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Poorly Trained Doctors in India make Wrong Diagnosis

Poorly trained doctors are making wrong diagnoses and dishing out outdated or even incorrect treatment in large parts of India, according to a study
The article in Health Affairs journal detailing the results of a scientific study performed recently in India (The Hindu,December 6, 2012 ) serves to underline what has long been suspected but rarely articulated or discussed on meaningful fora — Just how much do our doctors know? How accurate are they in making a diagnosis and how appropriate is the treatment they recommend?

If the study is any indication, the answer should be alarming. In Delhi, the rate of correct diagnosis was as low as 22 per cent and the rate of correct treatment was less than 50 per cent. This meant that patients in this study had only a one-fifth chance of having their disease diagnosed correctly and less than half got the correct treatment. The study focussed on primary care providers and in rural Madhya Pradesh it has found that in 42 per cent of the cases, unnecessary or even harmful treatment was prescribed.

There may be limitations with the study (it covered medical and non-medical providers, qualified and unqualified) and undoubtedly there are centres of excellence where the rates of correct diagnosis and treatment would be higher. But the study has drawn attention to the massive problem of poorly trained doctors making wrong diagnoses and dishing out outdated or even incorrect treatment in large parts of India.

It is widely acknowledged that the quality of the emerging doctors in India is not uniformly what it used to be. There are many new colleges, especially private, where the standards are not up to the mark as they just do not have enough clinical material or patients to teach the students, and there are far too many students who possibly should not be in a medical school (disinterest, parental pressure, poor academic capability, etc.) in the first place. The quality of the faculty is patchy at best.

All this means the doctor who emerges from the medical school is often a health risk to the patient. Doctors in India have no legal compulsion to keep re-training themselves. They are not audited on any quality of care measures and it is pretty much a case of being free to do whatever one wants after the basic qualification is obtained.

In a government set-up in most parts of India, the average patient encounter time with the primary care physician is three minutes or less and this includes the time taken for writing out the prescription. This means the doctor is effectively making a decision on the diagnosis and treatment option in two minutes. Clearly, it is unlikely that in two minutes the doctor would get all inputs (symptom taking, history, physical examination, etc.,) to make a persistently accurate diagnosis. Sometimes, the doctors have pre-defined prescriptions that are written out and then handed over to the patients based on the symptom complex.

All this means that millions of patients could be getting the wrong treatment and incorrect diagnoses, leading to disability or death. Since we are not even measuring the accuracy of diagnosis and appropriateness of treatment, we simply do not know how big the problem is. There has been a strong reluctance to address the issue and take corrective measures. It does appear that no one really wants to rake up this matter for fear of what may emerge from a Pandora’s box. As this study has shown (despite its small sample size and limited scope), there could be a huge problem and it needs to be addressed now.

The first step would be for the government to commission more such studies on a larger scale to continually assess the quality measures. This will at least give us scientific evidence of the size and scale of the problem. The second is to institute and fully integrate protocol-based diagnoses and treatment systems into the teaching programme for medical students. The third step would be to make doctors take a test every five years to assess if they have updated their skills. Doctors who fail could be given a grace time of a year or two (and multiple attempts) to pass the test, failing which, their licence could be suspended. The fourth step could be to use technology with applications like clinical decision support systems to improve the quality of care delivery. All these are vitally important patient safety measures.

The tragedy is that our society seems indifferent to the fact that visiting a doctor may actually be injurious to health. Perhaps, it is our belief in destiny or karma that makes us reluctant to fight for this cause. There are very few strong patient bodies or consumer groups that take these issues up with the state or medical associations. A society that does not fight even for something as basic as quality health care, perhaps, deserves the health care it gets. The next time you visit your doctor, remember that your odds of getting the right diagnosis and treatment may be even less than that from the toss of a coin.

