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On Being a Doctor |

Food for Thought

Sunil Badve, MD
[+] Article, Author, and Disclosure Information

From Mumbai, India.

Requests for Single Reprints: Sunil Badve, MD, The Ottawa Hospital, 1967 Riverside Drive, Ottawa ON K1H 7W9 Canada; e-mail, sunilbadve@rediffmail.com.

Ann Intern Med. 2005;143(2):149. doi:10.7326/0003-4819-143-2-200507190-00017
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In August 1996, I joined Lokmanya Tilak Municipal General Hospital (LTMGH) in Mumbai, India, as an internist–house officer. The LTMGH is well-known for handling medical crises, because it is the largest public hospital in Mumbai Suburban District and is located near Asia's largest slum, Dharavi. Initially, I had a difficult time managing the huge workload. One of the central tasks of the housestaff was to discharge as many patients as possible on preemergency days to make room for the many anticipated admissions on call days. The housestaff who kept their ward census in single digits were most valued. Those who failed to do this invited reproach from the registrars.





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We Live in an imperfect world
Posted on July 19, 2005
Sudhir S Sekhon
Florida Oncology Associates
Conflict of Interest: None Declared

I read with interest Dr Badve's essay. The answer to his query is clearly no. While practice guidelines are valuable in promoting evidence- based medicine they clearly cannot be applied to every patient everywhere. Guidelines especially those written in the United States seem to work on the assumption that we live in a perfect world with infinite resources available to every patient. One fact about American Medicine that may not be obvious to physicians elsewhere is that no cost effectiveness analysis is required prior to approving and recommending an intervention. Most guidelines are written to promote interventions that are effective. However the magnitude of the effect and the cost to the patient as well as the society is seldom computed. Many of the the guidelines are written to promote the use of new pharmaceuticals by experts who have significant financial relationships with Pharmaceutical industry. In my specialty of Medical Oncology this is particularly troublesome. Over the years progressively more expensive medications with minimal clinical benefits have been approved increasingly stressing Medicare finances (1). The sad truth is that if a new medication was developed today which prolonged the life of a cancer patient by one hour at a cost of a million dollars it would most likely get approved for use in the United States and be paid for by Medicare. It would also likely make its way into clinical practice guidelines.

References 1. Schrag D. The price tag on progress--chemotherapy for colorectal cancer. N Engl J Med. 2004 Jul 22;351(4):317-9.

Conflict of Interest:

None declared

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