Rational Medicine!

The social determinants of health – too much idealism?

Somewhere in the pages of Community Medicine, every medical student has learnt about the “Social Determinants” of health. Health does depend on various factors like the conditions where a person lives, how much he can afford to spend on health, education, food, etc. If the person does not have money to eat or pay rent then his health becomes the least of his priorities. Many diseases disproportionately affect people who cannot afford care and this makes things worse.

So what? Its life and life is not fair is it? Doctors and healthcare workers in India are already scarce and it’s not like we can go around solving all these issues. It’s not like doctors are charging a bomb themselves. Doctors rarely get to decide how much the patient pays. (Some hospitals do let doctors write off charges at least partially but that is the exception and not the norm). Doctors are employees themselves. We like to stick to the medical side of things and not concern ourselves with payments and other things. Many doctors wish they could do more and there is often a lot of frustration.

What can we do?

My personal take is that something can indeed be done. The best intervention that you can possibly do for your patients is to get better with your clinical skills! You may never be able to solve all the poverty problems in the world or feed all the hungry but 3 very powerful things you can control are the prescriptions you write, the tests you order, and the procedures you do. They cost money and affect the patient financially.

Use drugs rationally

The most expensive drug in the market is usually not the most effective. Ranitidine (~Re1/tablet) or Pantoprazole (~Rs7/Tablet) can be quite effective in managing gastritis. Yet we often see fixed-dose combinations of Rabeprazole+Domperidone (Rs 20 /tablet) being used. The cheaper alternative would have worked just as well. That is NOT to say that newer drugs should not be used. They may even arguably be more effective or have fewer side effects. But we have to ask ourselves if the patient can afford to spend that much more money for a marginal increase in efficiency. What is the cost-effectiveness of Ranitidine vs Rabeprazole? These are just examples obviously but they illustrate a larger point.

Order investigations wisely

The good rule of thumb is “Order investigations only if the results will change the course of management”. You do not always need an MRI for every low back pain. Of course, you will have certain conditions where an MRI is indicated. You do not need a Dexa Scan to suspect osteoporosis and start calcium in a 60-year-old woman! You DO need a Total Blood Count and blood cultures before starting an IV antibiotic. Be careful while placing the order. If you need only Haemoglobin, WBC Count, Differential Count and platelets, you don’t need to order the whole Complete Blood Count Package which may be more expensive. It may have values that you will not even look at! Investigations are a powerful tool and should certainly be used when necessary. At other times go with clinical sense.

Use Procedures only when appropriate.

The dictum is that “a good surgeon knows when to operate, a great surgeon knows when not to operate”. Not every knee that has the slightest ache needs to be replaced. Not every gall bladder stone needs to be removed! In some cases like end-stage cancer etc, i would even argue that not every patient who desaturates needs to be intubated! Pick the patients you choose to do procedures on wisely. I once saw a very poor, morbidly obese woman who had been immobile for over a year due to severe Rheumatoid Arthritis be offered a hip replacement! What are the odds that a hip replacement would be beneficial in this scenario? Next to zero! It gave her so much hope that she would walk again! She desperately went about trying to arrange funds for the surgery. It eventually got canceled.

Most things mentioned here are just good clinical practice. Yet time and again we forget to practice them. An estimated 63 million Indians are pushed into poverty every year because of healthcare-related expenses. We may not be able to go out and remove all the poverty in the world but if we consciously decide that we will keep the patients paying capacity somewhere at the back of our heads when we order investigations, prescribe medicines and plan procedures I think we can go a long way in helping out.

Hutchison’s Prayer

There is a famous piece that is on one of the first pages of Hutchison’s Clinical Methods. First published in 1897 this book is still one of the most-read clinical manuals in the world. This is as relevant today as it was when Sir Robert Hutchison wrote it all those years ago.

‘From inability to let well alone
From too much zeal for the new and contempt for what is old
From putting knowledge before wisdom, science before art, and
Cleverness before common sense;
From treating patients as cases;
And from making the cure of the disease more grievous than the
Endurance of the same, Good Lord, deliver us.’ – Sir Robert Hutchison

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