IN BAD TEST, DON’T MIND!

Loud Disclaimers:
1. This post was not written by me.
2. It is entirely hypothetical. Therefore, it is likely to be truer than the real news you read in the papers.
3. The blog owner, unlike his moniker, is not really a doctor.
4. If he is, he is one mean son-of-a-bitch (a Rambodog), who will likely be condemned by the honorable medical profession for besmirching its fair name.

Read at your own risk.

So you are unwell, and your doctor has ordered some tests? No? Maybe you need to take an executive health checkup or a pre-employment checkup: a clearance that will take your career to the next level?

Whether or not you hate hospitals, doctors and needles (for few are able to hate the nurses), you are going to be subjected to some tests one of these days.

This post is not meant to be a detailed exposition on medical labs. I will merely reveal some of the lesser known aspects of tests.

* Comprehensive health checkup, something that has been popularised by many leading hospitals, is a big rip-off. Not only do the hospitals make money doing so, but the down side is that diseases are revealed, when they probably would not have needed treatment at that time, if ever. In other words, not all abnormalities need to be detected or treated.

Let me give you an example:

Ajanta was a 26 year-old executive who was asked to undergo a health checkup at one of these modern Indian hospitals. An x-ray of the chest revealed a spot like a coin in one of the lungs. The doctor asked her to go for more tests to diagnose it.

“Is this cancer?” she asked, trembling.

“I can’t say, but it could be in some cases”, replied her doctor.

A CT scan of the chest was done, and the lesion was biopsied with a needle. Unfortunately, the needle went into a blood vessel, as well as into some airsacs, and Ajanta started getting faint and breathless as the blood and air kept leaking into her chest cavity and compressing her lungs.

Rushed to the emergency room, a tube drain was placed surgically into her chest to evacuate the blood and air. As she recovered from this mishap, more bad news came in. The biopsy was inconclusive. Another one would have to be done.

Alarmed, Aparna Ajanta left town for the best center in the country. Another scan-guided needle biopsy was done. The biopsy was again inconclusive.

Now she was heading towards surgery to remove and biopsy the coin lesion. The job was done cleanly by an experienced thoracic surgeon, and Ajanta recovered. The biopsy result?
Hamartoma, it said.
“What’s that?” she asked. Her doc replied that it was really not much except some abnormal tissue that was not a cancer.

If she had not known of this, she would possibly not have ever needed surgery for it.

Aparna was a Victim Of Medical Imaging Technology. VOMIT, in short.

VOMIT syndrome is now a well known complication of fruitless testing that throw up diagnoses that would often have been better left alone and unknown. This is one major reason why ‘let me find out if everything is okay in my body. Doc, I want all the tests, including the scans” is NOT a great idea. Treatment of many conditions is undertaken only because tests (like the chest x-ray in Aparna’s case) are done without indication, and doctors feel obliged to treat the newly diagnosed ‘disease’. Indeed, why do the tests if we are not going to treat what is found?

Other aspects of medical testing include:

* Poor standardisation of labs results in wrong reports that are sometimes dangerous.

Most labs are run with poor equipment. The tests are often done by unqualified technicians, and the pathologist or biochemist comes in only to sign the report. These doctors are rarely paid well enough for them to give much time at a lab. They, therefore, rush out of the lab after signing reports. Another center, same story. End of the day, some money has been made, but a bunch of useless or misleading reports are sent out.

* Labs, usually the ones not doing particularly well, give a hefty cut to the referring doctor, usually a medical specialist (internist). Of course, any one, from a general physician to a neurosurgeon, may avail of these ‘interpretation charges’ (‘IP’ in marketing jargon). Unfortunately, they might refer the patient to the highest bidding lab rather than the best one. Many doctors have their own lab, which could be another glorious example of the above prototype.

* In many Indian cities, of which Mumbai is a particularly obnoxious example, labs cheat patients, as exemplified by the Cheaterjee Labs. Look at this:

The marketing exec of the Cheaterjee Labs is telling the GP:

“Sir, we will cater to all your patients, rich or poor.
Please follow our system for the best results:
If you don’t really need the test, write out the tests in blue ink; we will just type a report and not waste our resources doing the test. In this case, we will give you 50% of the costs.
If you need us to give you a favorable report (for example, a higher blood sugar report, or a positive test for syphilis), please write in red ink. We will give you 40% of the costs of the tests.
If, however, you actually need us to give you accurate results, write in black. Your IP charges will be 30%.
Sir, here is a compliment from Mr. Cheaterjee, our Director. Please accept this set of three pens!”

