MUMBAI: Is surgery necessary? A city-based medical second opinion services centre has found an uncomfortable answer to this question that traumatizes every family whose member has been advised surgery. Almost 44% of the 12,500 patients for whom surgery was recommended were advised against it by their second opinion consultants.
Unnecessary surgery is not new in medicine. Orthopaedic surgeons in the United States were, four months ago, accused of overdoing total knee replacement surgeries by almost a third. Closer home, doctors in Andhra Pradesh rampantly performed hysterectomies in 2010 to get a higher payoff from government medical insurance schemes.
MediAngels, a second opinion centre based out of Navi Mumbai, recently studied its first 20,000 consultations over the past two years and found several people were advised "unnecessary surgeries" by their primary doctors.
Take the case of Kandivli resident Gaurav Sharma whose uncle was advised cardiac surgery due to a severe left shoulder pain. "We were told to undergo surgery the next day itself. Our entire family went into a tizzy wondering what to do." He logged into MediAngel's online chat with a cardiac surgeon in Delhi who looked at the ECG and said the patient only had an orthopaedic problem. "I then sought an opinion from a shoulder specialist based in the US, who diagnosed that my uncle's shoulder and arm bones were not aligned properly. He showed my uncle some shoulder exercises on an online chat," said Sharma and added that his uncle's pain has considerably reduced.
Dr Debraj Shome, a surgeon who owns MediAngels, said his centre's data showed poor adherence to surgery guidelines across all specialties. "We found that the discrepancy in opinions (between the patient's doctors and the second opinion-giver) was highest in heart problems at 55%," said Dr Shome. Knee replacements and hysterectomies were second at 48% while infertility was third on the list with 45% discrepancy in opinions. "We have doctors seeking opinions if they themselves are asked to undergo surgery. This says a lot about the trend," he added.
"This data shows that we have reason to be concerned," said liver surgeon Dr Sanjay Nagral, who is on the editorial board of the Indian Journal of Medical Ethics. "Everything in Indian healthcare is increasingly getting monetized. This is an indicator of that malaise."
Another surgeon who didn't want to be named said this was indicative of "market medicine".
"Doctors are like daily wage earners in India. They are paid on the basis of the 'business' they bring to a hospital. Obviously, a surgeon will be tempted to recommend surgery," he said. A doctor who works for a public hospital said an audit of government-run insurance schemes would reveal a similar trend of unnecessary surgeries. "Most money that the government pumps in for schemes such as the Rajiv Gandhi Arogya Yojana in Maharashtra is given to private hospitals that have been drafted in to do such procedures. One must investigate why public hospitals don't get as many surgeries or as much money as the private ones do in such schemes?" the doctor said.
Some specialists, though, say there is a logical reason for the discrepancy in MediAngel's data. "At present, there are many non-medical ways that compete with surgery as a form of treatment. So, in India, it is more a case of whom the patient goes first for consultation—whether a surgeon or a medicine specialist," said Dr Nagral.
In the United Kingdom, for instance, there are tumour boards in hospitals that comprise a radiotherapist, a surgeon and medical specialist who decide together on the treatment plan for a patient. "Radiation is emerging as a competitor to surgery in many cancers. Hence, instead of offering independent opinion from doctors, many hospitals there offer a tumour board's opinion," he said. In the US where healthcare is mainly paid for by insurance companies, some states require two opinions on the need for a surgery.
Incidentally, at a deliberation organized by the World Bank in July 2014, it was concluded that 'medical overuse' is emerging as a serious issue in India, especially as more people can afford to pay for medical interventions due to increasing access to insurance cover. "Individuals in India with private voluntary health insurance are two to three times more likely to be hospitalized than the national average. Many of these interventions deliver only marginal benefits and can actually harm the patients, leading to unnecessary suffering, especially among the frail and elderly," said the World Bank document.