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Physicians Heal Thyselves

Physicians Need To Heal Thyselves

Doctors need to come out clean on the ‘indiscriminate’ use of stents. The credibility of the entire medical fraternity risks being quashed, writes Gajanan Khergamker

It’s out in the open…once again. A study published recently in The Journal of American Medical Association suggested over 50 per cent cases involving the use of stents while performing angioplasty in the United States of America may have been “unnecessary”. In India, media reports have been pointing to the unnecessary use of stents in procedure for quite some time now. A section of doctors too have admitted to the fact that many doctors across cities use stents in cases when not required.

In 2009, when a Kolkata-based septuagenarian’s wife fell ill, doctors at a leading multi-speciality clinic suggested she opt for angioplasty and put five stents in his wife’s arteries.

And, when she died within a few days, the arbitrary use of stents made headlines.

Medical Council hints at use of stents being unnecessary
Around the same time, Medical Council of India had suggested a senior doctor at Safdarjung Hospital used stents ‘unnecessarily’ on a patient.

It is known secret that manufacturing companies give doctors commissions for every stent used. And, taking advantage of patients’ vulnerable situation, doctors scare them and their kin into installing more stents than needed.

Also, unlike medicines, there isn’t exactly a maximum retail price fixed to a stent. The cost of the stent is usually left for the doctors or the hospital to decide. The stent, in itself, isn’t very expensive either.

Doctor caught taking bribe from stent supplier 
In January 2013, the head of the department of cardiology at Nizam’s Institute of Medicine (NIMS), was reportedly caught red-handed while accepting a bribe of Rs 1.6 lakh from a stent supplier.

Anti-Corruption Bureau (ACB) investigators recovered the bribe money from Dr Rao’s office and subsequently arrested him for the offence. A case was registered against him under the Prevention of Corruption Act.

Dr Rao had allegedly demanded Rs 1.6 lakh as bribe from a stent supplier ‘for doing an official favour.’ The supplier reportedly approached the ACB. Dr Rao fell for the trap laid out for him and was subsequently arrested.

This is just tip of the iceberg. It’s usually the suppliers who offer a range of kickbacks to doctors to use their products and such deals do not come out in the open.

In the report published in the Journal of American Medical Association, a London-based cardiologist Dr Aseem Malhotra mentioned randomised studies have shown there is no clear evidence of stenting benefiting those with stable coronary disease, but a majority of patients believe undergoing angioplasty (stenting) improved their long-term survival rates.

50 pc of stenting done in the US, unncessary: JAMA 
In the article titled “The whole truth about coronary stents: The Elephant in the room,” Dr. Malhotra has cited a study in the US involving 1,44,737 patients in a total of 1,091 hospitals which suggested that almost half the stenting done was unnecessary. He cited another study which found that 88 per cent of patients undergoing a procedure for stable angina (chest pain or discomfort due to poor blood flow through blood vessels in the heart) believed that angioplasty would prevent a myocardial infarction and given various scenarios, 43 per cent of cardiologists would go ahead with stenting even when they thought it would not be of any benefit. In fact, a study by National Heart and Lung Institute in the US last year suggested one per cent to two per cent of people who have stented arteries develop a blood clot at the stent site which can cause a heart attack or stroke.

In India, last few years have witnessed an almost identical trend. Although, in most cases, stents are used when the blockage is more than 70 per cent, a few doctors have conceded using stents even when the blockage is around 30 per cent.

3.50L stents used in a year in India for 2.6L patients
The use of stents has been on the rise in different states across India. In February, it was reported that an increasing number of cardiac patients in Kerala were using heart stents. Last year, reportedly 3.50 lakh stents were implanted in more than 2.6 lakh patients in the country.

Concurrently, this spurt in the use of stents could also be attributed to the fact that the government had successfully brought down the cost of stents. “We felt that there was urgent need for the government’s intervention to reduce the prices of drug-eluting stents, the cost of which vary from Rs 50,000 to Rs 1.5 lakh. We successfully came to a decision to cut down on the price,” had said the state’s minister for public health Suresh Shetty.