Our GP is one smart cookie. He mainly treats the migrant laborers of Kurla, a Mumbai suburb. The Biharis and Bangladeshis are his patients. Illiterate, these poor, unsuspecting idiots think there is only one answer to their ailments: injections and glucose infusions.
For any problem, the GP admits them in his local hole-in-the-wall nursing home, and gives them the expected ‘treatment’. If the ‘customer’ is possessed of a little more cash, then tests are done. Now, the three-ink plan comes in handy. If the doc wants to squeeze some dough out of the patient, he can get a positive report for, say, syphilis, and then keep giving regular injections of penicillin, making a buck every week. A few such patients, and he has his sight on his next mutual funds investment.

* Most Government labs are horribly run. Exceptions are some of the good teaching hospitals in major cities.

* Most of the top private hospitals have decent facilities, but reports may vary. In case of cancers, it is the skill of the pathologist that makes the difference between right and a grievous wrong.

* Almost all healthy young patients below 40 years who need a routine surgery need NO pre-operative tests (useless, expensive, and wasteful). This international recommendation is zealously ignored by 99% of doctors.

There, I said it. Will I be a leper in the community of doctors now? Oh, I forgot, I am only a virtual one!

23 responses to “IN BAD TEST, DON’T MIND!

  1. bold indeed doc

    VOMIT: LOL!
    cheaterjee: ROFLOL!

  2. Thank you for sharing truth.. An Eye opener

    It’s so true that most doctors have their own lab or they are almost like owning the lab…

  3. As part of an employment check many years back, this pretty dentist doc told me that some seven of my teeth are in horrible shape, and need immediate attention. Six years later and still no signs of any dental problems 😀

    And this stuff is scary indeed…just hope that these people dont end up killing patients in their zeal to make money.

  4. woohaa !
    ur spilling the medical frat beans all over ur blog

    sorry i should have rephrased the comment on stock chat – curse my rather crude english abilities for that
    im well accustomed with ur humor phd,
    🙂
    but seriously in medical terms what have u specialised in doc ?

  5. Rambodoc: At times like these, I am grateful for our universal access, free-at-the-point-of-delivery healthcare system.

    Our resources are so stretched that rationing may ensure a real cancer patient could die before being treated; but we will be damned if we ever gave anyone an un-necessary test.

    How do we manage this?

    We give them such long waiting times for a basic scan that most start feeling better already in the meanwhile.

    However if one is near death, then the health service will do its best, so that nobody sues them. Our malpractice lawsuits however do not go far as it is tantamount to using a few 1000 taxpayers’ monies to fight the lawsuit and then to award damages. That, I think, is called socialism and we have long rejected that in the UK, I hear… 😉

  6. true true!
    I once had a cough and fever the doc (we were temporarily in bhopal) said ALL tests including for typhoid, and whatever. Fine I said, but why start taking the typhoid medicines straight away?
    ‘Its probably typhoid’ said the young doc. He looked awfully young and the thought of typhoid excited him I could see.
    Typhoid!! It scared me, but not enough.
    I thought I’d wait for a day and ALL tests came out negative. But I hadn’t failed to gargle that night and by the time the test results arrived my cough had gone and so had the fever.
    He was being on the safe side, defended my doc cousin.
    Talking about being on the safe side,
    been reading a lot about how the number of ceasarians are increasing too. Docs tell me it’s because of an increasing fear of litigation, no one wants to take chances.
    For a doctor to say what you did though, and that too in public, is quite a feat. Good thing your real name is hidden rdog. All the same, very brave of you as fellow dogs might just locate your IP address and decide to bite.
    But then there is always the teaching profession. 😉

  7. Nita: Where either of a possible viral and a possible bacterial infection could be responsible, a certain diagnosis can only be made after lab cultures come back. That takes about 2 weeks. Meanwhile doctors work with a hypothesis.

    Doctors start on anti-biotic treatment because it also gives them another marker in the meanwhile to dismiss or confirm their hypothesis. Besides it is immensely preferable to the patient dying, isn’t it?

    Sometimes things are minor and may go away, like your cold, which is also why they tell patients to take 2 aspirins and call them back in the morning.

    As for rising caesareans, I daresay it has less to do with doctors and more to do with mothers. Increasingly mothers have careers and they would rather schedule delivery to fit in their agenda rather than be kept waiting around for natural birth to come to pass. Also the more image conscious we get, the less likely are moms wanting to “push, push”.. What else can explain that incidence of caesarean births is higher in high-earning groups, and professionals in the image businesses such as modelling, fashion and films? (There may be a higher reporting bias too).

