Healthcare 2017- Ditch Robots And Bring Back The Doctors


Healthcare 2017- Ditch Robots And Bring Back The Doctors

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After yet another fruitful year of practicing what I preach, I thought it’s time to put up a post on my pet peeve, again. The said peeve being, the practice of medicine is slowly being changed into a robotic occupation, where a doctor is given a set of instructions and told to follow them to a “t”. But unfortunately the human body doesn’t not cooperate with this by the book approach as every individual is unique by himself and every disease affects a person differently. Given a set temple and asked to follow the protocols given is the surest way to prolong disease till the patient is deceased. And that’s the reason why I always take evidence based medicine with a pinch of salt.

Evidence based medicine to give its due, works in a fairly efficient way, in a limited spectrum. But given its limitations it is inefficient at best and dangerous at its worst. And why, I will explain now. For those not familiar with evidence based medicine- it’s a set of treatment protocols (usually developed in western countries) which says after checking these protocols this is the best treatment for this disease and hence, everyone worldwide needs to follow these protocols whenever/wherever they see this same disease.

The problems with this approach are manifold. Let me just discuss the top two. Firstly most if not all of these protocols were developed for simple diseases and straightforward diagnostics/treatment procedures. If you have any complicated disease requiring multiple procedures, you just cannot follow any protocol template, you have to diagnose and treat case by case using all your years of experience and intuition and hope for the best. Which in turn defeats the very purpose of evidence based medicine. You need best evidence protocols for the most difficult cases because these are the ones which test you to the limits and are prone to end up with the death of the patient and the doctor being blamed for inadequate/insufficient treatment. Where others who have the luxury of time, weeks and months to study the symptoms will second guess the decisions you make in seconds by the patient’s bedside as the patient lies gasping for air and fighting death minute by minute. What’s the evidence say? Did you follow the treatment protocol? These questions are very easy to ask in hindsight but doesn’t help at the moment when most required.

The second major disadvantage with this protocol based approach for treatment is that the template developed most often uses a particular procedure using a particular piece of equipment which study in turn is sponsored by that particular equipment manufacturer. You can’t blame them – for most of these studies are really expensive and require large scale funding which governments never do and hence the researchers raise money from private players who naturally have a vested interest in promoting their products. So even if there is a better or more simpler or more low cost way available to treat that particular disease it will never be accepted as mainstream – because no one does research on it and no one publishes it and no one by which I mean no respectable medical board or journal accepts it- which results in the low cost or simpler alternative having the status only of quack medicine. While the costlier company sponsored study gets accepted in prestigious journals and then becomes the accepted standard of care worldwide merely because there is no other alternative to it. This grant of legitimacy to costly treatments in the absence of alternatives is the primary reason that doctors from developing countries hate evidence based medicine. It’s all very well to recommend protocols followed in Boston or the Massachusetts general hospital but not everyone is lucky to be practicing in Boston or Massachusetts. What about somebody practicing in Nigeria? Or Nellore? With no access to the level of diagnostic or treatment machinery as given in the protocol as per evidence based medicine? Is it fair to punish that doctor for treating that patient but not following the best established practice protocol? Whose fault is that and how can you apportion the blame?

This craze of getting more and more evidence based protocols also has the side effect of developing and insisting on more and more tests, more than 90% of which are unnecessary- like treadmill test, stress test, angiogram, CT slice- 64/128/216 machines – all of them being developed just to rule out any cardiac disease and your doctor has to prescribe these unnecessary tests every time you go for a simple muscle sprain or gastric distress and indigestion or any other condition which does not involve the heart. But because the best evidence based medicine protocol says you have to rule out heart disease in all cases, everyone gets to do a CT scan at the highest possible resolution beyond 64, beyond 128 beyond 216 slices- even if you are a healthy person with absolutely no evidence of any heart disease. But because the protocol formed in San Francisco or New York or London says so- you have to get that CT scan, every time you over eat samosas and have gas. If this wasn’t a waste of resources and such a tragedy it would be such an inside joke, but I can’t laugh at it now. And neither should the poor unfortunate patients who end up paying for all that waste of time.

So the best thing that you and I can hope for is that the government gets into the act and funds medical research in a big way so that individual researchers do not have to go begging bowl in hand to equipment companies who in turn dictate the treatments to be researched and published. And secondly the realization that data mining and rigid protocol’s don’t work for human beings. There is ample space in medicine for hard won experience and intuition based on it. Or otherwise we will continue to take angiograms for every patient who comes to the hospital with an acidity problem and advocate cardiac by-pass surgeries based on minuscule blockages seen in every minor blood vessel, whether they want to or not get a major heart surgery done. Why? Because the evidence says so, and you want to get the best possible treatment at international level don’t you?

I hope national governments realize the immense damage being caused to local healthcare managements by these artificially imposed from abroad protocols and either help in developing local protocols for local people or at least stop penalizing doctors for using years and years of experience to treat patients instead of following Boston rules. Support doctors not robots.

