Medical Practice under Scrutiny: How much care is too much?

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:

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* 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).

+ Ambrosia — the divine potion, which gave the gods unending life.

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[1] Susan Sontag. Illness as Metaphor. Doubleday, New York, 1978.

[2] Siddhartha Mukherjee. The Emperor of All Maladies: A Biography of Cancer. Scribner, New York, 2010.

[3] Ivan Illich. Medical nemesis. J Epidemiol Community Health 2003;57:919–922. This article is reprinted with permission from Elsevier (Lancet 1974;i:918–21). (http://www.elsevier.com/locate/lancet)

[4] National health accounts [online database]. Geneva, World Health Organization, 2010  (http://www.who.int/nha,

 accessed 23 June 2010).

[5] World health statistics 2010. Geneva, World Health Organization, 2010.

[6] Grossman M. The demand for health. 30 years later: a very personal retrospective and prospective reflection. J Health Economics. 2004; 23:629-636

[7] Leibowitz. A. A. The demand for health and health concerns after 30 years. J Health Economics. 2004;23: 663-671

[8] Bunker JP. Medicine matters after all. J Roy Coll Physicians. 1995;29:105-12

[9] R. Moynihan, I Heath, D. Henry. “Selling Sickness: The Pharmaceutical Industry and Disease-Mongering”, British Med J. 2002; 324:886–891.

[10] Starfield B, Hyde J, Gervas, Heath I. ‘The Concept of Prevention: A Good Idea Gone Astray?’ J Epidemiol Community Health 2008;62:580–583. [doi:10.1136/jech.2007.071027] Quoted by Chan C.K. in ‘M. K. Rajakumar, Primary Care and Population Health’, in An Uncommon Hero, 2011 (in press), pp 308-320.

[11] Duff Wilson. Health Guideline Panels struggle with Conflicts of Interest. New York Times, Nov 2, 2011. http://www.nytimes.com/2011/11/03/health/policy/health-guideline-panels-struggle-with-conflicts-of-interest.html?src=un&feedurl=http://json8.nytimes.com/pages/health/policy/index.jsonp&pagewanted=all

[12] James Le Fanu. Beware the 'Janus face’ of modern medicine. The Telegraph, 14 Nov 2011.  http://www.telegraph.co.uk/health/8883956/Beware-the-Janus-face-of-modern-medicine.html

[13] Kaptchuk TJ, Stason WB, Davis RB, et al. Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ 2006;332: 391–7.

[14] Judith S. Hochman, MD; Harmony R. Reynolds, MD; Vladimı´r Dzˇavı´k, et al. for the OAT Investigators. Long-Term Effects of Percutaneous Coronary Intervention of the Totally Occluded Infarct-Related Artery in the Subacute Phase After Myocardial Infarction. Circulation. 2011;124:00-00. (Published online Oct 24, 2011)

[15] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.

[16] Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease (COURAGE). N Engl J Med. 2007;356:1503–16.

[17] Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004; 109:1371– 8.

[18] Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, et al. Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet. 2009;373:911– 8.

[19] Roger Chou, Bhaskar Arora, Tracy Dana, Rongwei Fu, Miranda Walker, and Linda Humphrey. Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:375-385.

[20] Aktas MK, Ozduran V, Pothier CE, Lang R, Lauer MS. Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program. JAMA. 2004;292:1462-8. [PMID: 15383517]

[21] Cournot M, Taraszkiewicz D, Galinier M, Chamontin B, Boccalon H, Hanaire-Broutin H, et al. Is exercise testing useful to improve the prediction of coronary events in asymptomatic subjects? Eur J Cardiovasc Prev Rehabil. 2006;13:37-44. [PMID: 16449862]

[22] Michael S. Lauer. What Now With Screening Electrocardiography? Ann Intern Med. 2011;155:395-397.

[23] Bruce RA, DeRouen TA, Hossack KF. Pilot study examining the motivational effects of maximal exercise testing to modify risk factors and health habits. Cardiology. 1980;66:111–9.

