India and Indians are enamoured of high-technology healthcare. You haven’t truly arrived unless you possess an iPhone, have had a foreign holiday and an MRI scan. But while health technology has reached India, another quiet revolution in how we understand and use clinical science appears to have passed us by. This is the science of clinical epidemiology and its offshoots, Evidence-Based Medicine (EBM) and the democratisation of medicine.
Most doctors in India practice rule-based medicine, stuff they learned from teachers. ‘If you have a high cholesterol, you must take a statin.’ But clinical epidemiology and EBM gives us the principles of how to find, and appraise and apply clinical knowledge. We know, therefore, that if 100 people with no known heart disease but with raised cholesterol in their blood take a statin for 5 years, 98 of them will not see any benefit. But, at least 20 will experience side effects, some quite debilitating.
A family member recently fell and sustained a tear in a shoulder muscle. After the obligatory MRI scan, her orthopaedic surgeon strongly recommended immediate surgery. I looked up the literature and found good clinical trial evidence that surgery offered no benefit over conservative management. Six months later, both groups had the same level of pain-free function. She did not have surgery and recovered as expected.
Clinical epidemiology has exposed many myths. One is the idea that if you diagnose a condition in its early stages, you can benefit by curing it at an early stage. Disappointingly, more often than not this is not the case. With a few exceptions, doing diagnostic tests in “well people” confers more harm than benefit. A well man is defined as someone who has been inadequately investigated by his doctor. It causes worry, may offer false reassurance, leads to further tests and procedures, each of which has its own problems of side effects and risks, and may lead to unnecessary medication.
Thanks to clinical epidemiology, we now have a good understanding of the twin modern scourges of Overdiagnosis and Overtreatment. Applying rule-based medicine without an understanding of clinical epidemiology and the wealth of evidence that is publicly available on the Internet, leads to doctors ordering needless tests in a knee jerk reaction to a clinical problem.
Some academic doctors are so worried about overuse of clinical technologies that they have collaborated in setting up an organisation called Choosing Wisely. A visit to www.choosingwisely.co.uk
This has led to a redefinition of the role of the doctor in an age where the Internet has democratised information. Instead of a paternalistic ordering of tests and prescribing of pills, the role of doctor is now seen as an adviser helping the patient understand the choices available, the risk and benefits of each option, and helping him or her in choosing what is right for his circumstances, and expectations.
Clinical medicine is not an end in itself. It’s the means to an end. It is for the patient to decide the ends that are important to him.
Jammi N Rao
Visiting Professor of Public Health, Staffordshire University