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Communist Medicine In A Capitalist World


Communist Medicine In A Capitalist World – The Evidence Based Medicine Conundrum

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Any casual reader of history or anyone at all with any general knowledge know that the discredited philosophy of communism and its paramount creation the soviet empire were both destroyed because both economically and even with common sense it beggars belief that decisions can be made in central committees and by fiat be implemented in all places and in all situations without a single thought for local conditions or differences. Crops to be sown, fertilizers to be used and harvesting times were all imposed on farmers from afar by fat-cat bureaucrats sitting in distant Moscow committees who thought they knew better than the local farmers born and bred up on their lands for generations. The result was total collapse of the agriculture sector and widespread famines everywhere in Russia. Production quotas and processes to be implemented in factories led to so many shoddy products that anyone who was just anyone at all in Soviet Russia preferred to use imported products for everything from shavers to ovens.  Rule by distant committee was comprehensively proved to be the stupidest idea to have ever been invented by the human race and believe me we as a species have made many, many more such mistakes.

So if I now told you that the same discredited theory of communism is now being touted as the only way to practice medicine what would you say? I kid you not- search evidence based medicine on the internet and you would find plenty of laudatory articles as the way to go for practicing medicine as per modern protocols. But read past the platitudes and rule by central committee is exactly what you would find.  And just because the committee distributing it is the internet itself it finds its greatest advocates on the net who tout it as the only way to go and not as one more way as it really is. Now enough with all the historical references and let me start explaining what evidence based medicine really is all about.

Sometime in the last decade of the last century (the 1990’s anyone?) there arose a new system of medicine called evidence based medicine. As with everything else when it was first introduced the intentions were noble and its advocates were sincere and it was definitely a step forward to the future. Doctors everywhere welcomed it because it seemed to offer a way forward during those times when doctors most need help- decision time. Evidence based medicine involved putting up the results of large scale clinical trials on the net to help doctors everywhere follow those same guidelines in their treatment for their own patients. It showed what worked or what didn’t work to others who were hard pressed to make difficult clinical decisions in real time. As such it definitely was a step forward. It even helped simplify which drugs to prescribe or which not to. For instance many of the old time doctors used to rely heavily on antibiotics where were popular during their heydays often not realizing that such antibiotics were no longer active due to an effective resistance built up by bacteria continually exposed to the same drugs for so long. Hence evidence based medicine pushed the medical fraternity into discarding old, tried and tested beliefs and adopting newer treatments. And that’s when things started going wrong.

When the popularity of evidence based medicine picked up worldwide big pharma was as usual right there to swing things in their favor. They started sponsoring the large clinical trials needed to get their evidence – often using low cost outsourcing firms in under developed countries where patients signed up for medical trails for a pittance- and used the results of such biased trials to push heavily in favor of their own drugs which had been used in such trials. Other drugs, even tried and tested ones didn’t stand a chance because all the latest evidence (sponsored of course) freely available on the net pointed towards such and such drug – as the only one with enough evidence available to show it worked. If a doctor wished to use any other drug which he felt could be equally effective he stood in grave risk of being taken to court by the patient for not following “internationally accepted standards of care available on the net”. Which led to all the doctors falling in line cowed by threatened medical malpractice suits and patients reading up the results of such biased trials on the internet and demanding of their doctors the same treatment that dr.google recommends.

If to take an example you have constipation and I as your doctor want to recommend to you a single plantain (local banana) every night and you go on the net and read that florida oranges grown in glass rooms in chilly Alaska when given to 5000 people led to 4000 people rushing to their toilets every morning and you quote that study to me and demand that I prescribe only Florida oranges to you- imported straight from Alaska- then I have no choice except to write a prescription of the same. Because I or anyone else for that matter have no evidence at all that bananas work, forget the fact that every single individual we know all around us for thousands of years have used bananas to evacuate their bowels. There is no large clinical trial for local bananas- no one paid money to large groups of people to eat a banana and shit in the morning and hence no evidence for banana which makes it a false treatment under the evidence based medicine guidelines and if despite this I want you to eat a banana, god help me, I would end up losing my license for practicing medicine- for not asking you to eat imported Florida oranges which might beggar you with just one months treatment cost. And this is the literal truth and I am not exaggerating. The costliest drugs are the ones which drug companies prefer to send for large clinical trials by recruiting thousands of patients. Hence when the results come out its the same costly drugs which become the default treatment option worldwide and any doctor who differs is branded a witch doctor for not following the evidence. Individuality has been stamped out and creativity rooted out in the name of the evidence based medicine fad.

Just like communists used to prescribe their guidelines from a central committee for everything, evidence based medicine has a central treatment guideline which every doctor has to follow to save their own skins or woe to them. Such evidence gathered in distant populations does not take into account individuals or their idiosyncrasies. Medicine is not an exact science and most prescriptions are based on informed guesses but that doesn’t mean that in the name of standardization a one size fits all variety of medicine becomes the only way to practice. The evidence based medicine fad has been taken to such ridiculous levels that surgeons who often make small incremental advances in surgery by trying out newer and innovative surgical techniques on individual patients cannot publish their results anymore as case reports and case series- which are about smaller groups of patients – are increasingly being not published or downright derided in favor of larger clinical trials. Surgeons are being forced to fall in line with the same efficiency as robots and an individual surgical technique (even surgical flair) is being eliminated in favor of standardization.

The day is not far off when patients can print off their own prescriptions off the internet from a published list of symptoms to treat themselves and a doctor (or a middleman) becomes superfluous to medicine. Is that a step forward? Or will it lead to more chaos? Based on the history of communism I am very skeptical of the future of evidence based medicine as it is now. But I can’t speculate on what the next medical fad will be. Will evidence based medicine escape the stranglehold of big pharma and sponsored clinical trials and evolve into something more inclusive and egalitarian taking into account individual knowledge. Or will it act the monolith and seem impregnable till it suddenly implodes on its own like communism did? Only time will tell.