Address for Correspondence
Srinivas Kakkilaya Bevinje
Associate Professor of Medicine,
K.S. Hegde Medical Academy, Deralakatte, Mangalore - 575018, INDIA
E-Mail: skakkilaya@hotmail.com
Web: www.rationalmedicine.org 

Healthcare industry is big business today with the best of technological innovation finding its way into the art and practice of improving and saving human lives. New diagnostic tools like imaging technology, genetic methods like the PCR; new therapeutic strategies like designer molecules targeting select components of bioresponse, gene therapy, organ and cell transplants; new preventive methods like vaccines etc. have all opened new avenues for patient care as well as 'markets' for the companies. And with 'globalisation' being the buzzword, every attempt is being made to expand and integrate this new 'market'.

Rational medical practice is about maximising the benefits for the patients at minimal cost, by making the prudent use of the resources. The essential ingredients of rational medical practice are a keen clinical sense, up-to-date knowledge on the pros and cons of the various diagnostic and therapeutic modalities and most importantly a sense of responsibility and concern towards the patients and their resources.

With the expansion of market forces, healthcare is becoming more and more irrational and expensive. Numerous studies have documented the continuing widespread irrational prescribing of drugs, including the overuse of antibiotics in primary health care.(1) A 11-year study found that 73% of the patients were given antibiotics for sore throat (mostly viral) and 68% of the prescriptions were for non-recommended therapy; the study also found an increase in the use of broad-spectrum macrolides and fluoroquinolones (2) thus increasing the cost of therapy on the one hand and chances of resistance on the other.(2) Another review found that 25-75% of antibiotic prescriptions in teaching hospitals in a large number of developed and developing countries were inappropriate in terms of either indication, selection, dosage or duration, or a combination of these.(1) 'Injection therapy', widely practiced in developing countries can also be an example of irrational drug use. One study showed that in some countries children have received on average 20 injections by the age of two.(1) Of all injections given, 5% or less were for immunization and 95% for curative purposes, most of which were unnecessary. Furthermore, over 50% of all injections given were unsafe, with increased risk of transmission of blood-borne pathogens such as hepatitis B and C, and HIV.(1)

Many new drugs and second-line drugs are very expensive and accordingly unaffordable for many governments and consumers.(1) Some of the new drugs, like the PPAR agonists,(3) cox-2 inhibitors,(4) biological response modifiers like etanercept,(5) donepezil for patients with Alzheimer's disease (6) etc. have been found to be potentially dangerous or less effective than claimed. The problems of inappropriate therapeutic drug use will only intensify as new drugs are introduced and new uses for established drugs are proposed.(7) In India, many available drug formulations are irrational (fixed dose combinations of NSAIDs and analgesics, antimicrobials, antihypertensives, oral hypoglycemic agents, multivitamins and 'anti oxidants' etc.) resulting in confusion, unnecessary (and unknowing) over-drugging, increased cost of treatment and possible adverse effects. 

Entanglement between doctors and drug companies is widespread, and evidence shows that interactions with industry influence doctors' behaviour and evidence based medicine can be undermined by clever companies.(8) In a Canadian study, most GPs admitted that they relied on medical representatives in addition to peer-reviewed journals; doctors writing the most prescriptions were found to meet with medical representatives twice as often as the average physician.(9) Medical detailers have been shown to be drug companies' most effective form of promotion.(9) It was also found that physicians working in government-funded community health centres prescribed more rationally than those working in private, group practices.(9) Evidence is strong that sponsored research tends to produce favourable results.(10) 

Irrational use of diagnostic tools is also common. A 2003 survey of more than 1,000 Americans by Opinion Research Corporation found that 67% believed that patients sometimes or always undergo unnecessary imaging tests, such as MRI, CT scans, and X-ray.(11) On the other, some of the new tests may not serve their purpose. The new, rapid diagnostic tests for malaria lack sensitivity and specificity, may not be reliable for diagnosis of malaria and are not approved by US FDA.(12) Although over 200 tumour markers have been developed, many have low accuracy in cancer detection, cost between $10 and $70 each, and only two are recommended for cancer screening by the USFDA.(13)

