Were you to compare the number of prescriptions written and the number of lab requests ordered by the doctor, the latter almost always edge in front. Medical professionals argue that there is collusion in Pakistan (and possibly elsewhere in the world) between doctors and diagnostic facilities, which may contribute to the gamut of tests, scans and screenings that a patient is prescribed.

“For tests ordered, doctors are known to get a cut from diagnostic facilities,” says Dr Sania Nishtar, head of Heartfile, an Islamabad based organisation that strives to change Pakistan’s health systems. “This incentive-sharing mechanism, while not kosher, is almost ‘official’.”

“It’s quite common, and is quite institutionalised,” adds Dr Amjad Siraj Memon, a professor of surgery at Karachi’s Civil Hospital. He says most doctors are reportedly involved in getting a certain percentage from the tests they order from a particular lab. “There are PROs hired by labs who go shopping for doctors with whom they can strike a business deal.”

But these “kick back arrangements” are also made with hospitals, diagnostic machine owners as well as pharmaceutical companies and reflects the “decadence of our society” from which those doctors emerge, points out Dr Tasnim Ahsan, former executive director of Jinnah Post-Graduate Medical Centre (JPMC), where she worked for 24 years. However, she claims that the number of such “rogue” practitioners was small.

When and why are lab tests ordered? Are these too many? But more importantly, are they the right ones and has it led to better health care and diagnosis?

There is a public perception that doctors are ordering often unnecessary tests that are far too pricey and then sending patients to specialists without considering the scientific rationale for getting these tests done. Many attribute it to the medical profession growing increasingly avaricious and unscrupulous.

But to understand whether doctors are ordering too many unnecessary tests and treatments and why, medical professionals explain that these should be viewed in the context of the particular system the doctor works in.

“In the US,” explains Nishtar, “there is a strong culture of recourse to litigation so as to enforce professional liability claims. Hence the doctors may tend to order more tests than may be required.”

At the same time, there is a continuous tussle between insurance companies who want fewer tests (on patients since they are covered under insurance schemes) and doctors who want to order more tests (both for reimbursements from hospitals and to protect themselves from expensive suits filed against them for malpractice).

“For tests ordered, doctors are known to get a cut from diagnostic facilities,” says Dr Sania Nishtar, head of Heartfile, an Islamabad based organisation that strives to change Pakistan’s health systems. “This incentive-sharing mechanism, while not kosher, is almost ‘official’.”

In the British system, on the other hand, the state provides free healthcare and “there the focus of the doctors is less tests so as not to overburden the system,” Nishtar remarked.

In Pakistan, Ahsan explains, the country has a completely bifurcated system for healthcare.

“The poor attend under-funded and over-burdened dysfunctional government hospitals. Doctors working and training in these hospitals learn to treat patients with limited investigations and drugs. But large private hospitals and teaching centres like to work as if they are in America,” she says.

“And the fear of being held responsible for malpractice is not always a factor since the ‘tort’ (a civil wrong that unfairly causes someone else to suffer loss or harm resulting in legal liability for the person who commits the tortious act) law is not fully developed,” says Nishtar, whose organisation provides financial support to those who are too poor to access healthcare and therefore has seen the working of the hospitals at close quarters.

Faisal, a public health practitioner heading Arjumand & Associates, an Islamabad-based consultancy group who offer their services to governments, universities and research institutions, argues that such practices merely reflect our social mores, since doctors are part of the same society that we all belong to.

“The poor attend under-funded and over-burdened dysfunctional government hospitals. Doctors working and training in these hospitals learn to treat patients with limited investigations and drugs. But large private hospitals and teaching centres like to work as if they are in America.

However, he says, young doctors today are “not trained to diagnose based on their clinical skills.” Poor teaching and not keeping their professional knowledge and skills up to date is often accompanied with the greed to make more money, he explains.

Dr Inayat Thaver, a health and population advisor at Mustashaar, a group of experts who offer technical and management services in the social and development areas with a special focus on health and population issues, concurs. “Compared to the good old physicians of yore, the new graduates prefer diagnosis by exclusion, rather than confirming the diagnosis by reaching a provisional diagnosis using their clinical skills,” he says.

These practices persist despite there being “practice guidelines” from reputed medical institutions which are regularly updated, based on emerging and new evidence from research. “These are considered the international standard of care for a particular disease,” explains Dr Ahsan.

“But few follow these SOPs and fewer still have confidence in their diagnosis,” says Faisal, as that requires meticulous history-taking and careful examination, which takes up a lot of time.

Having practiced as a doctor at Karachi’s Aga Khan University Hospital (AKUH) for well over 15 years, he recalls that when he was incharge of the community health sciences there, he ensured each junior doctor saw three patients, at the most, in one hour. “After seeing 12 patients in four hours, they had to take time off and refresh themselves before seeing the next batch,” he says.

But sometimes it is difficult to distinguish when what was judged by the doctor to be an important test later turned out to be unnecessary. At times, doctors order tests because they worry about missing but possible illness. There is, therefore, a need to check whether the diagnosis holds.

Conceding that there is just anecdotal evidence, Nishtar says that in the absence of a quality regulatory mechanism and scientific evidence, it was very difficult to say if there actually was “overconsumption” of diagnostics.

Defending her colleagues, Ahsan argues that doctors have to walk a tightrope as far as ordering investigations are concerned. “You are damned if you do and damned if you don’t.” This, she says, was especially true in an emergency where many things have to be ruled out quickly, in order to take a timely treatment decision to save a life.

And to be fair to her fraternity, she added that doctors inherently tend to “over- investigate” in order to not hold themselves responsible, “within their own minds”, for harming a patient as a result of “meagre investigative data”.

At the same time, says Ahsan, “the narrative that remains missing from these kinds of discussions is the life-time stress that doctors suffer from, on account of being responsible for somebody else’s life and meaningful survival.”

Lamenting the utterly “callous attitude at health centres”, she says it is further compounded by poverty and illiteracy.

“People are completely unaware of their basic rights in a climate of tolerating malpractice,” she says and concluded: “Reform won’t happen as certain cartels of doctors won’t like any kind of regulation placed on them.”

Published in Dawn, Sunday Magazine, August 30th, 2015

On a mobile phone? Get the Dawn Mobile App: Apple Store | Google Play