[24] Diabetes mellitus and exercise. American Diabetes Association.  Diabetes Care. 1997;20:1908–12.

[25] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.

[26] Smith R. Limits to medicine. Medical Nemesis: the expropriation of health. J Epidemiol Community Health 2003;57:928.

[27] Alice K. Jacobs. Rebuilding an Enduring Trust in Medicine: A Global Mandate. (Presidential Address American Heart Association Scientific Sessions 2004). Circulation. 2005;111:3494-3498.

[28] Brian Olshansky. Placebo and Nocebo in Cardiovascular Health: Implications for Healthcare, Research, and the Doctor-Patient Relationship. J. Am. Coll. Cardiol. 2007;49;415-421.

Are Doctors Violating Patients’ Confidentiality Rights?

This article is also published in the MalaysianMirror as a letter in reply, 16 July 2009














The National Union of Bank Employees (NUBE) had accused doctors of violating their patients' privacy, through various press releases on 13 July 2009.

Doctors are always faced with many dilemmas, when attending to patients who come to their clinics or hospitals for medical treatment, through a third party payer (TPP) mechanism. While we all have a duty and responsibility to attend to patients, with the strictest confidentiality, there are also reality bites which dictate that doctors have to abide by certain technical requirements.

One of these, is to complete insurance forms or Managed Care Organisation (MCO) forms, sometimes even before any medical consultation can begin. Oftentimes, there're also more forms to fill, post treatment or during treatment, estimations of costs, etc. when complications or prolonged stays are anticipated.

However, all of these forms require that the patient i.e. the employee, agree to and sign a formal consent for his/her medical condition and treatment details to be made known to the third party payer, which often serve as independent managers whose function is to help regularise and contain healthcare costs.

Whether this is to be construed as a conditional guarantee letters (GL) is subject to different interpretations by different people. But unfortunately, that is the process, which the employee has to work out, or agree to, with their employers as a benefit of employment. Like it or not, someone has to pay for treatment; even when self-paying, there is that implicit agreement that some payment is expected.

Panel doctors serve a similar function, at trying to keep costs reasonable and within ready checks and balances. However, disclosure of personal information about the employee’s health or medical conditions directly to the human resource department of the employer may sometimes be seen as breaching these confidentiality rules, and must be carried out with great circumspection and care.

The rationale for such disclosure is so that no frivolous or fraudulent claims can then be made, and the costing of some of these treatment schedules can be checked for consistency and that these are done in accordance with regulations and agreed reimbursement guidelines.

This is the reality that is the process of these third party payment schemes, which help to justify charges and reimbursement. Most employers demand such justification.

Strictly speaking, this exchange of information is purely to help the process of transparency and regularity of the billing process. Some insurers have on occasions even denied hospitalisation or treatment suggestions based on their so-called gate-keeping function to help curb cost and over-utilisation. In many instances, doctors have helped to smoothen some of these disputes in favour of the patient (employee).

Our doctors’ Code of Ethics dictates that one's health status and medical conditions are always personal and confidential, thus it is hoped that these third party payers would be willing to apply such strict confidentiality rules when interacting with the employers who are the ultimate paymasters.

Doctors will always support such strict interpretation of these confidentiality concerns, but we cannot be held responsible for what some of these third party payers would do if they breach these conditions, so as to justify payment claims.

While such information helps to put some substance into claims, to facilitate and validate the medical treatment process, it is not intended to and should not be used to disclose personal health records and data to the employers, unless expressly agreed to by the employee or patient.

Of course, it is possible for employers to place the fear of nondisclosure to mean non-approval for the intended medical benefit that is sought for by the employee. However, this arrangement and employer-employee agreement should be strengthened to strictly abide by such privacy concerns, and should never be used for victimization.

The MMA strongly believes that personal details should not ever be revealed to the employer, which may jeopardise their working conditions or promotion aspects. Moreover, when requested to provide medical reports to anyone other that the individual patient, doctors are reminded to stringently adhere by these confidentiality rules, and be very careful about divulging any information which has not been authorised by the patient.

