The Goldilocks Principle of Good Medicine

I was shocked when I first heard his story. A 45-year-old man sat across from me in my consultation chamber. Some time earlier, he had undergone an ultrasound scan which revealed a fatty liver, and he had consulted a senior physician. Slightly overweight, he recalled being told that if he started a weight-loss medication, he would receive three months of lipid-lowering tablets free of cost, along with a three-month supply of multivitamins.

For a moment, I wondered if I had heard him right. Since when were prescription medicines being offered like festival hampers or pizza deals: buy one, get two free?

Medicine, at its heart, is not meant to work that way. A drug follows a diagnosis. A prescription follows clinical need. Medicines are powerful tools that heal, relieve suffering and save lives. But they can also cause harm when used casually or unnecessarily. Somewhere in the speed and commercialization of today’s healthcare system, this simple truth seems to have been forgotten.

The New Healthcare Paradox

For much of independent India’s history, our greatest healthcare challenge was scarcity—too few doctors, hospitals, diagnostic facilities and essential medicines. That challenge remains: across large parts of the country, people still struggle to access timely, affordable care for conditions ranging from tuberculosis, hypertension and diabetes to cancer, pregnancy complications and countless other health needs that depend on a functioning healthcare system.

But alongside this old problem, a newer, perhaps more insidious, one has emerged, especially in urban and semi-urban India: too much medicine.

This is not an argument against modern healthcare—far from it. Medicine is one of humanity’s greatest achievements. The concern is regarding the growing tendency to medicalize the ordinary: benign discomforts become diseases, minor test abnormalities become lifelong burdens, and risk factors turn into identities. The longer the list of tests, scans, pills and procedures, the better the care appears to be.

This is the new Indian healthcare paradox. One family may not receive basic stroke treatment in time, while another spends ₹40,000 on an executive health check-up that produces anxiety, incidental findings and repeat consultations. One patient may be denied essential medicines; another may be buried under medicines of dubious benefit.

Why More Isn’t Always Better

The problem is visible everywhere. MRI scans are advised for backache when rest, physiotherapy and time should come first. Antibiotics are prescribed for viral fevers ‘just in case’. Supplements, immunity boosters, anti-ageing pills, energy tonics, liver detox products and brain enhancers are sold with promises that far exceed the evidence behind them.

Of course, many procedures are genuinely necessary. Caesarean sections save mothers and babies. Knee replacements restore mobility. Gallbladder surgery, angioplasty and cancer treatment can be life-saving. The problem lies in the grey zones, where fear, uncertainty, commercial pressure and patient expectations steadily push care towards doing as much as possible. But more is not always better.

Illustration: Adobe Stock

The Cascade of Harm

Every test carries the possibility of a false positive. Every scan can uncover an incidental finding that may never have caused harm. Most medicines have side effects, and all must be processed by the liver and kidneys. The unnecessary or prolonged use of even harmless medicines and supplements can place avoidable strain on these organs. The overuse of antibiotics poses another danger by driving antimicrobial resistance and making these drugs less effective when they are truly needed.

The costs are financial too. India’s out-of-pocket health expenditure has declined in recent years, but it still accounts for a substantial share of total health spending. For many families, medical expenses consume savings, require loans or force the sale of long-term assets such as gold or jewellery. In such a setting, unnecessary care is not merely wasteful; it can be financially devastating.

Globally, this problem is increasingly being recognized. The British Medical Journal has described it as “Too Much Medicine”, warning against overdiagnosis, wasteful care and the medicalization of normal experiences of life.

For India, the issue is especially acute because millions still receive too little care, while others receive too much of the wrong kind. Both represent failures of the system. The answer, therefore, is not less medicine, but the right medicine.

A Call for Proportion

I believe India needs a national conversation on appropriate care. Professional medical associations should develop clear ‘Do Not Do’ lists for different specialties. Oncology has already taken a step in this direction through the National Cancer Grid of India’s ‘Choosing Wisely India’ initiative, which identifies low-value or harmful cancer practices. Similar efforts are needed in cardiology, orthopaedics, obstetrics, paediatrics, endocrinology, radiology and general practice.

Diagnostic centres and hospitals should also be required to explain the scientific basis of preventive health packages. A comprehensive package should not become a fishing expedition. Screening saves lives when it is targeted and evidence-based. Indiscriminate testing creates anxiety, confusion and waste.

Prescriptions need greater transparency too. Patients should know which medicines are essential, which are optional and which are supplements. They deserve to understand what is life-saving, what is intended for symptom relief and what rests on weak or limited evidence.

Citizens should also be encouraged to ask five simple questions: Do I really need this test or treatment? What are the risks? What happens if I wait? Are there simpler alternatives? What will it cost me? These are not anti-medicine questions—they are pro-patient ones, and a good doctor should welcome them.

Insurance companies and government health schemes must reward value, not volume. Hospitals should not be incentivized merely for the number of procedures performed, scans ordered or admissions generated. Quality should be judged by outcomes, avoided complications, rational antibiotic use and adherence to empirical guidelines. Medical education must change as well. Young doctors should be taught that uncertainty is part of medicine and that good medicine is not maximum medicine—it is proportionate medicine.

India’s health agenda can no longer be measured by access alone. The fight to expanding essential care must continue—no citizen should be denied treatment because of poverty, geography or weak public systems. But the next stage of health reform must be judged by a second question: are we delivering care that is necessary, and genuinely beneficial?

Too little medicine harms the poor. Too much medicine can harm everyone. The future of Indian healthcare depends on recognizing both.

Dr. Chandrakant Lahariya is a practising specialist in Preventive and Cardio-metabolic Medicine. His book Pill-Free (Penguin Random House India) is slated for release on 30 September this year.

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