Saturday, August 09, 2014

Mindless checklists in medicine

Checklists have become extremely popular in medicine , specially after Dr Gawande wrote his book, Checklists. There is no doubt that they can be very useful when used properly – for example, in reducing medical errors in the OT.

However, checklists have lots of disadvantages , and this is especially true in the IVF clinic . Thus when a new patient comes in for a consultation, she is often seen by a junior doctor or assistant, who takes the history and fills in the data in the standard medical form the clinic uses. The senior doctor then reviews the file ( often for just a few minutes) and asks the assistant to order a series of tests. Most clinics have a printed checklist of all the investigations which the patient needs before starting an IVF cycle . This is an extremely long list of tests some of which can be very expensive !

The junior doctor will then mindlessly check off all the tests on the list, because this is what the clinic policy is . This becomes a mindless checklist , where the doctor doesn't apply his mind as to whether the patient actually needs a particular test or not .  These assistants become glorified box tickers who spend more time filling in the form , rather than talking to the patient. Care becomes depersonalized and the patient starts feeling she is a widget on an assembly line.

The doctor just orders all the tests on his list, because that what’s he’s been ordered to do. ( He is scared that if he doesn’t order the one test which the senior consultant may need later on, he will get into trouble. This is why it’s much easier for him to order all the tests. No one will criticize him for asking for too many tests, but if he forgets one, he may end up getting fired !)

This kind of mindless “tick the box” system can be extremely efficient for the clinic , because it increases their throughput and allows them to see many more patients , without the doctor to spend time thinking about whether a test is useful or not for that individual patient. Ticking a box is much easier than expending intellectual brainpower, which is often in short supply.

This is of course much more profitable for the clinic as well. The more the tests they order, the more the money they make . Even better (from the clinic’s perspective) is that if this battery of tests reveals some abnormalities, they can charge even more for “treating” this abnormal test result.

Unfortunately, this approach can be extremely harmful for the patient . It’s not just a question of the time and money wasted in doing unnecessary tests . The major danger is the problem of false positives . It’s a mathematical certainty that the more the tests you order, the higher the chances of getting an abnormal result.

Many of these so-called abnormalities are of no clinical importance , but the result comes back as abnormal, then rather than focus on the IVF treatment ( which is what the patient needs in order to help them get pregnant ), the doctor focuses on treating the abnormal test result. He often has to order even more tests to dig down deeper, and ask for consultations and expensive second opinions from specialists. ( This is extremely common in a hospital setting, where specialists are easily available !)

A primes example of this distressing problem is that of genital TB. One of the standard tests which most IVF doctors in India order today is a TB PCR test. They believe that TB is rampant in India and that it needs to be ruled out for every infertile woman who comes to them ( I have no idea how they come to this flawed conclusion ! Yes, pulmonary TB is common, but genital TB is very rare in an asymptomatic infertile woman with a normal menstrual cycle– and over testing can be much more harmful than missing the diagnosis in an occasional patient).

The TB PCR Test is completely useless because of the many false positive results it routinely generates. However, gynecologist order this routinely, because they have been brainwashed into thinking that just tuberculosis common in India, it is common amongst asymptomatic infertile women as well). Even worse than ordering just a TB PCR test, they order an entire panel of TB tests ( for example, blood tests for TB IgG and IgM, which are even more unreliable , and if any of these comes back as positive, they start treatment with antiTB medicines.

These poor women are then treated with nine months of potentially dangerous and toxic drugs , in order to treat the “ tuberculosis “. Not only does this fritter away nine precious months of their fertility, some of them with end up with side effects of these toxic drugs, which were never needed in the first place !

The only way we can fix this system is by teaching patients to push back. Patients need to start getting assertive, and if your doctor starts mindlessly ordering a whole series of tests for you, you should find out why each individual test is being ordered.

If a test will not change your treatment options , please refuse to do this. The problem is that many doctors are not happy fielding these difficult questions from assertive patients , and they will often answer with non-specific platitudes and non sequiturs by saying – This is the clinic policy . This is a useless answer which is not acceptable. It’s your hard earned money – don’t throw it away on wasteful tests.

You need to find a doctor who is much more specific and focused on your problem, if you want to make sure you're getting the best possible medical treatment . If your doctor refuses to do this, this means that you are in the wrong place , and need to find a better IVF clinic.

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