It is good practice to show the patient a copy of the letter or report and allow him or her to keep a copy even, get a signed consent, before sending this off to the employer. Medical reports are almost always given only to the patient, and rarely to his/her designated agent.

Herein lies the problem with these insurance pre-admission or pre-medical check forms, which must be approved prior to the medical process. They must also accompany the bills, but which must always also mandate the patient's permission (as a required signature), usually witnessed in full view of the doctor or his assistant.

How the third party payer then uses this information is unfortunately not within the purview of the doctor. Of course, doctors always support confidentiality and privacy rules, which is every patient's right. Therefore, it is untrue to say that doctors work in cahoots with these insurers and the banking establishment or any employer for that matter, to violate these privacy rights of the employee or patient.

In fact, the MMA fully supports the view (and perhaps through an improved regulatory framework) that protects the patient's personal information such as health or medical status. We support that such information be considered as fully confidential and only used impersonally (without identifying details) for the above disbursement or checking procedures, and should not be divulged to the employers, unless agreed to by the patient concerned.

Are there any circumstances, which allow a doctor or a panel of doctors to reveal their employees’ medical backgrounds to their employers? Without an expressed consent, the answer is an emphatic NO!

Some pre-employment medical check-ups are conditional, and are within the prerogative of the employer, which will usually demand full disclosure of health status and history before confirmation of employment. Such is the right of the employer or employing agency, and is usually made well in advance for the employee to agree to and formally approve before disclosure. Thus, this is a pre-employment agreement that is made in full cognizance and fully consented to, by the employee.

In certain conditions which require prolonged recuperation or when there is a need to modify work conditions, such as following a heart attack, stroke or certain major surgeries, some explanation to facilitate the employer's agreement to such work-related changes may be required. These are often requested by the recovering employee and are fully supported by doctors. In other words, doctors have always been very sympathetic and empathetic to employees as patients, and will always place their interests first and foremost.

Therefore, the statement by NUBE secretary-general J. Solomon that "this is not only a form of harassment but a clear violation of basic human rights and infringes on their privacy...", while understandably frustrating, needs clarification.

However, it is mischievous of NUBE to label doctors as colluding with employers to harass their employees. This is almost certainly never the case. In fact in the past when such requirements were mandated pre-treatment, many of us physicians protested exactly on such confidentiality concerns. It was only then that the Third Party Payers (TPPs), came forward with the requirement of the employee to acknowledge and sign their consent for divulging their medical information to the TPPs, that doctors agreed.

As concerned doctors, we continue to maintain that such information be used strictly to help facilitate issues of cost-checking, medication or investigation consistency, and reimbursement guidelines. No personal medical detail should be disclosed to the employer, which may prejudice the employee’s employability or personal status, or which may be used against the employee.

In many instances, doctors have bent backwards to help and assist their patients to access certain medical tests and therapeutic procedures, which have earlier been denied by their gate-keeping third party payers (TPPs) such as Managed Care Organisations (MCOs) and insurance agencies.

The MMA is also working closely with the Ministry of Health to come up with some comprehensive Regulations and Act to ensure that these MCOs and TPPs function within the remit of the law and thus protect the patient's rights more comprehensively. We understand that the MOH is in the final stages of putting this Act through Parliament.

In the meantime, we urge the banks’ unions to work out more consistent and transparent agreements so as to safeguard their members’ interests, privacy and rights. But please, remember that doctors are your friends and not ogres that we’ve been made out to be!

This article has now been published as a commentary in malaysiakini 16 July 2009

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Dr David KL Quek
President, MMA

Moments of Madness…

"A disciplined conscience is a man's best friend. It may not be his most amiable, but it is his most faithful monitor." ~Henry Ward Beecher (U.S. clergyman, 1813-1887)

"The shortest and surest way to live with honor in the world, is to be in reality what we would appear to be; all human virtues increase and strengthen themselves by the practice and experience of them." ~ Socrates (Greek philosopher, 470-399 B.C.E.)

