Thursday, January 18, 2007

Converting people into patients - a cautionary tale

I enjoy playing tennis, and had fun playing with a friend of mine who had come down from the USA . He is 30 years old and overweight, and because he hadn’t played for quite some time, I beat him comfortably on Saturday . He was raring to get revenge, so we fixed our next tennis date for Monday. On Sunday, however, he cancelled the match, saying his cardiologist had prohibited him from any strenuous exercise ! I was surprised , to say the least. Here was someone who’d had a great workout on Saturday – who was being forbidden from playing the next day by his doctor ! What had happened which had converted my healthy tennis partner into a patient ?

So I switched from my “tennis partner” mode to my doctor mode, and got the medical details. It turns out that because he was hypertensive, overweight, with a family history of heart disease and also had high cholesterol levels, his cardiologist in the USA had done a 64-slice cardiac CT for him to image his coronary arteries. These showed that two of them had a stenosis ( narrowing), which is why he had done to an Indian doctor for a second opinion on Sunday . This doctor had told him to get admitted on Monday for a coronary angioplasty, to treat the stenosis – and he was all set to do so, since this was such a “minor” procedure and would “fix “ his problem. So what’s the moral of this story ?

This guy is a smart MBA who is the CEO of a company, and it’s obvious that even smart people don’t behave very wisely when it comes to their own medical care. While he was very bright at tackling business problems and ran a multi-million dollar company very successfully , when it came to making personal medical decisions, he was quite content to leave everything upto his doctor – after all, “the doctor knows best” ! I am still not sure why intelligent people behave like this. While he would never ever blindly trust his lawyer or accountant , he just refused to do his “due diligence” when it came to his doctor’s advise – even though what was at stake was his entire life – not just a few dollars ! It’s fine to trust your doctor but verifying what he says is still a patient’s responsibility !

Because of the rapid advances in medical technology, it’s easy to take pictures of practically any part of the body – and doctors love doing this . Not only is looking at the pictures far more interesting than talking to patients – it’s also much more profitable ! The problem is that this leads to over testing and doctors routinely pickup abnormalities which are of no clinical importance – minor lesions which patients will carry to their grave without causing any mischief. However, once a lesion has been picked up, it’s a knee-jerk reflex to want to treat it – and once the medical behemoth has been set into motion, it’s practically impossible to stop it ! Few patients have the wisdom to question their doctor’s advise , with the result that few leave the medical maze unscathed and intact !

One of the results of this is that doctors end up treating the coronary angiogram – not the patient ! This is an easy ( and highly remunerative) procedure to perform , so that it’s done way too often. And while the benefits to the doctor are clear, few patients stop to ask how the procedure will help them ! So do these interventions really help ? Is it worthwhile “treating the narrowed artery “ Should the stenosis be “plumbered “ in an asymptomatic patient, with no complaints ? The sad fact is that no one really knows the answer to this simple question ! While the angioplasty will widen the narrowing ( at least for some time), no one knows whether it really helps in the long run ! Many of these “treated” arteries re-stenose in a few months, so whether the procedure helps or not is unclear. The end-point should not be a better looking coronary artery – it should be an improvement in life expectancy or a better quality of life. Since this has never been proven , most doctors are very happy to treat the narrowing on the “logical” basis that a widened artery is better than a narrowed artery. Sadly, most cardiologists today are just glorified plumbers – because that’s where the money is !

Key questions such as: What is the natural history of the stenosis ? What would happen if you left it alone ? Can it be reversed non-surgically with changes in lifestyle and medication ? What are the risks of the angioplasty ? are all left unasked and unanswered.

So why doesn’t the patient ask these questions ? This is because most doctors are very good at scaring patients into agreeing with them ! They congratulate the patient for seeking medical attention in “ the nick of time” so that they can save their hearts and their lives . They use fear tactics , create a sense of urgency ( which is completely unwarranted), thus precipitating the patient into taking action. Many of them warn the patient that the plaque which has caused the stenosis can ulcerate at any minute and lead to a heart attack , so that “ you may keel over and die any minute “ ! Imagine the amount of fear this creates in the patient – and his family members. They start treating him like a “time-bomb” which can go off any minute – and this is the exact same person who was working up a healthy sweat on the tennis court just 24 hours ago ! In reality, no one knows the natural history of these lesions – and doctors are not fortune tellers !

It’s very natural to want to do something – anything ! Most people are interventional by nature – “don’t just stand there – do something !” Many of these patients would have done equally well even without the angioplasty , but when they improve, they give all the credit to the doctor – credit which the doctor does not really deserve, but is happy to take ! And what of the ones who do poorly ? They attribute this to their fate – and some doctors even go so far as to suggest that this confirms that the patient was so sick that the complications would have been even worse if they had not done the procedure ! Patients are scared to death – and the doctor promises a lifeline they desperately want to cling on to.

The purpose of medicine is to help heal the ill – to convert patients to healthy people and restore them back to a purposeful life. Today, we seem to be doing exactly the opposite ! We seem to be converting healthy people into patients ! My friend has now become a “cardiac cripple”, who refuses to play tennis anymore – because his doctor won’t let him. In reality, physical exercise is the best therapy for ischemic heart disease, because it increase the blood supply to the heart – and improves the supply of blood to the heart tissue by promoting the development of collaterals ( the “natural bypass” which the body creates to deal with the stenosis). Stopping him from exercising is poor advise !

While doctors are meant to be professionals who are supposed to put the patient’s interests first , professionalism seems to have taken a back-seat today, because of commercialism . One of the world’s best cardiologists, Dr Lown, has documented this extremely well, in his marvellous book, The Lost Art of Healing.

Ivan Illich predicted that this would happen many years ago, in his classic, Medical Nemesis. The medical professional has medicalised nearly everything – ranging from simple activities like exercise ( “Please check with your doctor before starting an exercise regime”); to childbirth; and even dying. I can understand why doctors would want to do this – after all, the more power they have, the more they earn ! But why do average people allow them to get away with this abuse of power ?

This is not a healthcare system today – it’s an illness creating system ! And ironically, all our “ preventive medicine “ efforts today are devoted to this end – to suck more people into the system by doing “healthcare checkups” , thus converting them into patients
( because most of these tests will pick up some abnormality or the other – and the more the tests you do, the better the odds of picking up a problem ! Few doctors have the maturity to be able to reassure the patient that lots of these are minor variations, of no importance !) We have converted well people into the worried well !

So what’s the solution ? How do we put people in charge of their own healthcare ? How do we remind them that a doctor is just a professional who provides advise, and is not God ! The only solution is to empower them with information, so that they are empowered to make their own decisions. They need access to alternative viewpoints , and the pros and cons of all of these , at the point of use, so they don’t get browbeaten into doing what the doctor tells them ! Unfortunately, patients often feel powerless and helpless – and they are quite happy to let the doctor decide for them. While this can work well sometimes, it often doesn’t – and the buyer needs to beware !

An online personal health record can act as the nucleus of a patient networking system, where patients can ask for help from other patients – help which is likely to be much more authentic, since it comes from the “horse’s mouth” !

What of my friend ? Will he do the angioplasty ? I still don’t know. I just hope that some good will come of all this. Maybe the results of the scan will serve as a wake up call, so he spends some time on himself, and makes some healthy lifestyle changes. These are commonsense things to do , and these are what really help – not the surgery !

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