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Jul-Sep2003-11(3)
CORRESPONDENCE
Problems with private pathology practice
I have read the article entitled 'Why I don't
believe in referral commissions' by Arun Sheth (1). What struck me as odd about
this piece was the fact that we now need to justify the 'right thing to do'. The
very fact that doctors who don't give or take 'cuts' are a minority nowadays
speaks badly enough of our 'noble' profession. But that we now need to find
reasons and justifications for doing the proper things is truly a serious cause
for introspection. It appears that a wrong done over and over again by a large
number of people, and highly educated people at that, soon becomes the order of
the day. Hence, doctors who 'don't fall in line' risk greater marginalisation
from the mainstream. They take too long to establish themselves and some
finally just give up and change professions. This is especially true for people
like us who have dependent practices like pathology.
Let's look at some facts in the pathology 'business'. Technician-run laboratories are prepared to go to any lengths to secure their 'business'. Although it is degrading for qualified pathologists to compete with technicians, there is no other way because even top consultants accept these reports (sometimes even unsigned ones) from technicians. We even have a few technicians requesting us to report their peripheral smears or cytologies or even biopsies which means that even these investigations are sent to technicians' labs and not to pathologists. The flip side is that when it comes to the consultant's own relatives or friends they always come to a pathologist even for the simplest of tests. What's good enough for other patients is not so for the doctor's kith and kin.
Consortium-owned labs or group practice set-ups are the 'in' thing. Here, doctors invest money together in a diagnostic set-up and then send long lists of investigations for kickbacks and incentives. (From the layperson's point of view this is viewed as hunting in packs.) I think the main issue here is the percentage receivable, rather than what is necessary for the patient. It is one thing to make a project viable, quite another to burden the patient for your personal gain.
Then comes the choice of the patient to go to any lab. Due to the nexus that exists between the clinics and labs, unless a patient comes back with a report from a particular lab, he is subjected to another battery of tests with the explanation, 'These tests are wrong; why didn't you go to the other lab?' The poor patient fears the wrath of the doctor and does as he is told, in the process compromising his right to choose where he wants to go.
I have even heard of places where rickshawallahs and drugstore owners are roped in to direct patients. This absolutely unethical way of 'soliciting clients' just proves to what lengths we are now ready to go to succeed in our profession. It is even more depressing to think how the big reference labs have affected small private set-ups like mine to compete with their prices, especially when nobody cares about the quality of reports that these labs have to offer.
Thus, it is becoming very difficult to practise pathology in a clean manner. It is the patient who is being taken for granted all the time. I have managed so far to keep myself away from these practices but always get an 'explanation' from my male colleagues that it's because I am a woman and don't have to 'support' a family. I think we must take steps to create a space for ethical doctors to be able to earn a living while practising their professions with dignity and self-respect. In this, I feel the National Accreditation Body for Laboratories must play an important role and laboratories must be licensed and accredited.
Meanwhile, to those who wish to practise market-medicine, I wish you much happiness in your endeavours. But remember what Gibbon said: 'The first and indispensable requisite of happiness is a clear conscience, unsullied by the reproach or remembrance of an unworthy action.'
Let's look at some facts in the pathology 'business'. Technician-run laboratories are prepared to go to any lengths to secure their 'business'. Although it is degrading for qualified pathologists to compete with technicians, there is no other way because even top consultants accept these reports (sometimes even unsigned ones) from technicians. We even have a few technicians requesting us to report their peripheral smears or cytologies or even biopsies which means that even these investigations are sent to technicians' labs and not to pathologists. The flip side is that when it comes to the consultant's own relatives or friends they always come to a pathologist even for the simplest of tests. What's good enough for other patients is not so for the doctor's kith and kin.
Consortium-owned labs or group practice set-ups are the 'in' thing. Here, doctors invest money together in a diagnostic set-up and then send long lists of investigations for kickbacks and incentives. (From the layperson's point of view this is viewed as hunting in packs.) I think the main issue here is the percentage receivable, rather than what is necessary for the patient. It is one thing to make a project viable, quite another to burden the patient for your personal gain.
