Medical Practice under Scrutiny:
How much care is too much?
By Dr
David KL Quek, FRCP, FNHAM, FAsCC, FACC
NHAM Pulse, 2011 (December): 2-6
“Illness is the night-side of life, a
more onerous citizenship. Everyone who is born holds dual citizenship, in the
kingdom of the well and in the kingdom of the sick.”
~ Susan Sontag[1]
The Illness Metaphor vs. Medicalisation
Susan
Sontag’s introspection above encapsulates this very real if unsettling
Manichean truism about illness and health in man. This was recently re-quoted in the frontispiece of Siddhartha Mukherjee’s 2010 book ‘The Emperor of all Maladies’ — a Pulitzer Prize-winning book about
cancers and the heroic battles to conquer if not to deflect cancers’ dismal if
inescapable trajectories and outcomes.[2]
The narrative
on the history and advances of cardiovascular understanding and therapeutics
would probably reflect a similar but perhaps with a more positive
historiography.* But there
has always been that tendency for physicians from time immemorial to
over-extend our professional reach and our self-importance, as we insinuate
ever deeper into society’s socio-economic web of life. With affairs of the
heart, this is even more pronounced!
Sometimes,
as physicians we tend to forget that illness is an innate part of man—we will
always become ill at some points in our lives. Yet, most of us subconsciously
embrace and expect its opposite—health—as a given. Perhaps we have let Medicine’s
overarching narrative to reshape our societal psyche into embracing a
pervasively systematic but false Nemesis.[3]
Eventually
every one of us will die, sometimes suddenly, prematurely, but frequently
enough from a drawn-out chronic ailment, which may be subtly quiescent (‘silent
killer’) or which may visibly stress, depress, debilitate and occasionally
dehumanize us. Illness and loss of health in humans and our patients are why we
physicians are here in the first place—patients are our raison d’être.
Healthcare
issues now encapsulate some 3 to 17% of mankind’s economic activity, depending
on where you are in the globe.[4],[5] There is that growing conscious demand
and push towards ‘good health’ and more accessible health care.[6]
Health is regarded as an inherent component of life, and is rightfully demanded
as a human right.[7] As
physicians, we must serve as the natural guardians and advocates to ensure
this, by making every possible effort to improve universal access and coverage
for this increasingly out-of-reach ‘commodity’. At the same time we must remain
conscientious that we do not create ‘health’ into an unreachable ideal, which
can only bilk or disenfranchise the unquenchable demands and expectations of
our willing but poorly informed patients at large.[3]
Yet, as we
(as doctors) embark on our furious pace of modern medical practice, we embrace
sometimes almost blindly all the advances that come our way, not wanting to be
left behind in that unrelenting race to keep up with what are new and trendy,
in the name of progress. We readily adopt and utilize whatever technological
devices and drugs at our disposal, believing that most of these efforts would
benefit or even cure our patients, sometimes at huge costs! But in the sum of
all things, medicine does work—patients do benefit and perhaps arguably live
longer and enjoy better quality of lives.[8]
Why?
Because, as doctors we are trained to follow systematic if narrowly prescribed
heuristics on how we approach illness, how we deal with it and how we treat it,
piecemeal, one at a time. However,
increasingly we have been reminded to look at each patient in as holistic a
manner as possible—treat the whole patient, not the diagnosis, we say.
But because
medical information is continually growing and evolving we also need to
constantly keep abreast—hence, the exhortation to lifelong continuing medical
education and learning. Knowledge growth also implies periodic shifting of the
goalposts for what are recognized as normal or abnormal, sometimes akin to new
wines in old bottles—blood pressure, blood glucose and cholesterol levels are
now lowered for normal acceptable ranges.
This necessarily
implies treating more patients to achieve lower and lower targets, because
there have been growing research data that show that perhaps lower is
better—lesser complications, better prognoses, better outcomes, perhaps longer
survival, even better quality of life. But some detractors have decried such
measures as examples of ‘medicalisation’
of health, calculated to exploit human vulnerabilities and anxieties.[9]
By looking
at the patient as a whole, multiple risk profiles and factors also imply that
we treat that patient with more therapies than was customary in the past. Most
often this approach employs the easiest means—prescribing medications and
pills—one on top of the other! This approach remains controversial and is not
readily accepted by all. Lifestyle modification and counseling often take
backseats in our therapeutic armamentarium because these are either too hard or
time-consuming to carry out, too difficult to measure for results, or because
they are inadequately reimbursed or not at all!
