Doctors & Private Health Care: Challenges & Conflicts within the Confines of Business in Malaysia

Doctors & Private Health Care:

Challenges & Conflicts within the Confines of Business in Malaysia

By Dr David KL Quek

[Part of oral presentation at APHM International Healthcare Conference & Exhibition, June 4, 2014]

Accepted for Publication in Asian Hospitals & Healthcare Management

Private Healthcare – Expanding Influence

Private health care in Malaysia now commands some 22 percent of the total available hospital beds in the country. What that began as small scattered urban physician-led medical centres in the 1970s have now grown into huge conglomerates of hospital chains, some of which are now public-listed. Some 40-50 percent of these private hospital groups (IHH Healthcare, KPJ Healthcare, Ramsay Sime Darby Healthcare, Columbia Asia, etc.) are controlled or owned by Government-Linked Corporations and/or by our own national sovereign fund i.e. Khazanah Nasional Berhad.[1] Healthcare portfolios now account for some 10.9% of Khazanah Nasional Berhad.[2]

You might ask what all this has to do with the practice and the ethos of hospital care and its interactions with physicians? The private sector hospitals now look after 1 in 4 of all acute hospitalised patients in the country. To most people however, including government, media and citizens alike, private healthcare has become quite expensive. Costs have been escalating year on year, beyond the usual estimates of consumer price index for the country.[3]

From the tables below, it would seem that for this small percentage of private care, 76.8% of the payment mechanisms are out-of-pocket, totalling 34.2% of the Malaysia’s total health expenditure![4] Nationally, insurance and third party payers contribute less than one-quarter of private health care costs, meaning that most patients using the private health sector, pay on their own, out of pocket.

Of the total OOP payments, some 46% are spent for hospitalisation costs, the other 54% for ambulatory outpatient services. According to the recently updated WHO Malaysian  National Health Accounts, 70% of health insurance expenditure is spent on hospital care. Between 2000 and 2007, private hospital insurance funds in Malaysia grew from 12.5% to 14.7% of private expenditure.[5] However, in many private hospitals these days, 60-70% of private hospital bills are reimbursed by third party payers.

Health reimbursement – Growth of Third Party Payers (TPPs)

Hence, greater attention are being paid to third party payers who command to some extent, what, where and how much healthcare services, they would be willing to pay for. TTPs therefore control reimbursements including exerting rigorous documentation delays, possible denial of services, based on previous histories of poor outcome or higher payouts (out of the norm) when compared with other like facilities.

Competition indeed is the benchmark of these increasingly savvy business-oriented managed care organisations. They dictate which insured patient gets what treatment and from where. Thus, it is understandable why hospital administrators bend backwards to accommodate these bigger healthcare buyers, often offering bulk discounts for purchases of services based on simple bargaining, goodwill, of give and take, akin to many commercial undertakings. 

Conversely, physicians have construed these as fee-splitting particularly when their professional fees have been bundled into the discussion for greater volumes of business. But, it is hard to tease away this sort of contractual irregularity. Is this some form of negotiated mutually-acceptable business contracted services or is this outright fee-splitting?

Of course there is a real danger that using these bigger payer-players, physicians might be bullied into an unacceptable form of forced submission to accept the worst possible terms of the contract—‘take it or leave it’ scenarios have been exerted on those who baulk at such ‘negotiations’. Thus, this is also the rationale why the Malaysian Medical Council stand has been, that physicians and private hospitals must not engage in these sort of unfair bulk purchase discount practices, because ultimately due to lower fees (for gains), lower service quality could result, with the patients being at the losing end of this bad bargain!

However, some physicians at smaller private hsoptials have unhappily lamented that they have been coerced into agreeing to collective discounted fees not withstanding that they have been promised greater volume of services.

This is where many physicians fail to recognise and grasp the financial niceties and constrictions or the uglier business side of healthcare. Hence, conflicting tensions between administrators and physicians continue to simmer… For bigger private healthcare facilities and conglomerates, as the larger volumes are marketed and ‘traded’ for ‘bulk’ purchase of healthcare services, more of these negotiations, over and above the heads of physicians, would be the norm.

