MD, FRCP, FRCPE, FRCPG, FRCPI, FACC, FAMS, is presently the Chairman of State Health Society, Govt. of Bihar, India, Visiting Prof. Cardiology at The Middlesex Hospital Medical School – University of London, Affiliate Prof. of Human Health – Northern Colorado University, Visiting Prof. Indian Institute of Advanced Studies – Shimla, Retd. Vice Chancellor, MAHE University – Manipal. Prof Hedge regularly gives talks on AIR, Doordarshan, BBC and Zee TV, London.
Modern medicine, having had a great influence from the West, especially the USA, is slowing going away from the suffering patient to the laboratory, where most of the management decisions are taken. This is very unfortunate. The younger generation of doctors is brainwashed to think that if the laboratory reports are normal, the patient should be all right. On the contrary, when the reports are abnormal, the poor patient is either drugged, or operated upon, irrespective of whether he is suffering or not. The main thrust seems to be to get the report right! In the computerization era, this boils down to having the right boxes in the case-sheet properly marked in the right places- the euboxic state. Even when the patient dies, the doctors seem to be happy, as long as the patient had an euboxic death, – i.e.: at the time of death all the test result boxes were correctly marked, mainly to save the doctor’s skin.1
This is very sad, indeed! Many times, even when the person is absolutely asymptomatic and fit, some report or the other, of which there could be hundreds today, on a routine check-up, might deviate from the accepted norms for a given laboratory. The latter would result in the poor man being labelled a patient and dealt with accordingly. While trying to bring the test results back to the normal range, the hapless person might be robbed of his health and happiness. Sir George Pickering, regius professor of medicine at the Oxford and John’s Hopkins Universities, had once said about drug treatment of asymptomatic mild-moderate high blood pressure patients: " the patient loses the rights enshrined in the preamble to the American Constitution written in 1772 by Thomas Jafferson, of life, liberty, and pursuit of happiness." Antihypertensive drugs "may or may not change his longevity; liberty he hardly could have what with all the restrictions put on him, and happiness becomes a thing of the past," said Professor Pickering.2
I saw a young man today. He was 37 years old and has been working in the Gulf with lots of anxiety. His family was back home in India-young wife and two small kids. The man became very anxious and failed to get sleep. He got into the habit of taking alcohol for sleep and became addicted to it. He started getting vague chest discomfort, which was, clinically, anything but cardiac in origin. He consulted a couple of doctors in Dubai who told him that he did not have any heart disease. They did not, however, bother to relieve him of his incapacitating symptoms.
When he came back to India, he saw a doctor in Bombay, who got him completely, checked up, including a coronary angiogram, thallium scanning, echocardiogram, stress test etc, in addition to all the available blood tests in Bombay. At the end he was told that the pain was not from the heart, but was not told what the pain was due to, and how to get rid of the pain. An empathetic look at this hapless young man would convince a good doctor how badly depressed he was and, if one went into his mind, one could unravel the mysteries of his suffering.
Clinical, patient-oriented medicine, could have easily given away the diagnosis without the loss of such hefty sums of money, to get his heart into the euboxic state. This kind of medical practice does nothing for the relief of the patient’s suffering. But the whole process is now geared to get money for the establishment. Doctors are under severe pressure to perform or perish!
A recent study of diabetics, discovered by routine screening of the asymptomatic population, revealed that the meticulous control of blood sugar helped mainly those who were symptomatic to begin with, and not those who had no symptoms!3 Same logic holds good for coronary artery disease, where bypass surgery has become a fashion and a compulsion these days. Gullible public are told that "blood is better than drugs" in the management of coronary artery disease. The truth, however, is that only those patients with severe symptoms of chest pain and breathlessness, that get very good relief of their symptoms, allowing them to lead a near normal life, whereas the asymptomatic people with even advanced epicardial coronary artery blocks shown by the angiogram, get very little benefit, unless they have very poor heart function, again felt by the patient as incapacitating breathlessness.4,5
The inner secret is very simple. While, at a given point in time, there could be a few million patients who have symptoms, there could be at the same time, billions who could be shown to have abnormal reports of some sort or the other. The latter is a better business proposition, either to sell drugs or to do surgical corrections. Even the tall talk about early screening to catch diseases "young," has not borne fruit by the audits all over the world. This is graphically brought out in a recent editorial in the British Medical Journal under the caption Screening could seriously damage your health.6
It was estimated, at one stage, that there could be about 50-60 million `healthy’ Americans, who have white-coat hypertension. ( Doctor induced blood pressure rise) If all of them were to be immediately put on drugs like the latest calcium channel blockers and ACE inhibitors, drug companies could easily net about eight billion dollars per year! Lowering elevated blood pressures of the type described above, rarely does any good to the person concerned, but could, rarely harm him! In the long run, drug treated hypertensives have 2-3 times higher death rate due to various causes, compared to their normotensive cousins, even when their pressures are adequately controlled to get them into the euboxic state.