Risk Factors, Pre-disease & Injudicious
Polypharmacy
Barbara
Starfield et al., a pioneering advocate of primary care medicine has lamented:
“the progressive lowering of thresholds for
‘pre-disease’, particularly hypertension, serum cholesterol and blood sugar…
(where) risk factors are increasingly considered as equivalent to disease…
Encouraged by interests vested in selling more medications for ‘prevention’ and
more medical devices for testing, the pressure for increasing ‘prevention’ in
clinical care directed at individuals is inexorable – even though it is not
well supported by evidence in populations of patients…” [10]
Alas, it is
precisely this surge in preventive polypharmacy that has prompted so many
pharmaceutical companies to aggressively target the medical community with the
current deluge of blockbuster drugs in the hope to explicitly ameliorate the
perceived harms of concomitant risk factors/illness, but covertly perhaps for greater
profits as economic enterprises extraordinaire!
But the
physician’s professional need and mandate to keep current and up-to-date also
implies, that we become dependent on various modes of learning experiences and
sharing. Clinical and scientific research relentlessly redefines our perception
and belief systems about illness and health, so much so that we have sometimes
delegated some of these learning encounters to affiliates and peripheral
agencies. The danger is that, we might have been kept selectively informed by
incomplete snippets of ongoing if premature data by the very same aggressive
vendors of such cutting-edge advances and innovations—becoming unwitting agent
provocateurs of their surreptitious influence and propaganda, i.e. we become
too embroiled in possible conflicts of interest. [11]
Dr James Le
Fanu warns that “doctors are not just
doing more, but prescribing vastly more – an additional 300 million
prescriptions a year, half as many again compared to just 10 years ago.” He
went on to question the rationale of this modern shift in medical practice: “the merits of a coronary angioplasty in
promptly relieving crippling chest pains of angina is self-evident, but the
rationale for the majority of those 300 million extra prescriptions is very
different.” He estimates that globally, annual pharmaceutical revenues have
doubled from US$400 billion to US$800 billion (2.6 trillion Ringgit) over the
past 10 years![12]
“This, then, is the Janus face of modern
medicine, the most visible symbol of the power of science to banish disease for
the benefit of all. But the distinction between the relative contributions of
those technical innovations and the pharmaceutical industry to the spiraling
costs of healthcare reveals, with great clarity, the origins and harmful
consequences of medicalisation – and what indeed is required to control it.”
~ James Le
Fanu
Perhaps we
have become too indiscriminate, too undiscerning, and too gullible even. We
appear to have become uncritical on what needs to be critiqued, to be
critically analyzed and challenged. We have allowed possibly biased slants of
information to imprint, even distort our impressionable minds too easily!
We must
learn to acknowledge that we might have been somewhat less than judicious in
deciding which are truly best for the patients in front of us! Perhaps we have
become seduced by the glamour and the gloss of the pastiche of modern
innovations—new drugs and devices, new techniques that titillate our sense of
‘beauty’ and wonder; and perhaps that patchwork assemblage of molding plausible
theories into meaningful practices.
Perhaps,
all these newfound concepts go on to strengthen our physician empowerment as
society’s singular shamanic autocrats of medical knowledge. Perhaps, these
constantly reconstructed patho-physiological models of consistency, of newly
discovered molecules, gene-based proteomics, of mechanistic pathways, and
biological systems endow upon us that sense of puissance, of control, of
demigod status.
There can
be no denying that sometimes we may have become enamoured with too much care,
in doling out perhaps too many unwarranted tests and therapies, which could
arguably satisfy our egotistical self and enrich us personally, certainly more
so than our patients. We fail to be our patient’s best advocates, whose
interests should really be our unwritten if expected ethical compass.
Patients’ Interests—First and Foremost
Have we
failed in our duty to place our patients first and foremost, by possibly sacrificing
their dignity, their interests, thereby undermining their safety and long-term
health even? Have we fallen victim to our own entangled conflicts of interest,
our moral hazard of being less than fully impartial, by unfairly tapping into
the patient-doctor information asymmetry, or physician-industry ties and the
last-gasp hopes and anguish of many of our less than educated or informed
patients?[11]
Yet,
perhaps this statement is too harsh as an indictment to our dilemma as
specialist healthcare givers.