Healthcare Conglomerates Call the Shots

So why does larger private hospital ownership matter? They most certainly do, because they do need to justify their larger existence and outlays, and guarantee their bottom-lines. These private hospital chains to some extent, dictate the profit-orientated approach to healthcare, often with corporate demands for higher double-digit returns on investments (ROIs).[6]

Parkway Pantai revenues grew by 13 % to RM3.9 billion, and EBTIDA by 32% to RM968.8 million in 2013.⁶ Therefore, CEOs in these privatised concerns are given notice to achieve similar targets, year in, year out! Thus, not surprisingly, it has been suggested that the recent inflationary trends of private healthcare have been fuelled by GLCs’ forays into owning and aggressive investments in the healthcare sector.

But high profile investments into the private healthcare market leads to higher corporate expectations and costlier administrative processes too. With greater expected Return on Investments (ROIs), ‘governance’ and bigger administrative oversight, higher platforms and standards of fiduciary accountability, competitive amenities, acquisitions and other quality safety mechanisms have to be enhanced in tandem. 

So besides greater numbers of administrative personnel and its inherent costs, capital and infrastructural expenditure, there would have to be other unique healthcare-related quality assessment and compliance oversight, through agencies such as JCI and/or MSQH, besides the other technical ISO standards. These aspects are often oblivious to the physician whose remit appears to be purely focused on work alone! Thus, differing goals of healthcare stakeholders invariably lead to physician-management conflicts!

Therefore, hospital conglomerates tend to compete by dictating the terms and conditions of what physicians working under their jurisdictions are expected to perform and to deliver. There’ve been cynical if oblique complaints that huge investments into private healthcare industry, have led to aggressive marketing and overutilization of diagnostic and therapeutic amenities and services; these been openly encouraged, even incentivised! Thus, this commoditisation and commercialisation of private health care creates more conflicts between healthcare providers and the administrators / owners.

As healthcare services become more complex and expensive, more and more people are resorting to third party payers (TPPs): health insurance companies or employer-provided reimbursement managed care organisations (MCOs). For private care hospitalisations these days, the quantum of third party payers now approaches 70 to 75%. Self-paying only contributes to around 25 to 30%. 

Thus, more TPPs are demanding greater scrutiny of healthcare requests, enforcing more denial of service or partial payments, and mandating more elaborate if tedious auditable reporting, all adding to the growing tension of private healthcare malaise for both the administrator and the physician.

Changing Landscape of Patient Empowerment

As an insider for more than 30 years in medical practice, my perspective is understandably slanted toward that of the medical professional. But it would be foolhardy to purely focus on just physician practices, rights and autonomy alone.

The current scenario of near-universal World Wide Web access to information has created a climate quite different from just 2 decades ago. Then, physicians rule the roost. Physician ‘knows best’ paternalism dictates what patients need: to test, to treat, to operate, to cure. This information asymmetry or doctor-patient knowledge gap is slowly but surely diminishing.

These days, patients are more knowledgeable, increasingly demand their rights. They are not averse to second or third opinions, and they place their own interests first and foremost. But not only patients, the medical-legal fraternity, the healthcare payers are also demanding for more accountability, on patient safety and quality issues. Everyone now expects a fairer healthcare deal (at the best prices!), where patient harm is frowned upon and expected to be as low as possible!

The axiom of ‘Primum non Nocere’ (first do no harm) for physicians is now de rigueur![7]

Physician Scrutiny amidst Patient Safety & Quality Assurances

So what are we to do? As the immediate-past 2-term Chair of a Medical and Dental Advisory Committee and an elected Malaysian Medical Councillor for the past 10 years or so, I’ve been given that rare if unpleasant privilege to glimpse into the seedier side of medical miscommunications, medical errors and mishaps including incompetent care. But this exposure has helped me to focus more sharply on mounting patient grievances for unsatisfactory healthcare experiences and outcomes; including physician lapses and errors.[8]

Let’s face this squarely and bluntly. Whenever we audit or scrutinise any processes (particularly when a fault has been charged) there would be bound to be exposed worms in the cracked woodwork! So I would readily admit that it is hard to pass muster on all counts, unless our systems and processes are flawless! Thus, as inquiries mount to decipher the arcane perspectives of medical practice, we (council members, experts and medical litigation lawyers) have been forced to hunker down to scrutinise how doctors, allied healthcare providers and their facilities have been functioning—looking for avoidable errors, mishaps, weaknesses and failures, where preventable negligence aspects might be exposed. 

