title: Treatment as diagnosis and diagnosis as treatment: empirical management of presumptive tuberculosis in India.
abstract: BACKGROUND
  Mismanagement of TB is a concern in the Indian private sector, and empirical management might be a key contributor.
  
  
  OBJECTIVE
  To understand factors associated with empirical diagnosis and treatment of presumed TB in India's private sector and examine their effects on TB care.
  
  
  METHODS
  In this ethnographic study, 110 private practitioners of varying qualification who interacted with TB patients (90 in Mumbai and 20 in Patna) were interviewed, and a subset was observed while providing clinical care. Interviews and observations were analysed for indicators of empirical diagnosis and treatment.
  
  
  RESULTS
  All non-specialist practitioners began antibiotic treatment, especially quinolones, for persistent cough before prescribing a test. Several factors contribute to empirical management. These include a common practice use of medications as diagnostic tools, a desire to provide rapid symptom relief to patients, a desire to manage illness costs effectively, uncertainty about the presentation of TB, the effects of broad spectrum antibiotics on TB symptomology, and uncertainty about the accuracy of available TB tests.
  
  
  CONCLUSIONS
  Empiricism in general and in TB care is widespread in the urban private sector in India. Ethnography might offer useful insights for addressing this in public-private mix models.
authors.affiliation: McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
authors.forename: A
authors.initials: A
authors.lastname: McDowell
authors.affiliation: McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Pai
mesh_terms: D019468:Disease Management; D036262:Empirical Research; D006801:Humans; D007194:India; D010820:Physicians; D010818:Practice Patterns, Physicians'; D011331:Private Practice; D017149:Private Sector; D014376:Tuberculosis / Q000175:diagnosis* / Q000628:therapy*