TRICK or TREAT - A Survival Guide To Healthcare

CHAPTER - 1

1. The End justifies the Means ("Your uterus at any cost")

The Wolf and the Lamb: A wolf cornered a stray lamb and felt compelled to give a reason to justify devouring it. The wolf complained to the lamb, "You insulted me last year." The lamb bleated, "That is not possible, Sir, for I was not born then." "Well. You feed in my pastures", retorted the wolf. "That cannot be, Sir," replied the lamb, "for I have not started eating grass." The wolf raised his voice and said, "Then you must have drunk water from my spring." "No, Sir, I have not yet drunk anything but my mother's milk," said the poor lamb. The wolf ran out of plausible excuses and said, "Well, I am hungry. I have to eat you anyway." He then pounced on the little lamb and devoured it.

Sheela, a 30-year old teacher with pelvic pain, went to her gynaecologist for follow up advice. He had a cursory glance at her case notes and said, "The next step is obvious. Your uterus has to be removed. I shall do it next week."

Sheela started hesitantly, "But doctor, ..."

The doctor said, "Why do you hesitate now? You have severe pain every month."

Sheela: "The pain is now controlled on medicines and ..."

Doctor: "Moreover you have two kids already. Why do you need it anymore?"

Sheela: "No doctor, I would like to avoid surgery if ..."

Doctor: "No 'ifs and buts', Sheela. You don't understand. With ageing there are risks of getting tumours. Why not eliminate the risk and be happy?"

Sheela: "But, doctor ..."

Doctor: "No more questions, Sheela. You bring your husband tomorrow. I shall finalise with him and do you next week."

Comments

"You don't need a hysterectomy. It can do you more harm than good. These are strong words but the fact is that more than 90% of hysterectomies are unnecessary and worse, the surgery can have long lasting consequences. It is time we doctors stopped disassembling women. But nothing will change until more women look their doctors in the eye and calmly state their determination to remain intact." (Stanley West, 1994)

A senate committee of the USA has reported that 2.4 million unnecessary operations were performed there at a cost of four billion dollars (equal to 14,000 crore rupees) every year! If a hospital had a watch dog committee to check if surgery was necessary or not, the rate of surgery declined by two-thirds. (Fulder S, 1991)

This is the situation in US where health care seekers (patients) are generally aware of their rights and play an active role in medical decision making. One can then imagine the plight of an average Indian patient who unquestioningly accepts any medical advice as the gospel truth. I have come across many young women in their 20's who have had hysterectomy done. The general tone of medical advice for the surgery has been, "You have had your two kids. You do not need your uterus anymore." My colleagues working in gynaecology say that most of these unfortunate cases could have been managed without such a drastic step.

Doing a Caesarian section giving little chance for a normal delivery to occur is another act of taking young women on an unnecessary 'surgical ride'. Scientific studies in Maharashtra state have shown that it has little to do with medical indications and every thing to do with money. In these studies, the professional fees were fixed for every delivery conducted, regardless of its mode (normal or surgical). There was a significant reduction in the rate of Caesarian sections and a proportional rise in normal deliveries.

Removing the tonsils used to be a 'surgical epidemic' earlier. The ear-nose-throat surgeons are more conservative now. Due to the ease of laparoscopic surgery and the income generated by this hi-tech procedure, the gallbladder and the appendix have become the current victims. I find it hard to believe that even removal of the eye-lens has succumbed to the market pressures. My ophthalmic colleagues say that they have documented cases who went to a hi-tech ophthalmic centre with presbyopia (age-related problems of near vision) to be advised 'urgent intra ocular lens implantation'.

Bernard Shaw, in the preface to his famous play 'The Doctor's Dilemma', has made the following observations which were scandalous in 1906 but are entirely appropriate today.

"It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is what we have done. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the house breaker the judges of that. If we did, no man's neck would be safe and no man's house stable."

