New Delhi, Dec. 5: Sections of doctors in India, although armed with medical degrees and working in reasonably well-equipped clinics, may be managing patients no better than so-called quacks, a study has suggested.
The study by a team of economists and health researchers in the US has shown high rates of wrong diagnosis and faulty treatment in rural and urban India by doctors as well as medical care providers with no formal medical education whatsoever.
Their findings, some medics say, corroborate long-standing concerns about the quality of medical education in India and the lack of regulatory requirements on doctors to periodically and appropriately retrain themselves to be able to continue practising medicine.
The researchers used “standardised” decoy patients in what could be India’s first rigorous assessment of the quality of diagnostic and treatment practices followed by doctors and unqualified practitioners in sample rural and urban centres
“The results are disturbing,” said Madhukar Pai, an associate professor of epidemiology at McGill University in Montreal, Canada, who was not associated with the study. “They underline concerns that the quality of care in India depends entirely on who one ends up with.”
“We know India has some outstanding doctors and hospitals, but this study generates evidence that India also has health care practitioners who are likely to cause great harm by mismanaging patients,” Pai told The Telegraph.
The study, published in the journal Health Affairs, found that among decoy patients who received a diagnosis, only 12 per cent in the sample rural area in Madhya Pradesh and 22 per cent in the sample urban area in New Delhi, were correctly diagnosed.
“We find that medical degrees and well-equipped clinics do not guarantee good quality health care,” said Jishnu Das, a senior economist with the World Bank in Washington DC, and a fellow at the Centre for Policy Research in New Delhi.
The decoy patients were coached by experts for three weeks to complain about one of three conditions — angina, asthma, or dysentery in a child — each of which has a set of standard guidelines for the line of questioning, diagnosis and treatment.
In both the rural and urban samples, adherence to the correct diagnostic approach by asking the right questions and doing the correct examinations was poor and fell far short of the government's guidelines for these three conditions.
In the rural sample, for example, only 14 per cent of the practitioners asked the decoy patients who walked into their clinics whether their pain had radiated — a clear symptom of stable or unstable angina — a key question that doctors are expected to ask patients reporting chest pain.
The rate of adherence to the essential checklist during diagnosis in the urban sample in New Delhi was only 31 per cent, and the rate of correct treatment only 45 per cent — suggesting that some practitioners prescribed the right treatment without the proper diagnosis.
While the decoys went to fairly representative mix of private practitioners and public health centres in rural Madhya Pradesh, the doctors selected in New Delhi were main neighbourhood doctors.
The researchers concede that the urban sample may thus have been slightly biased towards relatively lower-quality private practitioners. “The knowledge gained through education needs to be translated into good clinical practice — that’s where we find gaps,” Jishnu Das told The Telegraph. “This should stir policy-makers into thinking about the value of training doctors receive and how it can translate into better practice.”
Jishnu Das and his colleagues from academic institutions in the US and Canada analysed 926 interactions between 22 decoy patients and 305 health care providers at the two sample sites, debriefing the decoy patients within an hour of their interactions.
“There is a serious and urgent problem that is unlikely to be solved by increasing regulations governing health-care or through measures like adding to infrastructure in public clinics or just increasing the salaries of public sector doctors,” said Veena Das, Krieger-Eisenhower professor of anthropology at the Johns Hopkins University in the US, and a co-author of the study.
A senior surgeon in India said the study’s results appear to portray gaps in education and training that have long been neglected by regulators of medical education.
“This should be a wake-up call for institutions like the Medical Council of India,” said K. Michael Shyamprasad, a cardio-thoracic surgeon and former member of a Union health ministry task force on medical education.
In the past, sections of doctors in India have often called for mandatory re-certification of doctors — a process that would require doctors to train themselves meaningfully so that they can renew their licences to practise every five years.
“Successive governments have been sitting on the re-certification proposal,” Shyamprasad said. “Each time, there is opposition from within the medical community, and there appears to be no political will to challenge the medical community.”
Veena Das, the Johns Hopkins anthropologist, said the study also highlights the role that unqualified practitioners are playing in health care. In Madhya Pradesh, 67 per cent of the health providers had no medical degrees. “We need to accept that if large numbers of patients in many areas of India are being treated by untrained practitioners, perhaps we need to improve their quality and set up systems of triage through which they get support from better trained physicians.”
While earlier studies have audited prescriptions written by doctors in India and documented patient-doctor interactions, this is India’s first study to use “standardised” patients which, the researchers say, has in recent years emerged as a “gold standard” to assess quality of medical care.”
“Standardised patients are people who are carefully trained to portray a medical condition so realistically that they are not detected by a clinician,” said Diana Tabak, associate director of the Standardised Patients Programme at the University of Toronto in Canada.