Promoting rational medical practice involves relentless education of doctors, patients and general public. Educating patients about the pros and cons of treatment may reduce expectations and demanding a particular treatment, for example antibiotics in respiratory infections.(14) It is found that clinical expert recommendations are often not synchronized with accumulating evidence, and this lack of recognition often resulted in delays in the acceptance of effective drugs and the slow abandonment of possibly harmful therapeutic practices. The rational use of therapeutic drugs can be achieved only through the routine use of meta-analysis on high-quality clinical data.(7) Extensive research has also shown that standard treatment guidelines, essential drugs lists and formularies promote rational prescribing of drugs by prescribers.(1) The WHO Model List of Essential Drugs and regional and international rational drug use courses form a large part of ongoing WHO efforts to improve drug use by health professionals.(1) The WHO Guide to Good Prescribing has proved to be another invaluable tool; primarily intended for undergraduate medical students who are about to enter the clinical phase of their studies, it provides step-by-step guidance on the process of rational prescribing.(1) Two randomized controlled trials with over ten centres in developed and developing countries have shown that the teaching methods transfer lasting skills in rational prescribing.(1) Reducing the interactions with medical representatives may help in reducing irrational prescriptions. Studies have shown inappropriate prescribing has been reduced by 12-49% through academic detailing done by a trained clinical pharmacist with education as the message rather than one-to-one meetings with medical representatives.(9) Audit and feedback initiatives, monitoring a doctor's prescribing pattern and then discussing it along with recommendations for better prescribing,.(9) may also prove useful. In the Indian context, it is absolutely necessary to improve teaching standards at medical colleges with special emphasis on imparting adequate clinical skills and rational approach to prescribing, to develop a essential drugs list on the lines of WHO recommendations, to prevent the pharma industry from packaging and marketing irrational and sometimes potentially dangerous formulations and to monitor and control the funding of medical professional bodies by the pharma industry.

Allowing a free run and one sided propaganda for the makers and marketers of diagnostic and therapeutic tools of healthcare will not only be suicidal for rational clinical practice but also detrimental to the health and economy of common people.

References:
1. Essential Drugs and Medicines Policy http://www.who.int/medicines/strategy/rational_use/strudprof.shtml 
2. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001;286:1181-1186.
3. Matthew Herper. Cancer worries dog new anti-Fat drugs. http://www.forbes.com/sciencesandmedicine/2004/07/15/cx_mh_0715ppar.html 
4. Roger Jones. Efficacy and safety of COX 2 inhibitors. BMJ 2002 (21 September);325:607-608. Available at http://bmj.bmjjournals.com/cgi/content/full/325/7365/607 
5. Updates: Infections, deaths prompt arthritis drug label change. Available at http://www.fda.gov/fdac/departs/1999/499_upd.html 
6. http://www.mult-sclerosis.org/news/Jun2004/StudySaysDonepezilisaWasteofMoney.html 
7. Lau J, Chalmers TC. The rational use of therapeutic drugs in the 21st century: Important lessons from cumulative meta-analyses of randomized control trials. Int J Technol Assess Health Care. 1995 Summer;11(3):509-22.
8. http://bmj.bmjjournals.com/cgi/content/full/326/7400/0-g 
9. Rational Drug Use http://www.haiweb.org/pubs/hailights/sep-98/rational.html
10. Ray Moynihan. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 1: Entanglement. BMJ 2003(31 May);326:1189-1192
11. "New System Delivers Critical Information in Real Time; Reduces Medical Errors, Costs," Associated Press Business Wire, February 11, 2003. Available at http://medicalimaging.org/efficiencies/imaging.cfm  
12. Kakkilaya BS. Rapid diagnosis of malaria. Laboratory Medicine. 2003 Aug;8(34):602-608.
13. Cancer test 'a waste of money'. Available at: http://straitstimes.asia1.com.sg/health/story/0,4395,255380,00.html 
14. Wheeler JG, Fair M, Simpson PM, et al. Impact of a waiting room videotape message on parent attitudes toward pediatric antibiotic use. Pediatrics. 2001;108:591-596. 

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