Time evolution in a dynamic human system does not depend on a few phenotypic characteristics, like blood pressure and blood cholesterol or sugar, but depends on the total initial state of the organism. In addition, changing the initial state in any direction with drugs, may not hold good to give better results over a period of time. Linear mathematics has very little to do with future predictions in human beings; non-linear mathematics is not being used in medicine, unfortunately.7
Similar audit reports are appearing about cancer screening as well8. Medical profession has enough on its plate if it cares to look after all the sick people in this world, and would, certainly, have no time to meddle with the apparently healthy in society. Even today nearly 80% of the world’s population does not have access to modern medicine. A recent BBC programme in London showed how the poor people in society still have the highest incidence of all diseases even in advanced countries, while the rich and the strong are healthier. The reasons alluded to are very simple. The rich these days have healthier life styles compared to the poor. The rich smoke less, eat more sensibly relying basically on fruits and vegetables, drink less or abstain, exercise more, and more than all that, have better incomes to be less anxious about their next meal. The last one is said to be the greatest distress for the poor. Poverty has been shown to be the womb of all illnesses.9
The poor get ill because they have unhealthy life styles with more distress than the rich do, and the rich get illness because of the fear of the less fortunate in society. Recent studies in the USA have shown that this fear of the poor drug addicts and criminals, is one of the main stressors for the rich in that country. As the gulf between the rich and the poor is widening, illness goes up on both sides of the fence. Those of us interested in the long-term solutions to man’s ills, should economically empower the poor and teach them better life styles.
There are a couple of other myths to be demolished in modern medicine. One is that it is the change in life style and better food that has brought down the incidence of all diseases, and not the hi-tech modern drugs or surgery. The second is that human life span has not gone up a wee bit in the last hundred years. What has gone up, on the contrary, is "life expectancy", a statistical term, which could easily be confused to be synonymous with life span. It is not! Genetic engineering tricks to increase life span have not succeeded so far; even if they do, one would not be able to halt senility. Those efforts might end up adding years to life but not life to those years!
Long live clinical medicine of doing most good to most people most of the time, following the Hippocratic code of "cure rarely, comfort mostly, but console always." Death and disease are two different entities and have very little in common. Death is inevitable, as of now. Modern medicine has not been able to postpone or avoid death, but it could make life tolerable if one lives sensibly. Trying to live forever is foolish even today, as it was during the time of Bernard Shaw. Euboxic medicine is not the answer to the ills of society, but human and humane medicine is the need of the hour. Let us pass on this message to the medical students when they are still young. Medicine should not be taken to the market place, where market forces distort scientific data to suit the business convenience. This was brought home so beautifully in a recent study published in the Journal of the American Medical Association.10
Many of the imaginary epidemics of diseases are brought on by the medical profession to scare the common man! In an editorial Do epidemiologists cause epidemic, The Lancet brings out the truth10. Let us, instead, concentrate on doing maximum good to the suffering humanity, dysboxic as they are, and try to bring their whole clinical condition to the euboxic state.
1) Davidoff F: Who has seen a blood sugar? Book Ed. American College of Physicians, 1998.
2) Hegde BM, Shetty MA, Shetty MR. Hypertension-Assorted Topics. Bhavan’s Publications, Bombay, 1995.
3) Goddijin PPM, Bilo HJG, Feskens EJM et.al. Longitudinal study of glycaemic control and quality of life in patients with Type 2 diabetes mellitus referred for intensified control. Diabetic Medicine 1999;16:23-30.
4) Hegde BM. Coronary artery disease-time for reappraisal. Proc. Royal. Coll.Physi.Edinb. 1995;26:421-24.
5) Krumholz HM. Cardiac procedures, outcomes, and accountability. N.Engl.J.Med 1997;336:1522-23.
6) Stewart-Brown S & Farmer A. Screening could seriously damage your health. BMJ 1997;314:533.
7) Firth WJ. Chaos-predicting the unpredictable. BMJ 1991; 303: 1565-68.
8) Selly S, Donovan J, Faulkner A, Coast J,Gillatt D. Diagnosis, management, and screening of early localized prostate cancer-review. Bristol: Health care Evaluation Unit. University of Bristol, 1996.
9) Hegde BM. Medical Humanism. Proc. Royal. Coll.Physi.Edinb. 1997; 27:65-67.
10) Cambell EG, Louis CS,& Blumenthal D. Looking a gift horse in the mouth-corporate gifts supporting life sciences research. JAMA 1999;279:995-999.
11) Editorial. Do epidemiologists cause epidemics? Lancet 1993;341:993-994.
Author: Dr. B. M. Hegde- India