Taking charge of decisions

If you want to be an informed seeker of health care, discuss the following points with your doctor before agreeing to undergo any procedure:

1. What is actually wrong with me?
2. How serious is this disease/condition?
3. What may happen to me if I leave it untreated?
4. What kind of procedure are you planning to do?
5. Is the procedure being done for diagnosis, for treatment or for both?
6. What are the risks of this procedure?
7. What are the chances that the proposed procedure will be successful in my case?
8. Will the benefits of surgery last long, or is it just a temporary measure?
9. Are any alternate procedures/treatments available?
10. Of these, which do you think would be the best for me? Why?
11. If your relative were in my position, would you choose the same for him/her? (If there is a difference between 10 and 11 please explain it.)
12. Could you suggest any source of information on this disease that I could read or watch?
13. What is the total cost of the procedure likely to be?
14. Is there any follow-up costs involved after the procedure?

It is good to take a second opinion before taking major decisions (see ch. 36). An ethical doctor would welcome it.

CHAPTER - 7

7. One symptom does not make a syndrome

The Spendthrift and the Swallow: A spendthrift had spent all his fortune. He had nothing left save the fine woollen clothes on his body. It was early spring and he wondered where his next meal would come from. Then he spotted a swallow and perked up. He thought, "Ah! There is a swallow. Summer has arrived. I do not need these winter clothes anymore," and sold all his woollen clothes. The weather unexpectedly reverted and there was a sharp frost that killed the swallow. When the spendthrift saw the dead bird, he cried, "You foolish bird! Thanks to you, I believed that summer has arrived. Now I am also freezing to death in the cold."

Velan, a 60-year old man who had been a hypochondriac throughout his life, woke up with hiccups. He remembered a Tamil proverb that states, he who has hiccoughs, will reach the heaven. He thought, "I am sure I have some terminal illness. I already feel weak and infirm."
Velan consulted many doctors, underwent very many tests and took various medicines. He spent all his savings on treating the hiccup which persisted for weeks. One fine morning the hiccups just disappeared as unexpectedly as it had started. Velan lamented, "You miserable hiccup! I thought I was going to die and spent all my savings on treatment. Now you have vanished and I am broke!"

Comments

Misusing modern science to pander to myths and superstitions amounts to quackery. Hiccup being a 'killer-symptom' is just one example of such false beliefs. I have seen several gullible persons fall prey to doubts and fears raised by proverbs, house-lizards, black cats, astrologers, palmists and numerologists.

People are susceptible to such divinatory practices and 'mind readers' because of Barnum Effect. This refers to the tendency among people to embrace generalised descriptions and predictions as idiosyncratically their own. Then they turn to modern medical science to quell their fears and phobias. Many medical practitioners are only too happy to exploit the situation as "It is good for the business". Shaw had some telling comments on this: "Without fear and credulity (in the public), half the private doctor's occupation and seven-eighths of his influence would be gone."

Under the pretext of ruling out all the possibilities and allay the anxiety, several tests may be performed. Tests should be critically selected to 'rule in' a disease rather than 'rule out' all other possibilities. The muddled thinking has unfortunately percolated quite deeply into the current medical education and practice. It shows up best during an MBBS examination where the scene is often like this:

Examiner: "So what is your diagnosis?"
Candidate: "Disease XYZ, Madam."
Examiner: "What laboratory tests do you want to do?"
Candidate: "Tests 1 . . ., 2 . . ., 3 . . ., etc., to rule out the disease XYZ."

The student wants to rule out the very disease that has been diagnosed by him! Imagine how judicious he would be while ordering diagnostic tests in medical practice. T.S. Eliot's warning against "action taken not for the good it will do but that nothing be left undone" applies to the offensive practice of the so called 'defensive medicine'.

Once, I admitted an 80-year old man with multiple symptoms of recent onset and a clutch of prescription slips. On thorough examination, he only had moderate anaemia due to hookworm infestation and perhaps had it for several years. He responded well to treatment and visibly cheered up.

At the time of discharge, I asked him why he felt so much concerned about such a minor disease. He smiled and then confided in me, "I also wondered why. Then I remembered it. When I was ten years old, my father had told me that I shall be strong and live till the age of eighty. Then a health crisis may occur and if I could survive that, I shall live for a decade more." He had forgotten all about it but the fear had survived in his subconscious mind and taken its toll after seventy years. This form of 'hex death' like situations are common in rural India even today.

Informed and enlightened individuals should break the shackles of age-old myths and superstitions and become truly autonomous. Social and health activists have to join hands to reduce the gullibility of the community and to reduce the current practice of defensive medicine.