Then comes the choice of the patient to go to any lab. Due to the nexus that exists between the clinics and labs, unless a patient comes back with a report from a particular lab, he is subjected to another battery of tests with the explanation, 'These tests are wrong; why didn't you go to the other lab?' The poor patient fears the wrath of the doctor and does as he is told, in the process compromising his right to choose where he wants to go.
I have even heard of places where rickshawallahs and drugstore owners are roped in to direct patients. This absolutely unethical way of 'soliciting clients' just proves to what lengths we are now ready to go to succeed in our profession. It is even more depressing to think how the big reference labs have affected small private set-ups like mine to compete with their prices, especially when nobody cares about the quality of reports that these labs have to offer.
Thus, it is becoming very difficult to practise pathology in a clean manner. It is the patient who is being taken for granted all the time. I have managed so far to keep myself away from these practices but always get an 'explanation' from my male colleagues that it's because I am a woman and don't have to 'support' a family. I think we must take steps to create a space for ethical doctors to be able to earn a living while practising their professions with dignity and self-respect. In this, I feel the National Accreditation Body for Laboratories must play an important role and laboratories must be licensed and accredited.
Meanwhile, to those who wish to practise market-medicine, I wish you much happiness in your endeavours. But remember what Gibbon said: 'The first and indispensable requisite of happiness is a clear conscience, unsullied by the reproach or remembrance of an unworthy action.'
Reference 1. Sheth A. Why I don't believe
in referral commissions. Issues in Medical Ethics
2003;11:58-59.
Asawari Sant, Aabha Diagnostics, 105 City Plaza,
Samadevi Galli, Belgaum 590002, India.
Audits of electroconvulsive therapy
Waikar et al. (1), in their diatribe against ECT
(electroconvulsive therapy) in general, and unmodified or direct ECT in
particular, were shocked that our institutional ethics committee permitted an
11-year 'study' of unmodified ECT (2), where patients whose 'fearful refusal of
a hazardous and life-threatening procedure' were 'considered as a mere symptom
of insanity, and further treated with sedatives'. They were appalled that ECT
was given to children, elderly and pregnant women. They contend that our report
trivialised the 'horrific' physical complications with direct ECT and 'the costs
of disability days following ECT'. They wonder 'why presumably rational
scientists produce such irrational arguments to safeguard a scientifically
dubious and highly hazardous procedure', concluding that it is because we 'make
a lot of money by giving ECT'.
ECT is an invasive procedure, like neurosurgery,
and considerations of morbidity or mortality must therefore be viewed in this
context. Untreated or treatment refractory mental illness kills and wastes
precious lives. There is incontrovertible evidence that ECT is an effective
treatment for depression (3), and substantial evidence that it is effective in
mania (4) and schizophrenia (5), especially when other treatments fail. There is
no credible evidence that ECT causes brain damage (6). ECT is not
contraindicated, and may be especially effective, in pregnant women, children or
the elderly (7).
Ours was not a prospective research study but a
retrospective chart audit of clinical practice (2). Over 11 years, 6.3% of the
28,929 patients registered at our centre were treated with ECT, hardly the
overenthusiastic and indiscriminate use implied by Waikar et al. (1). Of the
13,597 individual treatments given to 1,835 patients, the physical morbidity
included spinal compression fractures and transient myalgia in less than 1%,
resulting in short-lived pain but no disability, neurological deficits or
long-term sequelae over up to 8 years follow-up. One patient died (mortality
rate 0.05%) of a cardiac arrhythmia, though the subsequent 12 years and
approximately 2,000 additional patients treated have not seen additional
mortality.
