Questioning doctor’s orders
By AUDREY EDWARDSSunday Star, May 29, 2011
Patients must be informed of the various tests being ordered to ensure they understand their medical condition.
HOW much is too much? Patients or whoever is picking up the tab at private hospitals are beginning to question whether they have been subjected to too many tests or procedures and subsequently charged a wee bit too much for both.
Health Minister Datuk Seri Liow Tiong Lai says it is necessary for the patient to be informed of the various tests being ordered to ensure they understand their medical condition or the necessity for it to assist diagnosis or treatment.
“Patients need to give approval, whether verbal or written, prior to any investigation, treatment or procedure that needs to be performed on them; and this may require a signed, informed consent from the patients before the procedure is done,” he adds.
In cases where there is evidence of unethical practices, Liow advises patients to lodge an official complaint with the ministry's medical practice division.
“If the allegations are proven to be true, the doctor could be referred to the Malaysian Medical Council for disciplinary action under the Medical Act 1971. For the offending private healthcare facility or hospital, action can be taken against the licensee or person in charge under the regulations.”
His ministry has, however, not received any official written complaints or allegations from patients about doctors or hospitals carrying out unneccessary tests on them.
“There have been queries from third party organisations (such as managed care organisations) regarding procedures not mentioned in the Fee Schedule of the Private Healthcare Facilities and Services Regulations 2006, alleging that some unnecessary tests or treatments had been done. But on verification, we found that there were justifications for carrying out those tests based on the clinical judgement of the attending doctor,” he says.
Association of Private Hospitals of Malaysia president Datuk Dr Jacob Thomas points out that doctors are not paid for medical tests that they order for a patient as almost all private hospitals in Malaysia are owned by corporations and not doctors.
“The medical specialists who work in one or more of these facilities are not owners and have an independent contractor' status,” he adds.
“These specialists are credentialed to practise in one or more of these facilities . They do not own the hospital or its equipment. They, in fact, pay a rental for the clinic sessions which they choose to maintain.”
When a doctor asks for various tests and services such as X-Rays, blood tests and ECG, it is to make a diagnosis or help patients overcome their ailments.
“Once ordered by the doctor, the relevant hospital staff will carry out these tests and the patient is charged a fee for them. This fee goes to the hospital and not the doctor,” he says, adding that the doctor only charges for consultation.
Tests are carried out only on orders or requests of the doctor to ensure that only necessary and appropriate ones are done in the best interest of the patient, he says. However, Dr Jacob opines that complaints or unhappinees by patients or other payors come about when it is not clearly understood or explained when a test or retest is necessary.
“It is always a best practice' in healthcare for the doctor and his patient or family to discuss and understand as much as possible the plan of treatment and the various tests to be carried out,” he says.
“Most of the complaints or unhappiness occur when this communication is lacking or, in some instances, absent.”
He also points out that variations do exist in how two doctors would manage a similar illness.
Some are aggressive in both treatment and investigation while others tend to treat and observe the improvement during follow-up appointments and continue with reasonable discussions.
“These two styles of managing an illness will differ from each other, requiring different tests and different drugs. It all depends on what each doctor feels is best for the patient when he examines him,” he explains.
Dr Jacob adds that in this age of easy and ready access to current medical information via the Internet, patients may already know all about an illness and tests available when they visit a doctor.
“Doctors are often pushed by these patients to perform these tests.”
What is clearly needed, he stresses, is good and clear communication between doctor and the patient about the treatment plan.
Malaysian Medical Association (MMA) president Dr David Quek says while there have always been claims that some doctors, especially specialists, engaged in ordering too many unnecessary tests or investigations, it was difficult to prove.
Most of the complaints come from insurance companies that necessarily wish to reduce the utilisation of their insurance claims,” he claims.
“Some medical insurers are sometimes unfairly cautious that they deny necessary tests just to save costs, leading to some delays in diagnosis or treatment of some major disease.”
He adds that the association always reminds doctors to be more circumspect when patients ask for unnecessary testing to prove that they are healthy or without any major ailment.
However, more tests need to be carried out if symptoms or complaints from a patient suggest there could be a serious possibility of illness.
Citing an example of an individual who complains of chest pains, Dr Quek says it is difficult to dismiss that the pain is categorically not heart-related.
“What happens if the patient then goes on to develop a heart attack and possibly dies? The onus is on the doctor not to miss something so important,” he adds.
He says there are symptoms which are obviously not heart-related that can be dismissed if the physician is experienced and sure.
“But there have been rising concerns of missed diagnosis if the doctor fails to test for more serious conditions, no matter how low the risk is in some cases,” he adds, sharing Dr Jacob's sentiments that fear of litigation has made many specialists or general practitioners more cautious.
This results in them practising defensive medicine by referring early rather than late, he says.
The MMA is urging doctors to be more careful and practise good clinical medicine by being “more attentive and careful in examination”.
He advises patients to have a good and trustworthy family physician or doctor.
“Learn to trust the physician to be honest and prudent, and not be too pushy for urgent testing for this or that test,” he says.
“Not all tests which are expensive are good nor safe, some carry some risks too.”
He says that CT scans and X-Rays carry distinct but variable radiation risks, while other tests such as scopes may cause very low but never zero risk of possible rupture or tear in the intestine or gut.
“Most health authorities frown upon the need or benefit for whole body CT scanning,” he adds.
“A coronary angiogram carries a risk of around one in 5,000 chance of causing a heart attack or even sudden death, and should never be indiscriminately used to rule out or screen for heart artery disease.”
He says that if a patient is not sure about more tests being carried out or feels that a doctor is too eager to push them towards it, they could seek a second opinion.
“More important, do have a good personal physician who can then act as a muse and confidante to discuss the best options,” he advises.
“Above all, do not be too panicky and be persuaded that the tests are all without risks, and do not think that insurance coverage gives you the edge to demand more expensive testing.”