(The writer is a consultant in Internal Medicine. He can be reached at sumanthcraman@gmail.com)

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Replies to This Discussion

Permalink Reply by Jithin Bhagavati Kalam on April 24, 2013 at 12:37am

What's gonna change if theoretical knowledge from a set of books are assessed every 5 years? When will the writer of this article with a bunch of so called 'innovative' ideas understand the importance as well the immunity the practical knowledge can impart to a medical professional? This can't be funnier while our educational system is already a farse and is ridiculously imbeccile !

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Permalink Reply by Jitin Makker on April 24, 2013 at 4:48pm

There are many reasons whi'h everybody has pointed out. One thing what the writer missed is that there is a reservation system in India. 50 % of the seats are already reserved so half of the doctors from the beginning are not the best ones who should be in the profession. I am not against any caste but if you are talking about getting the results, you need people based on merit. This is a very important aspect of the stats which the author has mot mentioned.

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Permalink Reply by Sivanantham on April 25, 2013 at 7:59am

well said.. 100% true.. if u choose good fruits for ur appetite, ur health ll be good...

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Permalink Reply by Dr.Devendra Kumar munta md homeo on April 24, 2013 at 5:44pm

Yes I agree with the poorly trained doctors. Here my state and all over country there is great lacuna of lecturers,teaching staff, lack of practical sessions, I agree with jitin bhagavathi he is right in saying we are assessing only theoretical knowledge. privatization in medical education is to be stopped. Here in Homeopathic colleges aslo there is great lacuna of staff. Poorly trained doctors giving worsttreatment.

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Permalink Reply by Dr. Sasapu on April 26, 2013 at 4:13am

I agree with most of the above comments. The rate of misdiagnosis is very high and doctors are missing diagnosis and treating with wrong drugs due to lack of more quality training and also due to lack of time to talk to patient and correctly obtain complete history and exam. The issue is not about private vs. govt. medical colleges. It is the medical system’s fault at large. Medical education in India has allowed more students go to med schools and to become doctors, so that they can help the increasing population with increasing new medical problems. But the question is , does the increase in medical seats translate to more qualified doctors or improvement in quality of medical education and health care delivery? I say, not.

Here are where some of the issues in my perspective.

The medical education curriculum in India has not been really changed for the last several years even though there is lot of research in medicine and lot of new diagnostic techniques, and better treatment options. Medical students are still reading the same old text books which were not revised since 7-10 years. The same old traditional class room teaching, poor bed side teaching, lack of evidence based teaching or learning, lack of investigative minds in medical schools due to lack of interest from professors and lack of resources to do so if anyone is interested, poor testing strategies where medical students will be asked about some cramming material rather than relevant clinical and thought provoking questions, all these factors are playing a role in producing new generation doctors with outdated and obsolete thoughts and treatment strategies.

For example I went to a so called good medical college, even though I tried to learn the best I could and the college has given its best to me, still I feel like lot of things were missing. I remember presenting cases during the ward months to my attending doctors. We as a group of 5, were be asked to present one case per day for discussion. Most of the days, we would not finish the case during the discussion as my professor would stop me at my abdominal percussion for liver. He will discuss about how to do good physical exam every day but would never discuss with us about how to manage the patient and what is his approach treating certain patient. I never learned any management plan or current evidence behind any his teachings. I do know that history and physical exam is important part of the case but we also would like to know the management aspects, ethical issues and patient education aspects. I never saw any of my patients talking to the patient explaining about his medical condition and trying to ask the patient if he understood his problem or if he has any questions or not. Why is that? Who are we working for? Who are we treating? What are we getting paid for? Why is patient not in the discussion?