We’ve been tasked to look into standards of care to see if these meet the ethical obligations of not just bare minimum or competent care, but of empathetic but appropriate care and attention to safety as well. So it behooves every physician to be extra vigilant, and get his or her processes, expertise, knowledge and skills, communication and clinical results spot on. 

Don’t wait to be hauled up for an inquiry and/or a medico-legal challenge! Which leads to the next surrogate performance measure: quality and safety accreditations. These are not just acronyms for pride, they are there for improving systems and processes, to reduce errors to a tolerable minimum, to protect the patient, the physician and the healthcare facility![9]

Hence, the mandated surrogate application of hospital safety and quality accreditation exercises (Joint Commission International JCI[10], Malaysian Safety for Quality in Health MSQH[11]), so much the bane and scorn for many a hospital physician. Of course it’s true that we already have the very restrictive and punitive private health care facilities and services Act[12] and Regulations[13] that has stifled our medical practice, so say many a practitioner! Why do we need so much oversight?! We are being too straitjacketed by too many rules, it is lamented. Physician frustration has been growing globally. 

Physician Angst

Recently, an orthopaedic surgeon, Dr Daniel Craviotto has lamented that: [14]

“We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality?  Do we have more of a voice at the table or less? 

Are we as physicians happier or more disgruntled then 2 years ago? 5 years ago?  10 years ago? Once we're gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies?  Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.

“I don't know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not.”

Our physician autonomy has indeed been corroded… it is hard to be a physician these days! True, but sadly current reality bites must be considered. Although the angst expressed by Dr Craviotto is understandable, his various points of contention can be debated. Allowing the modern physician these days to a totally free run of his practice is no longer a given, nor is this the best option to assure quality care, at best lowest costs.[15] Unfortunately. Our carefree days of doing everything our heart desires, no longer count for much when quality assurances and longer term outcomes are measured, systematically.[16]
 

Physician Responsibility & Oversight  vs Patient Safety

Physicians free from oversight are more likely to deviate from tested clinical pathways based on his or her individual idiosyncrasies, belief in their own inflated personal skills and their dubious selective memories. And it has been shown over and over again that physicians like any other human professionals are as likely to perform based more for personal gain, than that for the patient, i.e. this warped vested interest, moral hazard, needs to be tempered by some Leviathan code of ethics![17]

So, like it or hate it, these ‘standards’, quality and safety policies and exercises will be here to stay. Not just because hospital owners want this, but health authorities worldwide too expect this to be the norm. In fact during the Bush administration in 2006, Senator Hillary Clinton and Barack Obama wrote just that paper for endorsing greater patient safety initiatives to help reduce medical litigation costs.[18]
 

The ultimate goal, of course, is patient safety, which should never be second guessed, least of all by the physician or healthcare provider who is conflicted by virtue of their profession. Therefore, there must be a reorientation in our ethos toward healthcare. We have to create a new paradigm shift in the spirit of our healthcare culture, community aspirations that places patient safety and interests first! But clearly there would be conflicting aspirations and goals between one party and the next, between physicians and administrators/owners!

Physician-Administrator/Owner Conflicts & Changing Dynamics

Hospital administrators would often resist reforms that they feel would impinge on their bottom-line to cover large fixed costs, while they would be averse to trying too hard to change physicians’ behaviour toward appropriateness use of medical technology or medications or reducing costs, for fear of reducing turn-over revenue.

Physicians themselves are also self-interested for financial and non-financial reasons. Physicians fear that talk of accountability and appropriateness of care would standardise their approaches to care, to restrict them to rigid clinical practice guidelines, subject themselves to too much outcome measurement and peer review, thereby reducing their autonomy, as well as capping their income.[19] Thus both are invariably opposed to too much ‘reform’ for better more cost-effective healthcare models and innovations![20]

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But increasingly many physicians working in the  private sector feel extremely frustrated at being hamstrung by what appears to be the widespread inadequacy and incompetence of employed allied health personnel. Hospital administrators appear to be blasé about this, preferring to function on ‘make-do’, ‘just enough’ cost-efficiencies and bottom-line ROIs, which just rankles the physicians all the more! 

