

• Public teaching hospitals such as the King Edward VII Memorial Hospital in Parel, Sir Jamsetjee Jejeebhoy Group of Hospitals in Byculla, Lokmanya Tilak Memorial General Hospital in Sion and the Bai Yamunabai Nair Hospital at Bombay Central in Mumbai are generally devoid of unethical practices though caution when dealing with individual doctors remains advisable.
• If you are fortunate in having a trustworthy family physician, he can prove an excellent guide to the specialised tests and treatment you may require. Unfortunately, such physicians are dwindling and can be almost categorised as endangered species.
• When you see a doctor for the first time pay attention to the time and effort he devotes to you. A friendly and cheerful attitude, concentration on what you are saying, the making of copious notes whilst he listens to you, a detailed physical examination are encouraging findings. On the other hand, the doctor watching the second hand of his watch as he sees you, handling innumerable telephone calls whilst you are trying to narrate your woes and the termination of his consultation within minutes of your arrival are disconcerting warning signals.
• As you have gathered from the text above, beware of the doctor ordering a multitude of tests after a cursory examination and of one insisting that you get them done at a particular centre.
• At all times, do not hesitate to insist on your rights – on the time spent by the doctor with you, a proper examination, explanation of the rationale for each test requested and for any other information you may need.
• Friends and relatives you trust can, at times, guide you based on their earlier experiences with doctors and hospitals.

Plight of doctors

This group deserves help, sympathy and encouragement. Many doctors graduating from the public sector teaching hospitals are motivated towards excellence and ethical practice. They enter the arena with aspirations and enthusiasm. The need to add to existing medical knowledge through research also inspires them. But, disillusionment strikes them hard as they encounter obstacles. It is difficult for them to get attachments to reputed private hospitals. Referral of patients are few and far between. Making ends meet is a recurrent dilemma. At such times they become vulnerable to unethical practice and lures set out by laboratories and imaging centres.

What can I, at the fag end of my career, say to them? I can point out examples of those who have resisted temptations of the unethical kind and have risen to the highest ranks of medical practitioners. Names like Dr Noshir Wadia, D Farokh Udwadia and Dr Homi M Dastur from the older generation and Dr Anil Karapurkar, Dr Sanjay Nagral, and Dr Shekhar Bhojraj from the younger generation will inspire them. There is much to learn from their perseverance and endeavour.

I appeal to the conscience of medical practitioners by quoting the great physician, Sir William Osler, “My message is chiefly to you … since with the ideals entertained now your future is indissolubly bound. The choice lies open, the paths are plain before you. Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow creatures as so many tools of the trade, and, if your heart’s desire is for riches, they may be yours; you will have bartered away the birthright of a noble heritage, traduced the physician’s well-deserved title of ‘Friend of Man’, and falsified the best traditions of an ancient and honorable Guild.”