Let us
return to practical considerations as we re-examine our roles as cardiovascular
physicians. Increasingly we have been cast as unwitting but willing diagnostic
as well as gate-keeping therapists all rolled into one. Some have even labeled
us as unremitting purveyors of ever-newer medical devices: expensive drugs,
balloons, stents, pacemakers, etc. Cardiac surgeons have rightfully questioned
our objectivity, that we might have unfairly usurped our unique position to
sequester all manner of revascularisation therapies, particularly emphasizing PCI
to the detrimental exclusion of CABG.
Perhaps the increasing
development and use of appropriateness and organizational care pathways,
consensus cardiology-cardiothoracic team approach, of hybrid procedures and
global budget or diagnostic-related groups (DRGs) remuneration models, can
reduce the tendency for individual physician decision-making, which tends to
bias the physician toward more costly or self-serving procedures.
Despite the availability of
clinical care pathways and guidelines (CPGs), their variable interpretation
also means differences in emphasis or practice. Many physicians disdain care pathways and CPGs as ‘cookie-cutter’ medicine,
and interpret these loosely. They argue that a one-size-fits-all approach
cannot apply to differing patient scenarios, best only known to the physician
in charge.
By the very
nature of PCI being conceptually ‘simpler’ and less invasive, cardiologists
have cornered the market so to speak, so much so that our patients appear to
prefer our services, although the actual long-term results may be inferior to
the initially more disabling bypass surgery.
Most
cardiologists these days appear to have become singularly coronary artery
disease (CAD) experts, but not much more, sadly. Almost every young aspirant in
cardiology wishes to be that interventionist, that doer who can heal, with that
magical balloon and stent. It appears that to do more, rather than simply
counsel and advice might be more effective—at least, it seems that way. It has
been well described that an injection (even if of sham medicine), surgery or
any intervention gives greater effects or is perceived of as being more
efficacious than some simple pill.[13]
So could it
be that we have become too conditioned into believing that all the percutaneous
interventions that we have performed on our patients, are but that ersatz
veneer of favourable placebo effects, instead of true outcome-evidenced
benefits? Hence, could this misconception lead to some of us becoming perhaps a
little too reluctant to relinquish control of that patient in need, to someone
else (e.g. cardiac surgeon, or heart failure expert) more capable, more
adequately, or more appropriately trained than ourselves?
Consider the recent findings
of the extended follow-up OAT cohort that showed
that delayed routine revascularization during the subacute phase, gave no
greater benefit. Long-term clinical events were not
reduced after routine PCI in stable patients with a totally occluded
infarct-related artery, if there was no severe inducible ischemia.[14]
It is also
important to note that performing such PCI in the non-ACS setting, for patients
who are symptom-free (silent ischemic heart disease, SIHD) just because of some
ECG or imaging changes during stress testing would not be associated with
survival benefits or even lessening of potential CV events. For most scenarios
of angiographic stenoses (other than significant LMS and/or proximal LAD
disease) the recommendations are Class IIB or even III.[15]
PCI versus medical
therapy in stable CAD can be summarized as follows:[ 15]
• PCI reduces the incidence of angina
• PCI has not been demonstrated to
improve survival in stable patients[16]
• PCI may increase the short-term risk of
MI[16],[17]
• PCI does not lower
the long-term risk of MI[18]
We should learn to re-examine our
clinical objectivity and soberly address such issues of potential moral hazard
for the ultimate benefit of our patients. Our therapeutic decisions should neither
be because of our overwhelming paternalistic influence, nor to our subconscious
desire to profit personally.
The
ACCF/AHA/SCAI guidelines also strongly recommend that every PCI program should
operate a quality improvement program that routinely: [15]
a) reviews
quality and outcomes of the entire program;
b)
reviews results of individual operators;
c)
includes risk adjustment;
d)
provides peer review of difficult or complicated cases, and
e) performs random case
reviews.
They
recommend too that every PCI program should participate in a regional or
national PCI registry for the purpose of benchmarking its outcomes against
current national norms. Perhaps this is the sort of benchmarking that every
cardiologist and heart centre must adopt, as we embark on our journey to make
our own ACS and PCI Registries more comprehensive and complete.