In spite of this low complication rate for an
invasive procedure, all treatment conducted here since 1995 have been modified
under anaesthetic supervision, and our practice, frequently audited, conforms to
the international technical and ethical standards. No patient has ever received
ECT without personally (or a responsible relative) consenting. Fear of ECT
is less with modified than with unmodified ECT but in both situations an unknown
and reputedly hazardous procedure does generate apprehension, just as with tooth
extraction or brain surgery. Pre-ECT sedation reduces apprehension. ECT, as
practised in our centre, is hardly a lucrative enterprise since costs are low
(Rs 180 per modified treatment, excluding anaesthetic drug costs) and many
patients' treatments are free or heavily subsidised. Finally, our patients and
their relatives have endorsed our use of ECT (8).
Unmodified ECT is aesthetically less appealing to patients and clinicians alike than modified ECT. Consideration of ways to phase out direct ECT such as changing from thrice a week to the equally effective twice a week regimen to reduce anaesthetist demand, or forming group practices with shared ECT and anaesthetic facilities, or deputing psychiatric personnel to get specialist anaesthetic training are inevitable, if ECT is to survive another 50 years. However, banning direct ECT overnight by legal action without ensuring the continued and effective delivery of ECT is tantamount to closing down mental hospitals without ensuring adequate community care. Many clinicians, without access to anaesthetists, would face denying seriously mentally ill patients an effective treatment. Such a 'collateral damage' resulting from well-intentioned action is as unethical and unacceptable as some recent international events.
Unmodified ECT is aesthetically less appealing to patients and clinicians alike than modified ECT. Consideration of ways to phase out direct ECT such as changing from thrice a week to the equally effective twice a week regimen to reduce anaesthetist demand, or forming group practices with shared ECT and anaesthetic facilities, or deputing psychiatric personnel to get specialist anaesthetic training are inevitable, if ECT is to survive another 50 years. However, banning direct ECT overnight by legal action without ensuring the continued and effective delivery of ECT is tantamount to closing down mental hospitals without ensuring adequate community care. Many clinicians, without access to anaesthetists, would face denying seriously mentally ill patients an effective treatment. Such a 'collateral damage' resulting from well-intentioned action is as unethical and unacceptable as some recent international events.
References
1. Waikar A, Davar B, Karhadkar C, Bansode D,
Dandekar D, Kakade S, Wayal S, Kulkarni Y. ECT without anaesthesia is unethical.
Issues in Medical Ethics 2003;11:41-43.
2. Tharyan P, Saju PJ, Datta S, John JK,
Kuruvilla K. Physical morbidity with unmodified ECT: a decade of experience.
Indian J Psychiatry 1993;35:211-214. 3
. The UK ECT Review Group. Efficacy and
safety of electroconvulsive therapy in depressive disorders: a systematic review
and meta-analysis. Lancet 2003;361:799-808.
4. Mukherjee S, Sackeim HA, Schnur DB.
Electroconvulsive therapy of acute manic episodes: review of 50 years'
experience. Am J Psychiatry 1994;151:169-176.
5. Tharyan P, Adams CE. Electroconvulsive
therapy for schizophrenia. Cochrane Database of Systematic Reviews
2002;(2):CD000076
6. Devanand DP, Dwork AJ, Hutchinson ER,
Bolwig TG, Sackeim HA. Does ECT alter brain structure? Am J Psychiatry
1994;151:957-970.
7. American Psychiatric Association. The
practice of electroconvulsive therapy: recommendations for treatment, training
and privileging. Task force report on ECT. Washington, DC: American Psychiatric
Association, 2001.
8. Prashanth NR. Attitudes of psychiatric
patients and their relatives towards informed consent for electroconvulsive
therapy. MD Dissertation. The Tamil Nadu Dr MGR Medical University, 1998.
Prathap Tharyan, Professor of Psychiatry,
Christian Medical College, Vellore 632002, Tamil Nadu, India. e-mail:
prathap@cmcvellore.ac.in
Unmodified ECT vs modified ECT This letter refers
to the article by Chittaranjan Andrade regarding the use of unmodified ECT
(1). The author has discussed the obvious advantages of modified ECT over
unmodified ECT. He also highlights the ground realities and difficulties in
practice of modified ECT. The author concludes that the use of unmodified ECT
may be preferable to no ECT, as in the case when ECT is indicated but
anaesthesiological facilities are unavailable or unaffordable.