    There are also broader sociological reasons. Women living away from home do not have the support of elderly women relatives and as a result, many fear pregnancy and labour pains. Those who can afford go ahead with a caesarean to ‘manage’ some of these issues proactively.

    I would rather a doctor cared, then not. Simply because our first port of call is a ‘generalist’ physician, not a specialist and his job is largely to generate alternatives if he suspects anything serious.

  8. I go for these checkups once in 2 years. Agreed, sometimes they tend to advice treatments that you can do without but don’t you think pre-warned is pre-armed. For example if I know my cholesterol is on a higher side I would take corrective steps. If any deficiency is detected I can take care of that. Blindly follwing their advice is not a good idea and that is where your friendly neighbourhood GP comes handy.

  9. Thanks to all who responded.
    Shefaly:
    What you have in the UK is socialism. You can call it by any name. The private sector plays a small role in health care. That said, the fact that the UK is an advanced country with its built-in checks and balances makes for a better delivery system than those available in developing countries.
    Shefaly and Nita:
    Antibiotics are prescribed on many (I would even say most) occasions as an insurance. What if? In the short term, it seems there is no harm. However, in the long term, the consequences can devastate patients. The MRSA epidemic is one important example. Another thing is the cost of unnecessary drug consumption. I don’t have the stats, but you are looking at billions of dollars in antibiotics spent on viruses every year.
    Nita,
    I am going to have to learn certain lessons in life before I am relegated to teaching. I am doggedly pursuing this course!
    Caesarian sections need another blog post, but I think Shefaly got it right in large part.

  10. I have different take on antibiotics but yes I have heard docs say what Shefaly has said. Many times. I ofcourse disagree vehemently that antibiotics are necessary for docs to prescribe when they see a patient with cold and a fever, without waiting for at least a day or two.
    Antibiotics are life-savers and they should remain so. Luckily there are enlightened docs as my family physician is one of them.
    About ceasarians, I don’t think what Shefaly said applies to India, I mean not the professional part. I don’t have statistics but the I don’t think it’s mostly the working women who go for ceasarians, not in India. At least that is what I understood Shefaly to be saying, but I may be wrong…
    and rdoc, yes let’s have a post on the galloping number of ceasarian sections in India. In fact I too have been researching this subject…

  11. I just sent a comment and I think it went into spam

    In other words, you said, “Rdog, fetch!”?

  12. Nita,
    Here is an extract from an article today. It pertains to one of the high powered latest generation antibiotics used for life-threatening infections. Just to show that antibiotics are not harmless:

    “Cefepime HCl injection (Maxipime, Bristol-Myers Squibb Co) may be linked to an increased risk for death, the US Food and Drug Administration (FDA) warned healthcare professionals yesterday in an early communication.

    The warning was based on data from a systematic review and meta-analysis published in the May 2007 issue of The Lancet Infectious Diseases showing that use of cefepime was linked to an increased risk for all-cause mortality compared with other beta lactam antibiotics (risk ratio [RR], 1.26; 95% confidence interval [CI], 1.08 – 1.49), particularly in patients with febrile neutropenia (RR, 1.42; 95% CI, 1.09 – 1.84).

    These findings have prompted an FDA review of new safety data and a request for additional data to further evaluate this risk, according to an alert sent from MedWatch, the FDA’s safety information and adverse event reporting program.

    At the end of the evaluation, which is expected to take 4 months, the FDA will communicate its conclusions and any resulting recommendations. Until that time, healthcare providers are advised to consider the risks and benefits of cefepime therapy as described in the safety labeling and the meta-analysis.”

  13. I am not sure I agree on the C-Section bit either. C-sections are perhaps performed not to fit the mother’s schedule, but the doctor’s. Despite being very fond of my ob-gyn, I secretly suspect that I had a C-S only because it was going to be a new year a couple of hours from the time I hit transition, and people were perhaps in a hurry to get done with me for auld lang sining. Of course, after 13 hours of labor and 45 minutes of transition, I was more than ready for a C-S, so it worked out fine after all.. But I can’t help wondering if I may have had a vaginal if we had waited an hour.. and a new-year baby 🙂

  14. Lakshmi, my mom, a healthy young woman, was in labour for 20 hours but in those days there was no question of c-sections. she had a normal delivery. each case is different ofcourse, but I was soooo lucky during my delivery. there was this doc called dr. chaphekar, an absolute legend!! I went a week beyond the date and he scolded me:

    what are you doing woman! Go and walk a mile!!