Well, guess what that is what I learned when I left the hospital, I initially started not explaining to the patient and then one day I realized, after looking at a good physician who was explaining the problem and asking questions to his patients, that I am not right and I need to change my way of thinking. I know now how important it is to talk to the patients and explain his condition in simple language. Most of the times, we as doctors assume that patients do not understand even if we explain their medical problems and they do not care about knowing about their problem, all they want is to get better. But that is not completely true; I talked to several patient in India and asked them what they know about their disease and what did doctor say about it? You know what the answer is? “my doctor rarely talks to me, he told me to take these pills and I will be fine”. If I were the patient I would like to know what are those pills for? How long I need to take them? What is the problem? What caused it? What can I do to prevent it? Do I have to worry about it coming back? when should I worry? How do I know these pills are not working? What did my blood tests show? Every patient has the right to know these things and every doctor as a role to tell these things to their patients. Why are we making wrong diagnosis? Why are we not trying to diagnose a case rather just prescribing some broad spectrum antibiotic hoping that it will take of care of “everything under the sun”. Why are we not trying to come up a differential diagnosis and working it up at least for the top three diagnosis? Why are we prescribing 3-5 days of antibiotics for pneumonia instead of the 7-10 day course? why are we using ampicillin for a clear cut picture of viral URI ? Why are we starting Z-pack on everyone who comes with throat pain, cough, runny nose? Why do we start norfloxacin and tinidizole for watery diarrhea? Why are we giving steroids, azithromycin, and nasal decongestents for acute 3-4 day history of sinusitis? What is the thinking, if any, behind these things? Do we really think about these diagnosis in our minds? Do we really try to investigate some of them?

Most of the private practice physicians see 40-50 patients every evening over a short period of 4 hours (from 6-10 pm). More than half of them will be new patients to him or her. That means on average they spend 5 minutes per patient. Ideally they should do history taking, exam, lab orders, treatment plan, patient education in that 5 minutes ! Are they really doing all of it in 5 minutes? It is impossible to do all those or even complete history and exam in 5 min or even in 15 minutes? So what exactly goes inside the doctor’s chamber when he sees a patient? They will smile at you, check your pulse and/or BP. Ask few questions about why you are here? may listen to your lungs and heart quickly, sometimes palpate your belly, then write prescription or labs and bye…This is what happens in many cases…It is not just my opinion, I saw doctors doing it and spoke to several patients and they expressed the same concern. How could one come up with a correct diagnosis and treatment plan in just 5 minutes?

That’s why doctors miss diagnose, because they did not ask him about his recent weight loss, constipation, all he asked about is - do have breathlessness and do you smoke, any cough? Any weakness? Patient said yes to his questions and patient did not complain about his weight loss or constipation. Instead of diagnosing him with possible colon cancer, he was diagnosed with anemia, COPD and given iron pills, inhaled steroids, and oral theophylline tablets. This is a true incident by the way. There are several occasions like this where patients are treated with 3 courses of antibiotics for presumed pneumonia when the patient has persistent lung mass for 6 weeks with no fever, no increase in sputum or WBC. She was eventually diagnosed with lung cancer, but she is already stage IV by then. Why is this happening? None of her two MDs asked her about her 10 kg weight loss or her left shoulder pain or concerned about her persistent dry cough for 2 months. All they thought was it is lung infiltrate, cough let’s try antibiotics for 1 month. There is another patient who died of septic shock as he was not told about the side effects of his cancer medication; he was having fevers for 3 days and was taking Tylenol as he thought it is just a simple fever. No one told him what to do if he has fever? what to expect with his chemotherapy drugs? He should have gone to his doctor on the first day of fever if he knows that fever while getting chemotherapy is serious thing. We lost this person not to the cancer but due to poor doctor-patient relationship. There are many cases like this; most of them are preventable and diagnosable if physicians spend little more time in talking to the patient and explaining to the patient.