[Some 2 years ago, I wrote an editorial on moments of madness following the infamous head-butting by football superstar Zidane, which had been coined a 'Zizou' Moment. I think it is good to review the principles of that message today...]

Possibly 2 billion people viewed the World Cup finals early Monday morning (10 July, 2006, in Malaysia) riveted by perhaps the most memorable incident of the entire month-long orgy of soccer extravaganza. French football maestro ‘Zizou’ Zidane head-butted Italian agent provocateur Marco Materazzi in what must count as the most inexplicably perplexing act of the tournament.

Notwithstanding whatever the provocation, that loss of control, that one moment of madness must forever be etched in the psyche of Zidane, as one final act of regret, which has blemished the demigod-like status of perhaps the most remarkable playmaker of soccer the world has ever known over the past twenty years.

What happens when one finally snaps may never be totally explained, nor can we ever hope to finally comprehend how or why it had taken place. Volumes have now been written about this indelible incident, and I do not wish to add to psychoanalyzing the whys and the wherefores.

This ‘Zizou’ moment however has been dissected and interpreted in several ways. One most recurring theme is that of justifiable violence/retaliation, taking the law into one’s own hands when provoked, when criminal acts or even insulting verbal or physical gestures are directed against us, when we feel that our honour has been tarnished.

It harks back to faintly-remembered times when lawlessness abounds and we the helpless wretched citizens cannot depend on the authorities or law enforcement agencies to deter or to take action against these perpetrators of wrong-doing. Thus, this wrought-up sense of unquenched frustration and blinding anger had swung many toward some form of vigilantism or justifiable retribution, which seems to have become more acceptable, but which in every civil society we have always resoundingly frowned upon.

Personally, I am of the opinion that physical violence and reprisal is never justifiable and that this can only amplify tensions toward an escalating gratuitous and senseless denouement, where innocents become embroiled and are hurt or slaughtered without rhyme or reason.

Consider the rising violence and tension in Israel, Palestine and Lebanon, and the potential for wider conflict in the Middle-East. Truly, as had been so well expostulated by Mahatma Gandhi decades ago, “An eye for an eye would make the whole world blind”!

I want however, to address here the more common moments of madness, the careless thoughtless actions which we sometimes act out, unthinking yet irreparable and irretrievable: small oftentimes silly acts which thankfully do not cast huge imprints or sequelae which can change, cripple or endanger someone else...

Most, if not all, are miniscule in their impact and are forgotten almost as quickly as they are committed—perhaps our ‘venial’ sins, our little ‘white lies’.

Sometimes however, these little acts become inured and acceptable, when they are repeated often enough to become subterranean habits or subconscious patterns of behaviour, which harden the insensate and Dr Hyde-like aspect of our other selves.

As doctors however, these may have been inadvertently but unprofessionally negligent, dangerous or even lethal to our charges, our patients, but we have become just too anaesthetized to recognize their gravity, their presence even.

Yet in rare instances some or even just one of these may have implications, which can be life-changing, life-defining or even catastrophic. Pleading in hindsight, with simplistic statements that we were just being human and had been pushed to the edge of our tolerance and control unfortunately, does not make this any better or justify its severity or gravity.

Consider some of these common instances of shame, these moments of weakness, of madness even:

• taking unfair advantage of our gullible but frightened patients by suggesting urgent but unnecessary tests or therapies;
• preferential referring to our doctor friends or hospitals who promise some kind of kickback;
• dishing out supplements because our patients urge or apprise us about their preference for alternative medicines;
• deceiving or defrauding our patients by inducing them to take part in some financial deals because of our special doctor-patient relationships;
• submitting to our baser self by engaging in sexual liaisons with our patients or their partners;
• choosing a convenient career path to become high-level drug-pushers by indiscriminate selling of hypnotics, sedatives, cough mixtures to drug addicts;
• selling medical certificates for a quick buck;
  
• becoming serial abortionists because there’s money to be made; etc…

We would all be remiss if we do not animadvert on such acts, which are growing more common nowadays.

