Health Care Reform and Plea for a return to better Clinical Culture

Health Care Reform and Clinical Culture

Posted by NEJM • August 26th, 2009 • 

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients.

Doctors are already, by training, sophisticated decision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.


The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” There has been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all of which are small or modest. Absolutes are discordant with the realities of sickness and health.

There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.


A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.

A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record.

My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.

Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.

Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.

Allan H. Ropper, M.D.
Brigham and Women’s Hospital
Boston, MA
This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org

Minister's Dialogue with Private Medical Doctors help clear the air...

Thursday's meeting (28 August 2009) with the Minister of Health, Dato' Sri Liow Tiong Lai and the Director General of Health Tan Sri Mohd Ismail Merican, was certainly a high point in timely dialogue between two seemingly disparate and separate sectors of the health service for Malaysia, particularly in the context of the current outbreak of the A(H1N1) influenza.

Among the many doctors (>60) who attended were several enthusiastic representatives from the MMA, PPSMMA, FPMPAM, PCDOM, APHM, AFPM, as well as several other interested medical practitioners from the Klang Valley, and even as far away as from Penang. It underscores the importance of such a meeting to help demystify the approach to the swine flu which has taken Malaysia by storm.

More importantly, the meeting was rather civil and accommodating with both sides cautiously trying to understand some of the undercurrents of unease which has permeated the relationship, especially whenever some untoward event related to the H1N1 occurs. The most recent recriminations took place when a woman teacher died after some supposedly possible delay in her treatment, when she had come down with the flu.

The difficulty in obtaining the antiviral drug (oseltamivir) was once again highlighted, and the restrictions in its use, were exposed, although in theory, the algorithm for managing the flu patient had been disseminated. Clinical judgement regarding moderate or severe symptoms and signs are not as clearcut as many would like to have believed.

The epidemiology of the Flu thus far was given by Dato' Dr Abdul Hassan, Director of Communicable Diseases, MOH. Dr Chris Lee gave a quick but comprehensive summary of the management guidelines as agreed to by the MOH and its task force and experts.

Clarifications were sought, with the plea by most private medical practitioners to further simplify the management of referring patients with suspected more serious complications to hospital sooner. Examples of patients being given the round around when referred for further action at various hospitals were given, which demonstrated that on the ground, practical issues still dominate the actual situation about whether the individual patient gets the treatment without too much delay. Some bureaucratic hiccups still take place, which may make the patient and doctor experiences very frustrating.

There was a further plea by the FPMPAM president, that there should not be too much finger-pointing at the private sector doctors, every time something bad or untoward occurs, because this is felt to undermine the credibility and morale of private doctors, who very often are not really to blame, and where circumstances and actual issues are the bugbears which create an environment of miscommunication and confusion.

However, in the light of the wide community spread of this H1N1 flu, there was a pledge on both sides to work harder to address these problematic areas, and ensure smoother and perhaps more constructive management of very ill patients.

Because, the MOH did not have a system in place to monitor or survey the usual flu like illness, in the country, it was felt that this makes it very hard to know if this current flu outbreak was really out of the ordinary, or perhaps just a little more virulent for some. Thus, it was agreed that GPs will assist the MOH by completing daily update notifications of all ILI, to help us maintain a closer surveillance and scrutiny of the situation on the ground.

Closer collaboration with the district MOH offices was also urged, with the plea for the MOH to circulate to all neighboring doctors any current or changed protocols so that GPs can be alerted to these more timely and accurately--the district MOH offices were felt to be the best community area to disseminate these updates.

Current changes will be notified at the MOH special H1N1 wbsite, and all doctors are urged to keep themselves apprised of changes or modifications regularly.

It was further announced that a National A(H1N1) Pandemic Influenza Conference 2009 would be organised very soon on 12 September 2009 at the Renaissance Hotel KL. This will be jointly organised by the MMA, the MOH and FPMPAM.

H1N1 Flu Guidelines: Is it Non-Compliance or Confusion?

PUTRAJAYA, July 30 - Doctors who fail to comply with the guidelines from the Health Ministry to detect the Influenza A (H1N1) infection much earlier will be called up by the Health Ministry for an explanation so that the problem would not recur.

The Director-General of Health Services, Tan Sri Dr Mohd Ismail Merican said the investigation was not meant to penalise the doctors concerned but to understand why they did not comply with the guidelines.