We as doctors study for many years, we are smart people, hardworking, pledged to serve, and only people on this planet who can make a real difference in patient’s lives and eliminate their suffering. Why are we failing inspite of all our good virtues? because we not talking to the most important person in our medical filed, namely “the patient”. We have achieved great cures for many cancers, we have achieved great things in diagnostic imaging, lab techniques, we have understood most of the disease molecular level pathogenesis, we have identified the whole human genome sequence and yet we are forgetting the very important person for whom we have achieved all these. We are not communicating to this important person, “the patient”. Why don’t we proudly tell our patients what we achieved and educate them about their diagnosis and ask them if they understood what is going on with them? Is it harder than isolating the whole human three billion DNA base pairs? Why do not we use our achievements in formulating more evidence based diagnosis and treatment strategies?

We, as physicians should try to be a good patient advocates, we should treat them with respect and educate them as much as we could so that they can help themselves while we are busy helping others. We all know that most of our patient stop their antibiotics for pneumonia after 3days when they get better, they stop BP medications when their BP normalizes at their RMP visit. They stop aspirin after taking for a month after a stent placement; they stop insulin when their blood sugar is normal after 1 week. Who should we blame for all this? We should blame ourselves first before blaming the medically illiterate and poorly guided patient. We could eliminate lot of end stage renal failure or hypertensive head bleeds or sudden heart attacks if we educate our patients better about the fact that HTN, diabetes are chronic illnesses and needs life-long care and follow-up. How many of our doctors in India give a follow-up appointment for a patient who goes home after diabetic ketoacidosis, sepsis, acute renal failure? Or how many of us tell patients that they have to come to see us after 1-2 week course of antibiotics for their complicated UTI or complicated pneumonia? are we really looking at the urine cultures to change or tailor the correct antibiotics?

There are too many questions, for a simple solution. Spending time with the patient and listen to him completely, ask questions, tell your patient what is going on? Educate them, invite questions from them. Be a mentor in shaping their health and be a friend so that he could approach without fear.

The last thing I want to comment on is medical ethics. Did anyone teach us ethics? Do we know what medical ethics are? Why there are no ethics lectures in medical education curriculum? Are we not supposed to know ethics in order to deliver ethical patient care? How many of us abide to our medical ethics? If all of us are practicing ethically, then why patients feel that they will get inferior treatments if they complain about a staff member in a particular clinic or hospital or if they ask the doctor too many questions? Why some of our colleagues do not listen to their complaints in OP or in ward services when they complain about a mis-treatment or poor care by nursing or other ancillary staff? Why medical students/PGs fell stiff at some of the patients when they complain that bothered by medical students too often for case taking? Why is that fear of retaliation? Why do we not smile and greet our patients as our important tool of learning and important customers to us, without them we are useless to this great intellectual world. How many times do you admit with patient that you wrote a wrong test or wrong medication or you did a mistake during surgery or your ancillary staff was rude with the patient and you are sorry for that? Did we forget our medical oath?

Future on bright side: We will still be able to live happily and respected even if we start doing the things which we were not doing well. We will not do as much mistakes as we do now, we will be able to identify diseases at any early stage if we pay more attention to the patient, we will be able to improve our diagnostic accuracy if we listen to the patient, do right tests, and treat with right medications.

Our medical education system should change its curricula. There should be more evidence based approach to both teaching and learning. New modes of communication and teaching should be introduced. There should be lectures about how to practice evidence based medicine. Medical ethics should be incorporated in to the curriculum. Medical students should be assigned mentors from first year on wards and the mentors (typically a post graduate or junior faculty) should try to identify the strengths and weaknesses and guide him or her. During ward rotations, they should try to formulate a plan and discuss with their teaching professor. They should rationale the treatment strategies and also bring relevant literature to the discussion when possible. Patient education, communication skills, and doctor-patient relationship should be stressed more in their training. Lectures should not be mere repetition of what they can read from text books. Lectures should include studies and current literature cited and should be thought provoking for students and post graduates. There should be grand rounds in each medical college at least once every two weeks; these should be given by eminent speakers in the respective fields covering important topics with current updates. There are lot more ways to improve the medical education which I am sure some of us are willing advise and share if someone listens to us!