Though I agree in principle with the points raised
and this discussion may be scientifically correct, we need to know the views of
the people who are going to be recipients of such treatment. It has been seen
that doctors show remarkably little interest in their patients' views of the
procedure and its effects on them (2). I think that in this discussion on the
ethical issues of administering unmodified ECT, a patient's perspective is not
being considered.
Though no data are available, most of the patients
who refuse ECT do so because of the fear associated with the procedure. This
fear may be attributed to the gruesome and barbaric picture of ECT projected by
the media in which patients are shown screaming and refusing ECT and later on
convulsing.
The use of unmodified ECT would only increase this
fear and lead to rejection and disrepute of this really effective modality of
treatment for psychiatric disorders at the hands of the media and anti-ECT
lobbies.
References
1. Andrade C. Unmodified ECT: ethical
issues. Issues in Medical Ethics 2003;11:9-10.
2. Abrams R. Patients attitudes,
legal-regulatory issues, and informed consent. In: Abrams R (ed).
Electroconvulsive therapy. New York: Oxford University Press, 1997.
Nischol K Raval, Lecturer in Psychiatry,
Maharashtra Institute of Mental Health, Department of Psychiatry, Sassoon
Hospital, Pune 411001, India.e-mail:nischolraval@hotmail.com
Unmodified ECT: what is the patient's
perspective?
Raval has correctly indicated that, when
prescribing a treatment, it is necessary to be aware of the views of the
recipients of the treatment. There is much literature on patients' experiences
with and attitudes towards modified ECT in developed countries (1,2) as well as
in India (3). There is, unhappily, no literature at all on patients' experiences
with and attitudes towards unmodified ECT in any part of the world; in fact, it
is uncertain whether, today, unmodified ECT is indeed practised in any other
country!
Data on the subject should help form a more sound judgement about unmodified ECT. Unfortunately, such data are best obtained only through a study in which patients are randomised to receive either modified or unmodified ECT. If the data were to be obtained in any other way, adherents of unmodified ECT would claim that, in the absence of a control group, the experiences and attitudes documented merely reflect experiences with and attitudes towards ECT in general.
Raval additionally suggests that the practice of unmodified ECT may fuel the fears of patients who see ECT portrayed as a gruesome and barbaric treatment by the visual mass media. With apologies to Shakespeare, the fault, dear Brutus, lies not in unmodified ECT, but in its distorted portrayal. For example, an open heart surgery is well known to result in short- and long-term cognitive deficits; if the mass media were to use this knowledge to vilify open heart surgery, would it be justifiable to abandon the procedure? Sadly, in expressing his opinion, Raval is actually right. The strongest case for the abandonment of unmodified ECT is that its continued use may provide grist to the mill of publicity-hungry, self-important civil rights activists and sensationalistic film producers, and thereby jeopardise the survival of ECT itself.
Data on the subject should help form a more sound judgement about unmodified ECT. Unfortunately, such data are best obtained only through a study in which patients are randomised to receive either modified or unmodified ECT. If the data were to be obtained in any other way, adherents of unmodified ECT would claim that, in the absence of a control group, the experiences and attitudes documented merely reflect experiences with and attitudes towards ECT in general.
Raval additionally suggests that the practice of unmodified ECT may fuel the fears of patients who see ECT portrayed as a gruesome and barbaric treatment by the visual mass media. With apologies to Shakespeare, the fault, dear Brutus, lies not in unmodified ECT, but in its distorted portrayal. For example, an open heart surgery is well known to result in short- and long-term cognitive deficits; if the mass media were to use this knowledge to vilify open heart surgery, would it be justifiable to abandon the procedure? Sadly, in expressing his opinion, Raval is actually right. The strongest case for the abandonment of unmodified ECT is that its continued use may provide grist to the mill of publicity-hungry, self-important civil rights activists and sensationalistic film producers, and thereby jeopardise the survival of ECT itself.