For this purpose, he said the Director of the Disease Control Division, Datuk Dr Hasan Abdul Rahman would instruct a team to question the doctors concerned to get further information on the medical examinations carried out.

“If there are doctors who still don't adhere to the guidelines issued by the ministry, we will call up the doctors concerned, ask them whether they understand (the guidelines issued).

“Some of them may not understand, so I will call them. Like in the case of the patient who died within 24 hours (first death of H1N1), he saw the doctor and after one hour, he died.

“So I want to find out from the doctor, did he examine the patient? And if so, why is it not recorded in the outpatient department (OPD) card? How can a patient collapse just like that?“ he said.

Dr Mohd Ismail said all doctors must also have their own computers with internet facilities to ensure that they kept abreast with current developments on the infection, particularly directives issued by the ministry on the matter.

“I was told that some doctors don't even own a computer, so please buy a computer, hook on to the internet and visit our (ministry's) website so that they will be up to date in the management of their patients, and it is not just for H1N1, it is for continual professional development (CPD).

“Find out what are the things that you need to do, be aware of things like guidelines about tamiflu, about wearing mask, about treating patients, everything is there. There is no excuse for people to say they do not know anything,” he said.

Dr Mohd Ismail said this when asked about the action to be taken against doctors who failed to adhere to the guidelines on examining Influenza A (H1N1) as stipulated by the Meeting of the Technical Committee on the Influenza A

(H1N1) yesterday. The guidelines which, among other things, stated that all severe cases of pneumonia for which a throat swab was required to be taken for Influenza A

(H1N1) tests and antiviral treatment given, were issued because there were doctors who failed to detect the ailment in the four fatal cases of Influenza A (H1N1) recorded earlier.

Asked whether the investigation was carried out in the four fatal cases earlier, Dr Mohd Ismail said so far the doctors concerned were only given reminders, and further action would depend on the subsequent developments.

He also said doctors could not refuse to see patients with influenza like illness (ILI) on their second visit, and the patients could actually insist on being tested for Influenza A (H1N1) on their second visit, if they had not recovered from their flu.

When asked about a case in Hospital Kuala Lumpur (HKL), where a patient suffering from asthma and suspected to be infected with H1N1 was asked to go home and rest instead, Dr Mohd Ismail said he would bring the matter up with HKL. - Bernama

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The MalaysianInsider has published this on 31 July 2009: H1N1 Measures: Confusion rather than Non-compliance

Malaysiakini too has published a version (31 July 2009) as Flu measures: Confusion rather than non-compliance

The news media appear to have started the blame game. More journalists are angling around the idea that because the H1N1 flu is fast spreading in the community and more and more people are reportedly succumbing to the infection, then there must be someone to blame, some agency which is at fault.

Perhaps the Health Ministry has not done enough, despite its earlier promise of containment and now mitigation. How is it that when we are now in mitigation phase, there are more people dying, comes the indignant cry of disbelief and alarm?

Sadly this is the myopic vision and misunderstanding of most people in this country. The Health Ministry and the Malaysian Medical Association (MMA) have been proactively warning of this possible scenario right from the outset of this pandemic.

But then many detractors (some tourism officials, air carriers, doctors even) have pooh-poohed our contingency plans as being too alarmist, too exaggerated, pointless even. They have been spreading counter messages that some of us have overstated the H1N1 flu threat, blowing things out of proportion, in our initial reaction to this 'benign' flu!

But I think we need not apologise for what our public health measures had been--these steps had been carefully put together according to well-thought out protocols accepted by health authorities, worldwide. It is precisely because these measures were put in place, that I think we managed to slow the unstoppable entry of this influenza into the country.

Believe it or not, our earlier stringent containment measures—which displeased many agencies, appear to have stemmed the more rapid spread of the H1N1 bug, until we are now closer to the more definitive vaccine, currently under tests.

We've also learnt from the mistakes, the resultant serious complications, the better management strategies of other countries with a runaway pandemic, such as Mexico, the United States, United Kingdom and Australia! It is our hope that we can now truly mitigate the final spread of this virus, decrease its lethality.

Perhaps, we may have a much greater chance to use the soon to be ready vaccine to help decrease the severity of this influenza, which has yet to show its potential true colors of devastation, yet to be played out...