    And I was so scared of him that I went for a brisk walk. The same night the pains started and I delievered by about 10 in the morning. On the other hand my friend was 3 days late and her doc put her on pills etc and finally even before a week past her delivery date scheduled a c-section. both of us were going to have our first babies, no complications at all, absolutely healthy young women with no blood pressure or whatever. I guess I should thank my doc.

    Rdog…er…doc, thanks for the info! You’ve been well-trained by your commentators I see.

  15. wow adv laproscopy should need lots of skill

    (Prax, I removed the rest of this message because it does not fit here. I really appreciate it. Thanks.)

  16. yes nita – this c sec business is huge business worldwide that other than navratra abortions

  17. Pr3rna:

    //…that is where your friendly neighbourhood GP comes handy.//

    True, but friendly neighbourhood GPs who are also competent are becoming increasingly rare to come by. Everyone who is any good wants to become a specialist, or a super-specialist.

    I was once sent to an otorhinolaryngologist 🙂 for an audiometry, which only yielded the finding that I was having trouble hearing because I had not fully recovered from a bad cold two weeks earlier.

  18. On a lighter vein (not mine):

    Let me tell you about my doctor. He’s very good.

    If you tell him you want a second opinion, he’ll go out and come in again. He treated one woman for yellow jaundice for three years before he realized she was Chinese.

    Another time he gave a patient six months to live. At the end of the six months, the patient hadn’t paid his bill, so the doctor gave him another six months.

    One time while he was talking to me, his nurse came in and said, “Doctor, there is a man here who thinks he’s invisible.” The doctor said, “Tell him I can’t see him.”

    Another time as I sat in the waiting room, a man came running in the office and yelled, “Doctor, doctor! My son just swallowed a roll of film!!” The doctor calmly replied, “Let’s just wait and see what develops.”

    One patient came in and said, “Doctor, I have a serious memory problem.” The doctor asked, “When did it start?” The man replied, “When did what start?”

    I remember one time I told my doctor I had a ringing in my ears. His advice: “Don’t answer it.”

    My doctor sure has his share of nut cases. One said to him, “Doctor, I think I’m a bell.” The doctor gave him some pills and said, “Here, take these – if they don’t work, give me a ring.”

    Another guy told the doctor that he thought he was a deck of cards. The doctor simply said, “Go sit over there. I’ll deal with you later.”

    When I told my doctor I broke my leg in two places, he told me to stop going to those places.

    You know, doctors can be so frustrating. You wait a month and a half for an appointment, then he says, “I wish you had come to me sooner.”

  19. //
    Ajanta was a 26 year-old executive…
    //

    //
    Alarmed, Aparna left town for the best center in the country…
    //

    Is this a trick by you to see whether the avid readers of your Blog really read the whole post or just run through the main points?

    🙂

    Voracious Blog Reader

    VBR,
    You are more awake reading it than I was while writing!
    LOL!
    😀

  20. VBR:

    It could simply be a trick to see if the readers can distinguish between ‘knows-better’ and ‘doesn’t-know-better’ errors… 🙂

    Now, Shefaly, you are making me wonder: where did I make such an obnoxious mistake?!
    😦

  21. Rambodoc: See VBR’s note.

    The reason why I did not comment on the “error” – although I comment on almost every slip-up; now you know me long enough – is because I classify it as a “knows better” error. In other words, a slip-up rather than a mistake.. 🙂

  22. Not a leper, but a hero and not just in virtual world but in real too. Thank you for an informative and enlightening write-up. An excellent post.

  23. R-dawg (woof woof 🙂
    Wish I’d known of the VOMIT acronym sooner. Friends have called me to ask whether they should submit to mobile full body scans these past couple years. These drive by “diagnostic” operations target civic groups and place newspaper ads.
    My spiel is: best to have targeted scans when indicated by your physician for problems based on your medical history or symptoms, etc.
    With these fly by night operations, too much potential for finding “something wrong” –that may essentially be benign. Unless you have a reason for a particular scan, why are you doing this outside your doctor-patient relationship? He/She will be pissed, and have to deal with any abnormal findings. What if the “abnormality” is innocuous? You now have a label and medical record entry for something that was never a problem!
    Then I go into the “lots of folks have abnormalities (such as herniated discs) that cause no problems” bit.
    Bottom line: talk to your doctor or primary healthcare provider. If you aren’t able to, that’s a problem. Regular, thorough checkups can catch most problems. If you really feel a certain test is needed, ask…

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