I felt a little vindicated by a recent NEJM article. Once you get into this business of shouting at the fringes, doubts do haunt, especially when routinely your voice hits a wall of silence and reverberates back in a prickly, acid form. Realization that someone else is thinking the same thoughts and that you are indeed not alone is somewhat soothing. More than consoling, however, some of the facts pointed out are terrifying.
There is one study cited in the article. The link to the article is here. It is worth looking at some of this study's findings.
Funded by Bill & Melinda Gates Foundation, the study authors were a team of multidisciplinary folks: economists, anthropologist, health policy experts and clinicians. Technically a very robust study, it was conducted in India to understand what factors determined a good quality of medical care. It is a very similar setup as ours and I can see no reason why the findings cannot be extrapolated to our context. Allow me to point out key findings in a plain language:
- Most of the health care is provided by private male providers (perhaps with big bellies, although the study did not measure the providers' abdominal girth!) both in rural and urban areas.
- Villages get quacks, cities get doctors.
- But the patient outcomes between quacks and the doctors are hardly any different.
- The providers hardly listen to patient or examine, they go straight to the prescription pads and write a robust list of medication.
- They don't talk to the patient. Well, don't start grumbling because even if they did talk, their mouths were more likely to spew disaster.
- You are more likely to receive unnecessary or harmful treatment than the correct treatment when you visit health care providers.
- "High patient volumes", "lack of infrastructure" for poor quality of care are just lame excuses.
- Whether a quack or a doctor, they performed better in private sector. Provider effort might be the key to quality outcomes.
When I ask my rural patients what their parents died of, they give very generic answers. They died of shortness of breath, swelling, suddenly with chest pain, they tell. With our health care systems, we bring these patients and tell them that they have squamous cell cancer of lung with massive pleural effusion, end-stage renal disease, massive acute myocardial infarction. Then we ask them to spend a fortune in proving these esoteric diagnoses. We then ask them to undergo risky treatments like radiation, chemotherapy or write medications that always have a potential to inflict harm.
What right do we have to bring these patients from their lives of simple diagnoses, simple deaths and give them esoteric diagnoses if we have no capability to actually alleviate their suffering?
That might be a fair question. Our debates have focused on improving access: access to health care facilities, access to qualified medical professionals, access to modern technologies. We have hardly thought about how to use those professionals and technologies so that they are delivering what they are actually intended to deliver.
Furthermore, not all access issues are created equal. Some are so urgent that their existence, regardless of quality might be important: for example, medical transport. Others are not urgent and if a sound basis of quality can not be established it might be dispensable: for example, diagnostic ultrasound for non-emergency problems.
There is no excuse for doing wrong things capitalizing on the vulnerability of people. If we have no capability to run things that are largely dispensable, we have no right to experiment on people and cause harm. Ensuring basic minimal quality of care is as much a talk about doing things right as it is about avoiding bringing unnecessary suffering to vulnerable citizens. At the least we have to make sure effort is being put; provider effort being a marker of better outcomes according to the study. It also means our institutions should stop being cots for sloths. Lives are harmed or lost while they snore and dream their dreams.
There is one study cited in the article. The link to the article is here. It is worth looking at some of this study's findings.
Funded by Bill & Melinda Gates Foundation, the study authors were a team of multidisciplinary folks: economists, anthropologist, health policy experts and clinicians. Technically a very robust study, it was conducted in India to understand what factors determined a good quality of medical care. It is a very similar setup as ours and I can see no reason why the findings cannot be extrapolated to our context. Allow me to point out key findings in a plain language:
- Most of the health care is provided by private male providers (perhaps with big bellies, although the study did not measure the providers' abdominal girth!) both in rural and urban areas.
- Villages get quacks, cities get doctors.
- But the patient outcomes between quacks and the doctors are hardly any different.
- The providers hardly listen to patient or examine, they go straight to the prescription pads and write a robust list of medication.
- They don't talk to the patient. Well, don't start grumbling because even if they did talk, their mouths were more likely to spew disaster.
- You are more likely to receive unnecessary or harmful treatment than the correct treatment when you visit health care providers.
- "High patient volumes", "lack of infrastructure" for poor quality of care are just lame excuses.
- Whether a quack or a doctor, they performed better in private sector. Provider effort might be the key to quality outcomes.
When I ask my rural patients what their parents died of, they give very generic answers. They died of shortness of breath, swelling, suddenly with chest pain, they tell. With our health care systems, we bring these patients and tell them that they have squamous cell cancer of lung with massive pleural effusion, end-stage renal disease, massive acute myocardial infarction. Then we ask them to spend a fortune in proving these esoteric diagnoses. We then ask them to undergo risky treatments like radiation, chemotherapy or write medications that always have a potential to inflict harm.
What right do we have to bring these patients from their lives of simple diagnoses, simple deaths and give them esoteric diagnoses if we have no capability to actually alleviate their suffering?
That might be a fair question. Our debates have focused on improving access: access to health care facilities, access to qualified medical professionals, access to modern technologies. We have hardly thought about how to use those professionals and technologies so that they are delivering what they are actually intended to deliver.
Furthermore, not all access issues are created equal. Some are so urgent that their existence, regardless of quality might be important: for example, medical transport. Others are not urgent and if a sound basis of quality can not be established it might be dispensable: for example, diagnostic ultrasound for non-emergency problems.
There is no excuse for doing wrong things capitalizing on the vulnerability of people. If we have no capability to run things that are largely dispensable, we have no right to experiment on people and cause harm. Ensuring basic minimal quality of care is as much a talk about doing things right as it is about avoiding bringing unnecessary suffering to vulnerable citizens. At the least we have to make sure effort is being put; provider effort being a marker of better outcomes according to the study. It also means our institutions should stop being cots for sloths. Lives are harmed or lost while they snore and dream their dreams.