This is especially so with the perennial problem of questionable quality nurses. Nurses form the ‘elegantly silent’ backbone of the hospital experience—the face-to-face encounters, the monitoring and their first contact interpretations, hence the timely and appropriate informed referral to further physician interaction, are critical in any hospitalisation experience.

Poor or inaccurate documentation or interpretation of patient features, delays in recognition of changes in vital signs or deterioration of monitored data, or failure of nursing attention, all affect patient safety and increase medical mishaps leading to poorer outcomes. However, in the eyes of many physicians, this conundrum appears to be consistently underplayed and compromised by the inactions or excuses of management.

It appears that most urban areas teeming with hospitals have severe problems with adequacy of competent staffing, particularly of good nurses. Hence the frequent movement and pinching of nurses from one centre to another contributes to discontinuity of consistent care and standards of care, that endangers patients.

But are health improvement measures just one-way regulatory or systems processes affecting the hapless physician, who just happens to be the easiest whipping boy for regulatory or administrative action? Are hospital administrators and owners exempt from the regulatory and punitive reach of the law, in order to improve safety concerns?

Would JCI and/or MSQH accreditation be sufficient to exculpate these corporate managers, who might seemingly be at odds with the complaining  or whistle-blowing physician, by sweeping the proverbial dusts under the carpet?

This appears to be addressed in some recent judicial rulings. Recently, a judge has imputed that hospital medical directors in charge would be held answerable and vicariously liable to charges of negligence when systems failure occur, particularly when these result in poor patient outcomes or deaths. An ill patient transferred in from a neighbouring hospital was left inappropriately attended to at an emergency department for many hours, and not properly triaged, resulting in gross delay in treatment, leading to her preventable demise. The entire broken process of triaging and systems of referral or management pathways would now be scrutinised for negligent care.[21]

Hopefully with this new sort of ruling, hospitals particularly private sector ones, would be more amenable to get their systems in place and not shirk behind the oft-repeated excuses of staffing shortages and unavoidable shared common experiences!

Below are two self-explanatory tables depicting the conflicting tensions that invariably exist in the dynamics of hospital practice between physicians/healthcare providers and administrators/owners.

So there must be continually evolving basic bottom-line agreements and clearer roles for doctors, administrators and/or policy makers of the private health care sector. There must be greater understanding as to the dynamics of this provider-administrator tension and conflict. Administrators and managers should explore with physician leaders on how private hospitals can best harness the intellectual potential of doctors, particularly in instilling committed leadership toward greater involvement and attention in improving patient safety. They should mutually agree upon how they can garner all-party support toward developing more inclusive patient safety and quality measures, scorecards and policies.

Conclusions… a reorientation of ethos?

Doctors in private health care settings must re-align themselves and their outlook beyond just declaiming their competence, autonomy and of course, their right to make money and make a living! We must work toward better institutional partnership, ownership and shared common identity.

But management must make greater efforts to accommodate the needs and aspirations of doctors beyond merely providing them a place to practice in peace. Similarly physicians need to become more involved and immersed in more patient-focus practice and quality-assurance system processes, to ensure high quality and appropriateness of care, amidst the changing dynamics of more stringent health policymaker oversight and greater more demanding patient expectations!

It is essential that we develop more inclusive physician-collaborators in quality and patient safety strategies to include as many, if not every one, of the healthcare provider work force—tapping into our usual nursing support staff, technicians and other allied personnel, even clerical documentation executives.

We need to get as much feedback from all stakeholders to become willing collaborators and partners in institutional policy making. Piece-meal, ad hoc, knee-jerk, disparate or confrontational approaches only derail the commitment toward better overall outcomes for all concerned.

As physicians we need to re-orientate and reformulate our professional and ethical obligations, beyond our own vested interests! We need to refocus on the patient and his or her interests, because ultimately, patients are our sine qua non or raison d’être for the practice of medicine!