References
1. Freeman CPL, Kendell RE. ECT: Patients'
experiences and attitudes to ECT. J Psychiatry 1980;137:8-16.
2. Benbow SM. Patients' views on
electroconvulsive therapy on completion of a course of treatment. Convulsive
Ther 1988;4:146-152.
3. Andrade C, Mariadas B, Kalanidhi K,
Reddy MV. Patients' knowledge about and attitudes towards ECT. Paper presented
at the 45th Annual National Conference of the Indian Psychiatric Society,
Lucknow, 1993.
Chittaranjan Andrade, Department of
Psychopharmacology, National Institute of Mental Health and Neurosciences,
Bangalore 560029, India. e-mail:andrade@vsnl.com
'Bust oil' and other bogus claims
Irrational, useless and even dangerous drugs flood
the market. A certain company's rubs and iodide products for local application
do business worth crores of rupees every year in India. Both multinational and
Indian companies are involved in such practices. Since we do not raise
objections, the manufacturers keep pushing new products to cheat consumers.
Initially, these tricks were restricted to what was sold as medicines. Recently, cosmetic products have been launched with advertisements that make false claims. Though vitamin E is not absorbed through the skin, soaps, creams, oils and lotions advertise vitamin E as an ingredient. Hair is just a dead extension of the hair follicle and its quality cannot be affected by external applications; even then products in the market promise to improve hair growth and retard greying.
With the entry of international brands in the Indian market, useless health drinks, herbal tea, nutritional supplements and breakfast cereals lure customers with the false promise of improving health. Buyers are lured by the nutritional and calorie content charts presented in stylish print and catchy formats. These products contain iron, calcium, minerals, trace elements or vitamins, but only in sub-therapeutic quantities. Such nutrients are present in larger quantities in the normal Indian diet.
Recently, the FDA in Mumbai raided a 'herbal' tea distributor. An analysis found the 'herbal tea' to be ordinary tea sold in fancy packaging for a high price. Because there are takers, there are sellers.
Recently, certain newspapers and magazines carried colourful advertisements for 'bust oil'. Among the claims made about the oil is that 'it keeps the breast toned up, it is needed by almost all age groups, it gives firmer, younger and tighter breasts,' and so on. Efforts must be made to counter such false and unethical advertisements.
Vijay Thawani, Associate Professor in Pharmacology, Government Medical College, Nagpur 440003, India. e-mail:thawani@nagpur.dot.net.in
Initially, these tricks were restricted to what was sold as medicines. Recently, cosmetic products have been launched with advertisements that make false claims. Though vitamin E is not absorbed through the skin, soaps, creams, oils and lotions advertise vitamin E as an ingredient. Hair is just a dead extension of the hair follicle and its quality cannot be affected by external applications; even then products in the market promise to improve hair growth and retard greying.
With the entry of international brands in the Indian market, useless health drinks, herbal tea, nutritional supplements and breakfast cereals lure customers with the false promise of improving health. Buyers are lured by the nutritional and calorie content charts presented in stylish print and catchy formats. These products contain iron, calcium, minerals, trace elements or vitamins, but only in sub-therapeutic quantities. Such nutrients are present in larger quantities in the normal Indian diet.
Recently, the FDA in Mumbai raided a 'herbal' tea distributor. An analysis found the 'herbal tea' to be ordinary tea sold in fancy packaging for a high price. Because there are takers, there are sellers.
Recently, certain newspapers and magazines carried colourful advertisements for 'bust oil'. Among the claims made about the oil is that 'it keeps the breast toned up, it is needed by almost all age groups, it gives firmer, younger and tighter breasts,' and so on. Efforts must be made to counter such false and unethical advertisements.
Vijay Thawani, Associate Professor in Pharmacology, Government Medical College, Nagpur 440003, India. e-mail:thawani@nagpur.dot.net.in