Medical Screening Dilemmas
The U.S. Preventive Services
Task Force has in recent reports pose yet more dilemmas in the way of our
clinical practice.[19] The simple
rest ECG and the more routinely performed stress ECG of annual medical
check-ups, so much a part of cardiology practice, are now considered too
indiscriminately over-utilized.
For the symptom-free person,
the benefits of these tests appear to have been inadequately studied. Whatever
few studies available apparently showed no major benefit for the population at
large. The taskforce warns instead of the potential harms of consequential downstream
therapies or decision pathways such as more angiography, bleeding complications, radiation exposure, and contrast
allergy or nephropathy; more statin use and its possible adverse effects!
This conclusion was somewhat
surprising because the pooled evidence actually says otherwise: “Abnormalities on resting ECG (ST-segment or T-wave
abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis
deviation) or exercise ECG (ST segment depression with exercise, chronotropic
incompetence, abnormal heart rate recovery, or decreased exercise capacity)
were associated with increased risk (pooled hazard ratio estimates, 1.4 to
2.1). Evidence on harms was limited, but direct harms seemed minimal (for
resting ECG) or small (for exercise ECG). No study estimated harms from
subsequent testing or interventions, although rates of angiography after
exercise ECG ranged from 0.6% to 2.9%.”
The
main message appears to be quoted from 2 previous studies which state that “a small proportion (<1%) of patients have
revascularization with coronary artery bypass graft surgery or a percutaneous
coronary intervention after screening exercise ECG, despite the risks of these
interventions and their lack of benefits in asymptomatic persons.” [20],[21]
So
what are we to do, stop screening of symptom-free patients, and perhaps only
judiciously target those who need further evaluation based on complaints and
not necessarily for global risk assessment? The recent accompanying editorial
addresses this conundrum, but did not offer specific solutions, except to urge
for more research.[22]
Should
we then not perform
electrocardiography at all in asymptomatic adults? Apparently so. Chou and
others of the Task Force argue that because of this persistent lack of
evidence, clinicians should not incorporate screening with resting or exercise
electrocardiography into their practices except in the context of clinical
trials! This sadly sounds counterintuitive to most of us physicians and
cardiologists!
The
more plausible American Academy of Family Physicians recommends the following
for the asymptomatic
patient, that:
“Exercise
stress testing may provide valuable prognostic information in asymptomatic men
older than 45 years who have risk factors. The higher the number of risk factors,
the higher the pretest probability (hyperlipidemia > 6.20 mmol per L,
hypertension: systolic > 140 mm Hg or a diastolic >90 mm Hg, smoking,
diabetes mellitus, and history of MI or sudden death in a first-degree relative
younger than 60 years).[23]
“In
asymptomatic patients with diabetes mellitus, there is a higher risk of CAD in
the presence of at least one of the following factors: age >35 years, type 2
diabetes >10 years, type 1 diabetes >15 years, microvascular disease e.g.
proliferative retinopathy, nephropathy, or autonomic neuropathy. It is
recommended that patients with (these) criteria undergo exercise stress testing
before embarking on moderate-to high-intensity exercise.”[24]
Currently, the
ACCF/AHA/SCAI Guidelines recommend that: In patients entering a formal cardiac
rehabilitation program after PCI, treadmill exercise testing is reasonable. But
routine, periodic stress testing of asymptomatic patients after PCI without
specific clinical indications should not be performed. For cardiac rehabilitation
purposes however, medically supervised exercise programs should be recommended
to patients after PCI, particularly for moderate- to high-risk patients for
whom supervised exercise training is warranted.[25]
Discussion
My
malaise with these newer perplexing recommendations or restrictions is not
intended to curb or straitjacket medical or cardiovascular practice. But, it is
perhaps timely for us to seriously reconsider our own trajectory of clinical practice
and professionalism.
Are
we not somewhat complicit in inventing some new entities of health ailments,
i.e. increasingly medicalising health? What are we trying to achieve as we push
the boundaries and contemplate expanding such concepts as pre-diabetes,
pre-hypertension and lower and lower acceptable levels of serum LDL-cholesterol,
as we tag along more biological markers such as hs-CRP, hs-TNT, BNP, etc.?
Already, many other entities such as serum homocysteine, fibrinogen,
lipoprotein (a), PSA (arguably), have fallen by the wayside of bumf rather than
useful reliable knowledge!