Finally, it would be appropriate to conclude as Reinertsen has⁶

“We are losing our clinical autonomy in part because the public has learned that the basis for it, the full power of our scientific knowledge, is not being consistently applied for their benefit. We will not regain that autonomy by lamenting its loss, or by making shrill cries to preserve it.

“The most effective approach, the professional approach, would be to join together with our colleagues, in venues large and small, to decide on and apply the best science together, as a profession. The Zen paradox of clinical autonomy is that by giving it away to our colleagues, we gain it as a profession.”

References:

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[1] Quek DKL. Private-Public Partnership in Healthcare for Malaysia. Jan 16, 2009. http://dq-essays.blogspot.com/2009/01/private-public-partnership-in.html

[2] Khazanah Nasional Berhad. Creating Value through our Investments. http://tkr.khazanah.com.my/2012/creating-value/

[3] Chee Heng Leng. Ownership, control, and contention: Challenges for the future of healthcare in Malaysia. Soc Sc Med 2008;66:2145-2156. https://www.academia.edu/3840924/Ownership_control_and_contention_Challenges_for_the_future_of_healthcare_in_Malaysia

[4] Safurah Jaafar et al, Malaysia Health System review (Health Systems in Transition, Vol. 3 No.1, 2013)– WHO Western Pacific 2013.

[5] World Health Organization (WHO) (2011) [website]. National Health Accounts: Country Information. World Health Organization, Geneva. Accessed June 2014 [http://www.who.int/nha/country/en/index. html]

[6] IHH Healthcare Bhd. Committed to Excellence 24/7. Annual Report 2013.

[7] Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138(12):992-995.

[8] Thomas H. Gallagher, David Studdert, Wendy Levinson. Disclosing Harmful Medical Errors to Patients. N Engl J Med 2007;356:2713-9.

[9] Health care at the crossroads: strategies for improving the medical liability system and preventing patient injury. Joint Commission on Accreditation of Healthcare Organizations, 2005. (http://www.jointcommission.org/NR/rdonlyres/3F1B626C-CB65-468BA871-488D1DA66B06/0/medical_liability_exec_summary.pdf.)

[10] JCI. http://www.jointcommissioninternational.org/improve/create-effective-policies/

[11] MSQH. http://www.msqh.com.my/msqh/manual-and-guidelines

[12] Private Health Care Facilities and Services Act 1998 (Act 586). PCNB, Malaysia, 1998.

[13] Private Health Care Facilities and Services Regulations 2006 (P.U. (A) 137/2006). PCNB, Malaysia, 2006.

[14] Daniel Craviotto Jr. A Doctor’s Declaration of Independence. Wall Street Journal, April 28, 2014. http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310

[15] Ezekiel J. Emanuel, Steven D. Pearson. Physician Autonomy and Health Care Reform. JAMA, January 25, 2012 (307) 4:367-8.

[16] Thomson-Reuters. The 2011 National Physicians Survey: frustration and dismay in a time of change. http://mikemeikle.files.wordpress.com/2011/01/2011-thomson-reuters-hcplexus-national-physicians-survey.pdf. Accessed June 12, 2014.

[17] ABIM Foundation; American Board of Internal Medicine; ACP-ASIM Foundation; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.

[18] Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med 2006;354:2205-8.

[19] Richard A. Culbertson, Philip R. Lee. Medicare and Physician Autonomy. Health Care Financing Review 1996 (18) No. 2:115-130.

[20] Victor R. Fuchs, and Arnold Milstein. The $640 Billion Question — Why Does Cost-Effective Care Diffuse So Slowly?  N Engl J Med 2011; 364:1985-1987 May 26, 2011, DOI: 10.1056/NEJMp1104675

[21] Pengarah Hospital Selayang & Ors v. Ahmad Azizi Abdullah James & Ors. CLJ 2013, 3:833-842. [Civil Appeal No: W-01(IM)-388-2011] February 2012

[This is part of a Plenary Lecture entitled: “Doctors & the Hospitals they work in. Are they True Partners? Challenges of Ensuring Clinical Governance within the Confines of a Business” presented at the Association of Private Hospitals of Malaysia Conference 2014, at Sunway Pyramid Convention Centre, on 4 June 2014.]

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.