The Need for Limiting Investigations in Medical Practice

Jayasree Chandrasekharan Naira

a. Associate Professor, Department of Community Medicine, SreeMookambika Institute of Medical Sciences, Kulasekharam, Tamil Nadu, India

Sir

This letter is regarding the move initiated by a group of cardiologists at the All India Institute of Medical Sciences, New Delhi towards curtailing unnecessary investigations on patients. They have established a   “Society for Less Investigative Medicine” (SLIM).1

“One of the first duties of a physician is to educate the masses not to take medicines” – said the great Sir William Osler. This cannot be overemphasized, for we are struggling with antimicrobial resistance and desperately searching for newer, effective drugs.2

Similarly we see patients being ordered to undergo various investigations again and again often without any real benefit to them. The various reasons put forward for this state of affairs are.3,4

  • Expanded clinical indications
  • Intolerance to the delay caused while reaching a definite diagnosis through fewer  number of investigations
  • More availability of various investigations
  • Going with the general trend
  • Demand from the patients’ side
  • As a precaution against possible litigations in future
  • A lack of confidence in one’s clinical skill and acumen
  • To oblige diagnostic centers, laboratories etc for personal gain

Why should this practice be curbed? 4,5,6

  • Most of the investigations done are contributing neither to a better diagnosis nor do they have a real prognostic value. Studies have shown that the overall mortality and morbidity due to various diseases especially cardiovascular diseases and cancer are virtually not affected.
  • Many patients, especially the seriously sick ones undergo much pain, discomfort and suffering while being subjected to certain needless investigations.
  • Patients may be subjected to hazards like excessive radiation unnecessarily
  • Increases the health care costs hugely which makes it inaccessible to the weaker sections. So obviously the large amount of money spent does not benefit the patients but only the multi crore diagnostics industry and may be the few medical practitioners catering to them.
  • In India we do not have any guidelines stating the appropriateness of a particular investigation in a given situation. No medical audit is in place to scrutinize the decisions made regarding the choice of investigations.

So it follows that it is the need of the hour for us doctors to teach ourselves to refrain from subjecting our patients to many irrelevant and unnecessary investigations.

A considerable degree of unlearning has to take place on both the doctors’ and the patients’ side.7

  • Doctors should learn to depend more on communication with the patient and thorough clinical examination while coming to a diagnosis. The revolution in information technology could be made good use of.3,5
  • Increased collaboration between the various specialties is essential
  • It is the duty of the concerned doctor to make the people understand why a particular investigation is needed/not needed and to undertake only the really necessary ones.3,5,7
  • Periodic, regular checkups, if done should be always based on a patient’s risk factors and back ground.
  • It is high time that  guidelines are made available regarding these. Auditing by competent bodies should be routinely done. These measures would also protect the doctors from unfair litigations.
  • Last but not least, one should ask one’s conscience whether one would contemplate doing a particular investigation if the patient were a dear and near person.

The SLIM is definitely a step in the right direction. I wish all success to this initiative and hope that it inspires doctors practising every where.

Keywords: , ,

References

  1. AIIMS doctors lead the way, wage war on unnecessary medical tests: Times of India June 29,2014.
  2. Antimicrobial resistance,www.who.int/media center/fact sheets/fs 194/en/
  3. Factors Contributing to Inappropriate  Ordering of Tests.  In an Academic Medical Department and the Effect of an educational Feedback Strategy SpirosMiyakis,Georgios Karamanof ,Theodore Dmountokalakis Postgrad MedJ.Dec2006;82(974)823-29
  4. What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’perceptions http://www.biomed central.com/1472-6963/9/155 accessed on 1-07-2014.
  5. Educational Intervention to Reduce Inappropriate TransthoracicEcho cardiogram:The Need For Sustained Intervention.BhatiaRS, DudzinskiDM, MilfordCE, PiccardMH, WeinerRB.echocardiography. 2014Jan22
  6. Screening Chest Radiography:  Results from a Greek cross sectional survey Konstantinos Kampsiores,Giovanni Casazza,David Mauri,Velisarios Lakiotis et al BMC Public Health 2006,6:113
  7. Why Do Physicians Order Unnecessary Preoperative Tests?A Qualitative Study :Brown SR,Brown J FamMed 2011May;43(5):338-43

Author Information

Jayasree Chandrasekharan Nair, Associate Professor, Department of Community Medicine, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Tamil Nadu, India. Email: jayasree_cs@yahoo.com

Conflict of Interest: None declared

 

 

Open Discussion

  1. my very hearty congratulations for publishing this . it should make doctors think of the damages they are doing to the patients in guise of helping them.

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