Even among within some of our own physician communities, there have been suggestions to just let this pandemic loose into the community so that we can rapidly reach some form of spontaneous equilibrium, some herd cross-immunity, sooner.

The problem is no one wants to talk about the expected consequences of any outbreak, no matter how 'mild' or how 'generally benign' such pandemics appear to be at first glance.

Have we really considered the likely fatalities which must necessarily accompany this outbreak? Who should cope with explaining or even looking after the rising number of deaths and the very critically ill?

Now when the fatalities begin to ring in, we are suddenly sensitised to the rude truth that this H1N1 flu can kill. More disturbingly, the deaths so far have been unpredictable, the victims were not necessarily the most ill or immune-compromised to begin with, except for some comorbid features... obesity being one of them. And, these are relatively young people, who normally should not succumb to common cold/flu ailments...

To make matters worse, there appears to be more confusion on the ground. Guidelines and press releases are fine, but so far have been difficult to implement on the practical side, not necessarily due to not trying hard enough.

Reports from the mass media have been skewed differently by disparate interests, without giving the entire picture, but only highlighting preferred slants quite dependent upon the journalists covering the news, or even their editorialising staff.

Sadly, we do need all the mainstream and alternate media to play a more accurate and comprehensive role in educating and informing our citizens, not to play the blame game, nor second-guessing our hardpressed Health Ministry's personnel and facilities, or worse to apportion blame of inadequacy on the private sector, which has of late become the convenient 'whipping boy' of the media.

The dedicated H1N1 website (http://h1n1.moh.gov.my) by the MOH is not sufficiently updated and spot-on contemporary, being at least one to 2 weeks behind, except for the daily numbers and DG update. Unfortunately the website is entirely in Bahasa Malaysia, and this may discourage some people from accessing this site...

And again, how many of our citizens bother to check with these information on a compulsive manner, daily, to keep themselves totally abreast of the most current information?

Realities of the ground however, are proving to be tricky and frustrating. With the high alert mental state among some of our citizens, there has been growing exasperation for some people (including some foreigners, visitors) when trying to seek treatment and confirmation on what appears to be influenza-like illness (ILI).

Directives from the MOH are not entirely clear, and although on paper these may look good. The interpretation of what constitutes serious symptoms always pose a dilemma and a bone of contention with many a presenting patient, who demand to know for sure, to be tested and be confirmed (or dismissed), and treated appropriately, quickly.

There has been crescendoing demands for the Tamiflu antiviral drugs, which are now under strict control and distribution by the MOH. To be fair, this rationing is to prevent indiscriminate use and the possible creation of resistant strains of the H1N1 flu bug.

As of now, 21 major private hospitals have been supplied the Tamiflu antiviral drug to help look after the expected rise in H1N1 infections. Whether this stringent control is practical or simply too bureaucratic remains to be seen.

Conflicting media calls, purportedly attributed to the DG of Health, do not help the already pandemonic situation... At a press conference, a patient demanded to know why she could not be tested earlier despite having symptoms for a few days, when she had been sent away each time, by an MOH facility in KL, which prompted the DG of Health to reassure her that she should be examined and then tested. This was reported by The Star as “Docs cannot refuse requests for swabs to be taken”.

At my hospital there have angry demands for testing for the H1N1 virus: an irate expatriate father demanded to have the testing for his child who had been having mild fever for a few days, but with no other features of high risk. Because the protocol demands that the Emergency department doctor teleconsult with a MOH officer before submitting or sending a throat swab, this was not understood, especially when the MOH officer did not agree with the need for the swab or testing!

Thus, this artificial stumbling block is yet another area of gap for public-doctor misunderstanding. It is therefore, not simply a question of compliance, the ground rules are fluid and are not black or white!

This pre-approval necessity for H1N1 virus testing is making it very hard for doctors out there who are facing daily demands from worried ILI patients to be tested. Almost invariably there will be those who feel that their illness is more serious than what some of us doctors would feel otherwise, even after full examination/reassurance—so what do we do then?

In the early phases, can this ailment be so readily distinguishable from other more benign colds and other URTIs? Are we expected to be spot-on diagnosticians who must get this correct every time? Would our patients and the MOH officials understand this difficulty?

