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Choosing wisely your interventions and tests is the right way

Choosing wisely your interventions and tests is the right way

It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigations. Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a competently performed physical examination.  Doctor’s ability to gather a sensitive and nuanced history and to perform a thorough and accurate examination deepens doctor- patient relationship, focuses on patient assessment, and sets the direction of clinical thinking. This entails empathic listening; ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body parts; and, finally, the process of clinical reasoning. This is an opportunity to explore the patient’s needs and expectations; not a waste of time. Clinical examination needs to be as focused as history. After good history and examination the need for investigations is minimal. However, unnecessary laboratory testing is widely perceived as being pervasive. The fact that nine out of 10 physicians admit to ordering medically unnecessary tests indicates that there is a widespread misuse of lab tests. Ace ophthalmologist and former dean of PGI Dr. Amod Gupta has always been a votary of ‘medical audit’ to curb unnecessary tests and interventions and enhance accountability. Physicians continue to order low-value diagnostic and  pre-operative tests that add unnecessary costs. Clinical tests that do not reflect patients’ real needs represent a huge cost for the health service. Studies have shown that a relatively large percentage (up to 42%) of laboratory testing can be considered wasteful.  No amount of tests can make a physician infallible, as medicine is an uncertain and imperfect science, and every doctor sometimes makes mistakes in diagnosis and treatment. But the frequency and seriousness of those mistakes can be reduced by “understanding how a doctor thinks and how he or she can think better”. Wasteful tests cannot make the physician wiser!

Avoidable obsession

Ordering blood tests and other investigations has become an obsession with the doctors as well as patients on self-prescription. While doctors indulge in this malpractice due to abdication of their clinical acumen, defensive medicine for fear of litigation, lack of concern for the poor patient’s pocket and reasons like ‘cuts’.  The patient self prescribes tests due to malaise of medicalization i e mindset of solving problems through tests or medicines. Several experts suggest a halt to this practice. There has been a dramatic increase in the use of advanced imaging despite scant evidence of associated improvement in patient outcomes.  In a study conducted in US, 97% physicians acknowledged ordering some advanced imaging scans, such as computed tomography and magnetic resonance imaging that were not strictly necessary. In addition, more than 85% of responding emergency physicians said too many diagnostic procedures, from blood and urine tests to scans, were ordered in their departments, suggesting that the problem is systemic. By conservative assessment, 30 per cent of health spending was found to be wasteful or went on procedures and treatments that were of little benefit or could actually be harmful. In the United States, 96 per cent of specialists practicing in fields at high risk of litigation confessed to practicing defensively, including 43 per cent who reported ordering unnecessary diagnostic imaging tests. “Don’t perform repetitive complete blood counts and chemistry testing in the face of clinical and laboratory stability,” is just one of the latest recommendations highlighted this year at the American Society of Hematology (ASH) 57th Annual Meeting. Taking blood for routine tests can quickly add up, mounting up to half a liter or more, and very sick patients cannot afford to be losing that much blood, especially if the tests are not providing any useful information, experts said.

 

Excessive healthcare

Experts questioned the bias in the medical profession to provide intensive care, including “heroic interventions”, for very ill patients in the terminal stages of life– 30 per cent of health funds are spent on health care in the last year of life, including hospital care to the elderly or cancer ridden patients – and suggested a more conservative approach involving a shift in focus away from treatments that do not improve survival beyond six months or enhance quality of life. Avoid using PET or PET–CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.

Physicians have access to an ever-growing array of tests and studies, but they often forget that the results may be less sensitive or specific than their own eyes and ears. And when the two are in conflict (i.e. the patient looks terrible but the test is normal), they often default to trusting the tests. Doctor needs to listen to the patients, trust what they are saying, then verify their complaints with own exam, and use labs and imaging sparingly to confirm or rule out your diagnosis. Understand the limitations of each study, and do not dismiss patient complaints too easily. Keep probing and asking questions. Learn more about their concerns – open your mind to the possibility that they are on to something. Do not blame the patient because your tests aren’t picking up their problem.

If a patient doesn’t look well – doctor should obey his own instincts and do not walk away because the tests are “reassuring.” Cancer, strokes, and infections will get their dirty tendrils all over your patient before that follow up study catches them red handed. And by then, it could be too late.

Doctors will be better off to rely on themselves than the labs. There is a need to improve primary healthcare in India. But why a family physician gets less money and less respect?

 

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