Are these baser instincts simply trivial moments of madness? I beg to disagree, but no, these are not momentary lapses of conscience or behavior, they are consistent patterns of ethical breaches, which should be loudly denounced. They are definitely not conduct becoming of a medical professional.

Are they occurring more frequently than we have recognized? Sadly, perhaps so. Are they simply the work of a tiny segment of our fraternity? We certainly hope so, that these are the fringe numbers which bring shame to the profession and are unfortunately tarnishing our good name with their very thick brush strokes of professional delinquency.

Nevertheless, there are other possible moments of weakness that rarely can afflict the medical doctor. These uncommon out-of-character and enigmatic errors are often one-off, but may sometimes be extremely serious and egregious, and then become ethical challenges, which have to be scrutinized.

These are moments sometimes squeezed and secreted out due to tremendous pressures of internal conflict. Pertaining to these, we must be very resolute in our self-restraint and be extremely mindful so as to maintain our innate sense of proportion, our professional ethics.

There is unfortunately for us as doctors, very little hope of retraction or turning back, once these actions are set in motion or are enacted out to the full, and we would have to face all the attendant consequences and possible sanctions.

But this is one human dimension which doctors could perhaps be better understood from the public and the governing/regulatory authority perspectives.

Because of our lofty position in society—our innate and traditional trustworthiness which the public has endowed upon us—we are often placed in an unreal pedestal of pre-eminence, which may not always be in our best interests (and certainly not in our patients’ either!), and which are often too high and haughty for us to sustain continually as fallible human beings.

It is true that as doctors we welcome even relish such respectability. Sometimes we deceive themselves that we indeed deserve such supercilious placements and snobbishly surround ourselves with such arrogance that we fail to see our humanness, our human frailty and our foibles.

But any thinking person, much more so because we are doctors, will concede that we are all imperfect and will make mistakes; that medicine is altogether more of an art (with more uncertainties than we can imagine) than an exact science that we would want it to be—whatever evidence-bases there may be to embrace and ratify.

We doctors have differing standards of practice, experience and perceptions, largely because of the multitudinous medical colleges and training that we individually have passed through. We are also of disparate personalities, which range from the benignly empathetic Dr Marcus Welby-type to the arrogantly cocksure Dr Christian Barnard-type.

We range from the placid, contemplative doctor to the brash, trigger-happy knife-wielding surgeon or catheter-brandishing interventionist, willing to try out any medical procedures or therapies whether they are experimental or just because they are simply possible.

Let the devil in the details look after themselves, benefits or harms are immaterial and does not immediately concern us in the near term… Our patients become our playground, our artistic canvas to create and display some of our audacious skills and derring-do prowess… Some of our patients may fare poorly, but some may also do superbly well, often in spite of us and our actions, or our lack of it.

Some newfangled techniques have actually been discovered from just this type of intrepid cutting-edge experimentation and hit-and-miss try-outs. But at what costs? At this current point in time when more and more documentation and accountability is expected of the medical profession, what would be acceptable and what not?

How do we draw the line on what is ethical and what may be professionally dubious or even reckless endangerment?

We must each and every one of us, contemplate and decide for ourselves, periodically and conscientiously that what we profess as medical therapy are indeed in the best interests of our patients—our raison d’être for our existence.

Our pecuniary, entrepreneurial or other self-enhancing interests must always be subservient to this singular precept, and we must make that especial effort to keep this alive and as an overarching conscience to contain our potential excesses.

How best can we help avoid or contain our moments of weakness, or madness? Simple, and yet perhaps the hardest to implement… review our code of professional conduct frequently, be mindful of our Medical Act at all times, and keep our medical professionalism at our highest level of conscientiousness always. Be what our medical training has always taught us to do—the right stuff!

Let us strive to forever be known as healers par excellence, and not be remembered for lesser baser misconduct or acts unbecoming. Let us always tame our recurrently straining moments of madness, and retain our moral anchor always.


[MMA Editorial, June 2006; Vol. 36 (6):pg7-8]