Or should we expand our testing facilities much more widely until this can be performed on demand by anyone, anytime? Would this be too expensive and would we really have sufficient test kits to answer to this need? Is this really necessary and shouldn't our citizens be made more aware of this, so that they do not panic and demand unnecessarily?

In fact, although in our frustration, the media and some of our officials may wish to find someone at fault, it is more likely that there are real logistic problems on the ground, rather than non-compliance on the part of some doctors, clinics, or even hospitals—be they private or public institutions!

We must strive to iron out some of these glitches, these inconsistencies, and perhaps, where posible, allow every health facility (public or private) to carry out such heavy demands for testing, treatment, since almost every interested physician and major medical facility have already been empowered to now treat the more seriously complicated H1N1 patient.

We have to make the handling of this pandemic easier and less bureaucratic... If the WHO projection is to be believed, it will become even more devastating once the spread escalates to unimaginable proportions!

At a recent briefing to the National Influenza Pandemic Task Force meeting (29 July 2009), Dato' Dr Tee Ah Sian, Director of communicable diseases of WHO, painted a possible scenario for the Malaysian H1N1 pandemic. While I do not wish to be alarmist, it is good to at least recognise the least impact scenario which has been projected.

For our 27.7 million population, if simply 20% are at risk and exposed, then some 5.5 million people will contract the H1N1 flu. Based on other serious influenza statistics, if 2% to 9% require hospitalisation then, some 110,000 to 500,000, respectively, would need hospital care.

From these numbers, if we estimate the case fatality rate to be from 0.1% to 0.5%, then some 5,500 to 28,000 of infected patients would die, respectively. In the latest updates of the most seriously ill patients identified and confirmed infections, the global case fatality rate has risen from the 0.4% to 0.66%...

So, the hardnosed reality is that it is more than likely that the worse is yet to come. We can only hope that this is the worst case scenario!

In the meantime, let's keep cool heads, and work together. We must maintain, even heighten our sense of vigilance, so as not to miss out the more serious complications and the more potentially at risk people, so that we can help reduce the death rate.

This pandemic is expected to linger on for at least a year or two, before it burns itself out, by hopefully mutating into a more benign form, indistinguishable from the seasonal flu bugs; or because it is finally controlled to near-eradication by specific vaccines.

But there is that possibility that it may also mutate by reassortment into a far more lethal form, that much feared second or third wave, which would then demolish all our efforts achieved thus far!

Of course, if this does not pan out, then hooray for us! We'd have survived the wiser, slightly poorer, bruised, but alive and healthy! A "Y2K-like non-event" would be a most welcome projection, if and when this does come to pass!

But, we are not anywhere near out of the woods as yet. So let's be vigilantly proactive, while remaining socially responsible.

The Health Ministry can only help put in place some instruments to help mitigate and systematically monitor the spread, but it cannot ensure our own personal health safety on this H1N1 outbreak.

Only we as individuals and groups, can. We will all have to do our part.

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“Medicine is knowledge, judgment, experience, and luck"

These past few days since 25 May 2008 has been a sort of a misty daze with me.

My mother who is going on 77 years, suddenly on Monday became very symptomatic from chest tightness, syncope and extreme fatigue. She has been having hypertension, chronic asthma and probable coronary disease for some time but had elected for medical therapy. She had become fearful of any surgical option after having undergone 3 painful and eventful knee replacement surgeries, the last of which was some 6 years ago. But she has remained physically active and mentally alert, and she certainly knew her own mind.

This time unfortunately, she is diagnosed as having calcific left main stem disease, where the only therapeutic option is bypass surgery. As a cardiologist, this is especially frustrating, because her disease extends into the ostia of both the LAD and circumflex (ironically they are relatively disease-free otherwise) which renders the option of percutaneous intervention extremely high risk.

Datuk Dr Zainal who had kindly consented to help look after her and carried out the angiographic study was also disappointed that we could not proceed to revascularise her via PCI. And so the urban legend that doctors' relatives are often those who present with the least expected of ailments, and complications, persists.

Some say that Lady Luck is simply not with us, or so it seems. But at least, she now has the chance for corrective surgery, for which we are hopeful, because her cardiac function remains very good.

These past few days also provided another insight for me as a relative, a son of a patient. It has not been easy. In fact it is quite frustrating to be on the other side now of the doctor-patient relationship. The agonisingly slow pace of events/test-results unfolding can be unnerving, and it becomes worse when unexpected unfavourable results emerge piecemeal. It is difficult breaking disease pronouncements to any loved ones; relatives and immediate family members are hardest.