The fact of the matter is, patients have to be educated about their condition fully so that their decision is a sound one. The decision made by the patient or his/her kin has to be an ‘informed’ one. But, most doctors tend to scare the patient into accepting the ‘only’ option available. With the doctor getting a ‘cut’ out of the cost of the stents used, there is a direct conflict of interest in the treatment involved.

Spreading awareness, informing the patient of every possible treatment option available including briefing the patient and the kin about the risks and benefits involved are the cornerstones of medical treatment. Coaxing a patient into opting for a ‘favourable’ option or scaring one into making a hasty, misinformed decision does amount to a breach of law.

Cases of medical negligence or cheating have hit news in the past couple of years in India. Patients, assuming the role of consumers, have learned to question things and when wronged, are not afraid to take the hospital or the doctor to court.

Rs 11 crore compensation awarded  in negligence case
Last year, the Supreme Court passed a landmark judgement in which the kin of patient was rewarded a compensation of Rs 11 crore in a case involving medical negligence. Just a few years before this landmark judgement, an RTI application revealed, in West Bengal, only nine per cent of the doctors, accused of ‘medical negligence or ‘ethical violations’ in the preceding 10 years, were prosecuted or dismissed. For the rest of the cases, either the cases were closed or the concerned doctor, let off the hook.

According to data revealed by the RTI application, a total of 515 cases were filed against doctors in 10 years’ period and of those, only 15 doctors had been removed from the council’s list of registered practitioners and another 30 had been let off after ‘warnings’.

In 2013, a worrying fact had come to light. In India, there is no centralised collection of data on medical negligence cases filed or details of their outcome.

In 2012, the Medical Council of India had said it would make the names of doctors convicted in medical negligence or ethical violation cases, public on its website. But, there still isn’t any centralised data pool of such cases.

Developed counties like USA, Canada etc., keep a database of such cases and names of hospital and doctors involved to help prevent cases of medical malpractice, negligence and ethical violation. India needs to take cue and follow suit swiftly.

250 patients sue US doctor for using stent arbitrarily
In 2013, in Maryland, US around 250 patients filed a lawsuit against a doctor in a hospital alleging he had performed hundreds of procedures to implant heart stents that were not medically necessary.

The patients later on reached a settlement with the hospital in question but the doctor accused of malpractice lost his job and his medical license.

In India, we too need to monitor, track and maintain a record of cases of medical malpractice and ethical violations to better our medical facility and ensure such cases are reduced to naught.

From a time when ’no action were taken in 91 per cent of medical negligence and ethical violation cases’ in 2011 to compensation of Rs. 11 crore for a medical negligence case of 15 years ago, we have come a long way.

There yet is a lot that needs to be done to enhance accountability and eliminate ethical violations and malpractice within the medical fraternity.

Prescribing ‘lowest price’ drugs and procuring a patient’s ‘informed consent’ with regard to the use of procedures such as ‘stents’ and ensuring the patient get the ‘best deal possible and the lowest cost and risk’.

Stents ‘not needed’ in most of the cases
What are stent?
Stents are tiny metallic wire meshes or scaffolding devices that are inserted in the heart to keep clogged arteries open in order to facilitate blood flow.

Types of stents available: Bare metal Stents (BMS) which hit the market in the late 1980s, Drug Eluting Stents (DES), which are coated with a drug and the more recent bio-absorbable stents which dissolve in the artery after a year.

While DES accounts for 70 per cent of the market, BMS accounts for 25 per cent and the more expensive Bio absorbable stents, 5 per cent, say stent manufacturers.
It is a booming industry. Previously most of our stents were imported but now competition within the country is stiff. In Chennai, there are close to 20 stent suppliers.
International giants like Abbott and Johnson & Johnson are active players in the Indian market.