[This essay is published in the July 2012 issue of Infomed (pgs:36-37)]
An annual or biannual screening check is a common reason to visit a medical facility for people of any age. It is also common knowledge that medical screening is a steady revenue stream prompting the rise of the business model in health-care called, diagnostic centre. These establishments deliver an important and useful ancillary service by alleviating some of the problems that plague large tertiary centres. They absorb patient overflows, reduce time-delays for procedures and provide flexi-hour service in convenient neighbourhood locations that underscore more intimate doctor-patient interactions. It is worth pondering however whether such a business model would have either existed or thrived, if medicine was still practised in the traditional way where a doctor first saw a patient and only then asked for an investigation to advance his/her clinical diagnosis. Today, the advance of technology and the plethora of diagnostic aids have put machine ahead of a doctor’s clinical assessment with the result that, often an investigation is ordered even before a patient is examined. The diagnostic armamentarium is tweaked every year to yield more sophisticated versions that reveal evermore early stages of an abnormality much before a symptom experience, let alone a doctor’s examination. The end result? Patients are put through a glut of screening tests regardless of their need and sometimes, repeatedly without the application of reason or standards. There are diagnostic tests for many health conditions. The prevailing credo of ‘earlier we catch it; the better we cure it’, has resulted in their use as screening tests. Diagnostic tests, when used in normal and healthy individuals are called, screening tests. Their use is prescribed by the medical profession whose publications routinely publish age/gender specific guidelines for establishing standards of practice.
So far, so good. But, how much is too much. And when or where is the line drawn between necessary and excessive screening. The advantages of screening are obvious – conditions that are diagnosed early are managed better. However, there are disadvantages too and with rising health care costs; it is these that are increasingly coming to light. Screening tests are expensive; naturally therefore, the spotlight is focused on their effectiveness. A common argument runs like this – how many tests must be run to save one life? In other words, how effective are these tests in reducing morbidity (disease suffering) and/or mortality? A valid enough query; but in fairness, it takes time to assess the long-term benefits and exhaustive data analytics (which take time to collect) are needed to initiate a revision and reset of earlier recommendations. The other argument against their rampant presence is that, widespread screening increases the number of false positive diagnoses with the attendant evil of further testing to confirm or disprove the results. The anxiety inflicted on the hapless patient is not to be taken lightly either. Incessant testing accelerates patient suspicion, unease and doubt with the process. The current practice environment is full of mistrust between health care provider (doctors, hospitals, labs and diagnostic centers) and patients. An erosion of the doctor-patient relationship brought on largely by the attitude of providers who focus more on the business of medicine and less on communication and empathy has widened the divide. When screening translates into more profit for the providers; it is easy to paper over the benefits and view every additional test the doctor orders with suspicion. Worse, the particular business model of diagnostic centers fosters a cut-throat competition where doctors are urged to contribute to revenues with either referral kick-backs or monetary incentives.
What then is to be done? Clearly, the relationship between provider and patient needs to be rebuilt. The onus of that rests entirely on the providers and many simple but effective solutions can and should be implemented. At the institutional/governmental level: 1) ensure full disclosure of industry affiliations from doctors who sit on the advisory panels that establish screening guidelines 2) standardize testing guidelines 3) recommend hospital associations to meet annually on the subject of diagnostic testing to ensure practice standards and 4) initiate regulatory action against the practice of incentivizing doctors for referrals or for revenue surges. At the level of hospitals/diagnostic centres that conduct screening: 1) ensure strict adherence to the recommended guidelines 2) foster patient inclusion and trust by making the printed recommendations available to patients and have display boards in the premises that inform the patient that such access is available 3) if the patient chooses a different provider, ensure that the tests are accepted and not unnecessarily repeated before the prescribed time 4) share the data and results with the patient and 5) use outcomes and patient feedback on quality of care as a remuneration incentive in lieu of institutional revenue spikes. At the individual patient level: be informed, do not be afraid to ask your doctors for clarifications and remember, that it is in your doctor’s interests to ensure, that as his/her patient, you get the best treatment you rightfully deserve.
Article in Infomed (pgs 36-37): http://www.infomed.com.my/1979551506/index.html