Making decisions on loved ones are even more difficult, doubly so when as a doctor, you know so much more about the risks and possibilities of whatever occurrences and events which can go wrong, expectedly or otherwise.

Besides, the emotional sensations of being a son is felt especially acutely, and an overpowering sense of inadequacy and hopelessness seems to pervade my being. Little wonder that it is almost always advised that one should avoid having to treat one's own family members because this is fraught with ethical and objectivity concerns. Unless we are born so cold-blooded, the emotional attachment can be so enervating that it can transform many a physician into a powerless objectively-feeble wreck!

Aside from the emotional clouding and oppression, the choice of therapy or doctors for your beloved ones is also not as straightforward as it may seem. There are so many factors to consider--who you know, who your usual practice mates are, their perceived track records and reputation, logistics and proximity, affordability, availability, our own personal bias and who amongst one's influential family members who calls the shots, etc.

Yet, how many of us as doctors give our patients that right to make such informed or 'biased' options? Almost routinely in day-to-day clinical practice, we make automatic blase pronouncements on diagnosis and therapeutic plans for our patients.

How often do we spare a second thought for the patient/his/her family to reconsider their options, much less offer an opportunity for second opinion? Choice of referring to which other physician or surgeon is seldom considered, much less frequently, even offered.

Furthermore, how many times must our humdrum decisions appear arbitrary and severe to someone who might be justifiably anxious, a little more curious, or demanding or simply confused? But we appear to believe in our own routine judgment, our so-called experience to make that informed or accustomed decision. In reality we do so without the requisite thought that perhaps, if or when it occurs to us or our family members, we might consider otherwise... or would we?

Most importantly, have we not sometimes asked ourselves whether we have made the correct choice or the best possible decisions for our patients, or do we simply believe that we have done all we can, out of routine, hurried or tired and/or even lazy habit? Is it possible that there might arise complications or untoward outcomes because of our mistaken or dismissively/ dispassionately-made decision?

In a recent NEJM article (The Moral of the Story) Dr Perri Klass discusses how these niggling fears, incessant self-questioning and doubt can occasionally paralyse one's own thinking and decision-making process:

"So I have been thinking about the voices that echo in your head when you make a clinical decision — even a relatively low-acuity decision about a child who doesn't seem critically ill. You can't let all the what-ifs terrorize you...

"So you just go on practicing, haunted by stories — stories you're a part of, stories that happen to people you love or know well or take care of, stories you hear from your teachers and colleagues, and the occasional well-told story that enters your brain and lives there . . . all those ghosts that hover at your shoulder or in the dark places of your mind. I had a peculiar sense of multiple levels of precepting...

"I'd like to think of it, in part, as a collective medical memory. And also as a way of honoring the patients who have suffered 'bad outcomes' — and their physicians, too, the ones who are grieving still, who have told and retold these difficult stories.

"Bad things can be only a step away, and we need to absorb that knowledge and yet still do our job. It seems to me right and proper that even in everyday primary care, there should arise these unexpected, unpredictable moments when the collective memory catches at your sleeve, when the ghosts whisper to you to watch out, to think again, or at least to scribble a cell-phone number on a piece of paper towel and call later just to be sure that everything's truly okay."

Perhaps, most times in medicine 'luck' turns out for most patient-doctor encounters, so that far more benevolent outcomes trump the far and few in-between, bad ones.

However, this 'chancy' approach might be that possibly avoidable but significant weakness that undermines better and more consistent health care for our patients. Should we not have better and more failsafe systematic approaches, which would greatly reduce adverse or untoward outcomes or even life-threatening catastrophes?

Or do personal professional decisions honed out of determined knowledge-acquisition, prolonged preceptorships/training, engaged experiences, and a consciously-developing acumen and judgment satisfy our medical therapeutic approach? Luck should simply be too rare a dicey affair to matter... at least that is what we all hope it would be...

I wonder if we could ever realise or make a greater effort to ensure that the practice of medicine becomes more predictable, more consistent and ultimately safer for our patients, as well as for ourselves and our loved ones! For my beloved mother, I hope and pray this will all turn out for the best possible results, and that she be allowed to return to better health soon.