Who
indeed do we serve as we trundle along with exciting if unproven new devices,
new paradigms of interventionist procedures, as we become increasingly invasive
even as we miniaturize our techniques and devices? Does the spirit of medical
adventurism justify medicine’s push for cutting-edge innovation and advances?
Does potential future benefits and ends for the many, justify the experimental
risks as a means for a few and the now?
What
about that ‘life sentence’ of medications for life or for as long as deemed
necessary? Yes we appear to have many long-term prognostic outcome data that
implies sustained therapies for the best effect — extending this or that
survival by perhaps weeks or months, on a statistical basis.
But,
how much of our patients’ lives are we interfering with and for what quantum of
greater good or longer-term benefits, the possible lost opportunity costs and
the inconvenience, that background intrusion into their lives? It is precisely
this expropriation of health that philosopher Ivan Illich had lamented.[3] Has health become such a scarce even elusive commodity that the common man now
has to “depend upon the consumption of
Ambrosia”?+
But
perhaps more importantly, we need to reignite our medical professionalism. We
must become more critical and discerning, as we embrace change and development.
We must learn to stand back from and reappraise the increasing use of
industry-sponsored spectacles of ‘show-and-tell’ ‘live’ demonstration courses. We must re-evaluate the allure toward more
procedures, devices and interventions than perhaps what might truly be
necessary medical care, no matter how promising or how technically beguiling
these appear to be!
This
includes even pharmaceutical junkets, which invariably encourage greater use of
newer, more expensive drugs among physicians. But this is not to say that we
have to revert back into being Luddites, opposing everything that is new and
good. We just have to be more circumspect, judicious, be really objective and
evidence-based! We should be imbued with a healthier dose of common-sense
skepticism!
The
former editor of the British Medical Journal, Dr Richard Smith had this to say
when he reviewed the life and work of Ivan Illich following the latter’s death in
2002 from debilitating cancer: “Technology can help, but
modern medicine has gone too far — launching onto a godlike battle to eradicate
death, pain and sickness. In doing so, it turns people into consumers or
objects, destroying their capacity for health.” [26]
We
must re-engage with our patients more candidly and transparently, and place
them and their interests first and foremost, after all truth telling is one of
the universally accepted pillars of ethics and professionalism. We should
inform more openly and widely (to include risks, especially material risks
peculiar to this or that patient). We should also propose and discuss alternative
models of therapies and lifestyle modifications, so that we allow patients to
decide on their own, which options to choose from and live by. This is perhaps
the modern expectation of patient empowerment and choice.
Already
there is declining trust and belief in physicians. We have to reclaim our
trust. Dr Alice Jacobs, president of the AHA in 2005 stated that: “This issue is the erosion of trust.
Lack of trust is a barrier between our intellectual renewal and our ability to
deliver this new knowledge… to the bedside of our patients, and to the public.
Trust is a vital, unseen, and essential element in diagnosis, treatment, and
healing. So it is fundamental that we understand what it is, why it’s important
in medicine, its recent decline, and what we can all do to rebuild trust in our
profession.”[27]
“A 2005 U.S. News and World Report cover stated: ‘Who Needs Doctors? Your next doctor may not
be an MD and you may be better off.’ Have we finally come this far, where
the human touch of the physician can be replaced by healthcare reduced to
guidelines, tests, algorithms, procedures, and drugs?”[28]
This is
indeed a possible scenario as we move further and further along in that
loosening of the physician-patient bond, that ever-widening chasm of
information asymmetry, with Internet or email consultations, video computer-assisted
medical appointments/consultations, telemedicine, etc. But at the end of every
patient-physician encounter, what is still most needed is that caring
empathetic relationship, with the physician serving as that trusted health
caregiver who can provide the best that modern medical care can offer, in the
best interest of the patient, and no one else! Above all, we are called upon to
provide medical care well and prudently, no more and certainly no less.
References:
* historiography — the writing of history based on the critical examination of
sources, the selection of particular details from the authentic materials in
those sources, and the synthesis of those details into a narrative that stands
the test of critical examination (Britannica.com).
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[2] Siddhartha Mukherjee. The
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[3] Ivan
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[4] National health
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[12] James Le Fanu. Beware the 'Janus face’ of
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