Wednesday, June 11, 2008

Diagnosis is really bad in poor nations

Julianne Gilmore sent me a link to an article on the Marginal Revolution blog which in turn quotes Das, Hammer and Leonard's "The Quality of Medical Advice in Low-Income Countries".
...doctors in Tanzania complete less than a quarter of the essential checklist for patients with classic symptoms of malaria, a disease that kills 63,000-96,000 Tanzanians each year. The public-sector doctor in India asks one (and only one) question in the average interaction: "What's wrong with you?". In Paraguay, the amount of time a doctor spends with a patient has nothing to do with the severity of the patient's illness...these isolated facts represent common patterns...three years of medical school in Tanzania result in only a 1 percentage point increase in the probability of a correct diagnosis...One concern with measuring doctor effort through direct observation is that the doctor may work harder in the presence of the research team.
Comment: The first rule in medical diagnosis is not to ask for information you can't use. So part of the problem may be the lack of means to treat patients in Tanzania and other really poor countries.

Remember, most illness is self limiting. Moreover, lots there are very few things one can do for viral diseases in developing nations, and doctors are likely to prescribe a fairly broadband antibiotic for a bacterial disease, rather than wait for the specific diagnosis of the bacterial agent.

Still, the purpose of the visit is not per se to identify the disease but rather to decide what the patient should do about his illness. Thus frequently in the United States a general practitioner will refer a patient to a specialist without himself/herself making a definite diagnosis. If there are few alternatives available to the physician serving a very poor population, then the amount of information needed to select appropriately among them may be very limited.

So it may well be that the physicians serving the poor in poor countries are too poorly trained to diagnose accurately, or it may be that they are too overworked to use their training, but it is also possible that they have too few resources at their disposal to make it worthwhile to do a diagnosis that would meet the standards of practice in rich countries (or in rich communities in their own poor countries).

In the case of paramedicals, it has been recognized that there are lots of health problems that are very much alike from patient to patient, and that can be treated successfully in the community. Thus the training of paramedicals focuses on providing them with the tools to recognize when to treat and when to refer on to a physician, and to instill a few relatively simply algorithms for the diagnosis and prescription or treatment for common, simple illnesses that can be treated in the community.

Many years ago Abraham Flexner, who is credited with stimulating the reforms of medical education in the United States that eventually resulted in our modern expert physicians, recommended that China not try to train its own physicians to Western standards. He (correctly) recognized that better health results could be obtained by using China's resources in the early 20th century to provide less training to more practitioners, who would recognize only the more common conditions and who would treat only the more amenable ones of those diagnosed.

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