House of God Rule No 13: The delivery of good medical care is to do as much nothing as possible (Dr. Samuel Shem - @writer_samshem)
My friend Dr. Saurabh Jha from UPenn in the US tweeted his outrage at this prescription given to a 15-years old by a senior physician in New Delhi. It mentions a bunch of tests, including a CT scan of the chest, and a cocktail of around 7 drugs, most of them unnecessary and with no known efficacy.
Since the 2nd pandemic wave started, I have been besieged by calls from friends and relatives asking for CT scans of the chest. At the beginning, I would try to counsel them and find out why they wanted a CT scan for Covid-19; was it the doctor who had asked, were they breathless, was the O2 saturation falling?
I soon realized that barring a small percentage, no one was interested in my questions or answering them. They just wanted the CT scan to be done and were only calling me because I am a radiologist and I do CT scans of the chest for people and patients, Covid positive or not.
Let me give you one example. A 55-years old man, known to me for the last 20 years, called saying he was Covid-19 positive and would like a CT scan. When I asked him the usual questions, he told me that he did not have breathlessness and had one episode of fever and was fine…I told him there was no need to get a CT scan done. He then called again saying his physician was insisting on getting one done…so it got done. I then called his physician, who told me that the only reason he had asked for it, was because the patient’s relatives were going berserk and questioning his credentials as a doctor because he was not asking for a CT scan…he wasn’t “doing something”. Apparently, the non-medical friends and relatives of the patient believed that a CT scan was a must in every Covid-19 patient and wanted one done, irrespective.
Another friend asked me to do a CT scan because his wife was getting panic attacks and accusing him of not “doing something” for her. And so on…
Today, there are diagnostic centres across the country performing over 100 to 120 “Covid-19 CT scans” per day, most of them on patients who have no breathlessness and have normal O2 saturations. Why? Just…as a part of the “doing something” syndrome. And if the CT scan is negative or shows mild disease (which is true of 90-95% of the scans anyway), everyone feels relieved, the CT scan report apparently acting as a “comforter”, allaying anxiety.
When I ask doctor friends of mine the reason for these high CT scan chest numbers…most of them say it is the patients who want them done and if they are seen to not “do something”, they are perceived as being “not good”. Apparently, it is only the senior-most doctors who can get away by saying “if you don’t have breathlessness and if your saturations are normal, all you need is paracetamol and isolation”. The rest have to be seen to be “doing something”. The funny thing is that whether you “do something”, or “watchfully wait” in asymptomatic or mild to moderate patients, the outcomes are the same.
It is a vicious cycle. Perhaps, you as a patient are fine with a valid “watchful waiting” approach, but your physician may have become so used to writing out 10 test and 10 drug prescriptions, that unless you discuss the situation in detail and question your doctor you will also be given that very same prescription.
In most parts of the world, it is impossible to get a CT scan of the chest done, unless the patient is symptomatic and/or admitted to a hospital with breathing difficulty. It is only in a medically anarchic country like India, that tests like CT scans can be done anytime, anywhere, as long as the patient can pay for it. In the US, a CT scan of the chest for Covid-19 would cost upwards of 1000 USD (Rs. 73,000 or more) if the patient were to pay upfront, while in India it costs just Rs. 3000 or so (50 USD). And though it seems that the cost is low, it is an unnecessary cost that constitutes 20-30% of the monthly salary of a large part of our country and gets added to the other avoidable test and drug costs, all of which needlessly drive up the overall healthcare expenditure.
(This article by Dr. Danielle Ofri - @danielleofri in 2011 is worth a read)
When physicians prescribe antibiotics for flu, that is another example of “doing something” medicine…the parents are comforted that the physician is “doing something”. The same holds true for prostate cancers in those above the age of 80 where “active surveillance” is an acceptable method of treatment…even there, surgeons who insist on operating and “doing something”, often win the argument over those who are seen to exhibit “clinical inertia”.
In medicine, it is the “doers” who are feted…the interventional cardiologist who saves a life by doing an urgent angioplasty in a patient with a “heart attack” is a “savior”, but the physician who saves countless lives, by assessing the cardiovascular risk of every person who walks through their doors, prescribing statins and counseling them about sensible eating and “moving”, gets no credit at all.
How did CT scan of the chest in India become a “meme” gone viral?
It is the unintended consequences of the actions of the “powers that be”. All through March, April and May last year when Covid-19 was raging through the country and the Indian Council of Medical Research (ICMR) and the Govt authorities kept coming out with strict guidelines limiting RT-PCR (swab) testing, CT scan became the surrogate method of testing for Covid-19. A friend of mine used to do 40 scans a day in April and May last year…they would diagnose Covid-19 on the CT scans, RT-PCR wasn’t done (it was mostly impossible to do anyway) and then the patients would be told to take paracetamol, azithromycin and hydroxychloroquine, isolate at home, told to check their O2 saturations and to go to a hospital if they fell below 92. This practice became so rampant that once RT-PCR testing became common-place and easy to access, CT scan was used to circumvent testing…if the CT chest was positive, then the patient would not get the RT-PCR test done to avoid sealing of the floor, building, society, etc. Once it became mandatory to report every Covid-19 positive CT scan patient to the authorities, the number of CT scans actually dropped considerably. But now, they have gone up again, simply because of the “doing something” syndrome.
Just to make sure I have made myself understood, before I close this out. CT scan of the chest is indicated in Covid-19 only if you have symptoms related to the lungs such as difficulty in breathing or falling O2 levels, (just cough does not count) in which case, you should ideally be making your way to the hospital. Perhaps in some very specific circumstances with a negative RT-PCR test and a very strong clinical suspicion of Covid-19, a CT chest could be justified. But that’s it.
The sad part is that our authorities including ICMR, our national radiology and physician bodies, despite knowing the situation at the ground-level, are making no attempts to publish guidelines about what should be done or not. This is not just about CT scan of chest, but also about all those unnecessary blood tests and drug cocktails. And in the absence of some sort of guidelines, those who are seen to be “doing something” the most, rule the roost.
It is worth revisiting Voltaire here (courtesy Dr. S P Kalantri).
So what is your matka here? If you are suspected to have Covid-19 or have Covid-19 and are surrounded by well-wishers who want to “do something”, you will land up undergoing unnecessary tests and ingesting mostly worthless drugs, with all the attendant issues these bring to the table.