become enamoured with too much care, in doling out perhaps too many ..... Have we finally come this far, where the human touch of the physician can be ...
Medical Practice under Scrutiny: How much care is too much? By Dr David KL Quek, FRCP, FNHAM, FAsCC, FACC NHAM Pulse, December 2011: 2-‐6 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.
“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.” 1
~ Susan Sontag
Healthcare issues now encapsulate some 3 to 17% of mankind’s economic activity, depending on where you are in 4,5 the globe. There is that growing conscious demand and 6 The Illness Metaphor vs. Medicalisation push towards ‘good health’ and more accessible health care. of life, and is Susan Sontag’s introspection above encapsulates this very real Health is regarded as an inherent component 7 rightfully demanded as a human right. As physicians, we must if unsettling Manichean truism about illness and health in serve as the natural guardians and advocates to ensure this, man. This was recently re-‐quoted in the frontispiece of by making every possible effort to improve universal access Siddhartha Mukherjee’s 2010 book ‘The Emperor of all Maladies’ — a Pulitzer Prize-‐winning book about cancers and and coverage for this increasingly out-‐of-‐reach ‘commodity’. the heroic battles to conquer if not to deflect cancers’ dismal At the same time we must remain conscientious that we do 2 not create ‘health’ into an unreachable ideal, which can only if inescapable trajectories and outcomes. bilk or disenfranchise the unquenchable demands and The narrative on the history and advances of cardiovascular expectations of our willing but poorly informed patients at 3 understanding and therapeutics would probably reflect a large. ∗ similar but perhaps with a more positive historiography. But Yet, as we (as doctors) embark on our furious pace of modern there has always been that tendency for physicians from time medical practice, we embrace sometimes almost blindly all immemorial to over-‐extend our professional reach and our the advances that come our way, not wanting to be left self-‐importance, as we insinuate ever deeper into society’s behind in that unrelenting race to keep up with what are new socio-‐economic web of life. With affairs of the heart, this is and trendy, in the name of progress. We readily adopt and even more pronounced! utilize whatever technological devices and drugs at our disposal, believing that most of these efforts would benefit or Sometimes, as physicians we tend to forget that illness is an innate part of man—we will always become ill at some points even cure our patients, sometimes at huge costs! But in the sum of all things, medicine does work—patients do benefit in our lives. Yet, most of us subconsciously embrace and expect its opposite—health—as a given. Perhaps we have let and perhaps arguably live longer and enjoy better quality of 8 lives. Medicine’s overarching narrative to reshape our societal
psyche into embracing a pervasively systematic but false 3 Nemesis.
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 Eventually every one of us will die, sometimes suddenly, prematurely, but frequently enough from a drawn-‐out chronic time. However, increasingly we have been reminded to look at each patient in as holistic a manner as possible—treat the ailment, which may be subtly quiescent (‘silent killer’) or which may visibly stress, depress, debilitate and occasionally whole patient, not the diagnosis, we say.
∗
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).
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,
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blood glucose and cholesterol levels are now lowered for normal acceptable ranges.
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 This necessarily implies treating more patients to achieve by incomplete snippets of ongoing if premature data by the lower and lower targets, because there have been growing very same aggressive vendors of such cutting-‐edge advances research data that show that perhaps lower is better—lesser and innovations—becoming unwitting agent provocateurs of complications, better prognoses, better outcomes, perhaps their surreptitious influence and propaganda, i.e. we become longer survival, even better quality of life. But some detractors 11 too embroiled in possible conflicts of interest. have decried such measures as examples of ‘medicalisation’ of health, calculated to exploit human vulnerabilities and Dr James Le Fanu warns that “doctors are not just doing more, 9 anxieties. but prescribing vastly more – an additional 300 million prescriptions a year, half as many again compared to just 10 By looking at the patient as a whole, multiple risk profiles and years ago.” He went on to question the rationale of this factors also imply that we treat that patient with more modern shift in medical practice: “the merits of a coronary therapies than was customary in the past. Most often this angioplasty in promptly relieving crippling chest pains of approach employs the easiest means—prescribing angina is self-‐evident, but the rationale for the majority of medications and pills—one on top of the other! This approach those 300 million extra prescriptions is very different.” He remains controversial and is not readily accepted by all. estimates that globally, annual pharmaceutical revenues have Lifestyle modification and counseling often take backseats in doubled from US$400 billion to US$800 billion (2.6 trillion our therapeutic armamentarium because these are either too 12 Ringgit) over the past 10 years! hard or time-‐consuming to carry out, too difficult to measure “This, then, is the Janus face of modern medicine, the most for results, or because they are inadequately reimbursed or visible symbol of the power of science to banish disease for not at all! 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 Risk Factors, Pre-‐disease & Injudicious Polypharmacy reveals, with great clarity, the origins and harmful Barbara Starfield et al., a pioneering advocate of primary care consequences of medicalisation – and what indeed is medicine has lamented: required to control it.” “the progressive lowering of thresholds for ‘pre-disease’, ~ James Le Fanu particularly hypertension, serum cholesterol and blood sugar… (where) risk factors are increasingly considered Perhaps we have become too indiscriminate, too as equivalent to disease… Encouraged by interests vested undiscerning, and too gullible even. We appear to have in selling more medications for ‘prevention’ and more become uncritical on what needs to be critiqued, to be medical devices for testing, the pressure for increasing critically analyzed and challenged. We have allowed possibly ‘prevention’ in clinical care directed at individuals is biased slants of information to imprint, even distort our inexorable – even though it is not well supported by impressionable minds too easily! 10 evidence in populations of patients…” We must learn to acknowledge that we might have been Alas, it is precisely this surge in preventive polypharmacy that somewhat less than judicious in deciding which are truly best has prompted so many pharmaceutical companies to for the patients in front of us! Perhaps we have become aggressively target the medical community with the current seduced by the glamour and the gloss of the pastiche of deluge of blockbuster drugs in the hope to explicitly modern innovations—new drugs and devices, new techniques ameliorate the perceived harms of concomitant risk that titillate our sense of ‘beauty’ and wonder; and perhaps factors/illness, but covertly perhaps for greater profits as that patchwork assemblage of molding plausible theories into economic enterprises extraordinaire! meaningful practices. 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
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
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mechanistic pathways, and biological systems endow upon us By the very nature of PCI being conceptually ‘simpler’ and less that sense of puissance, of control, of demigod status. invasive, cardiologists have cornered the market so to speak, so much so that our patients appear to prefer our services, There can be no denying that sometimes we may have although the actual long-‐term results may be inferior to the become enamoured with too much care, in doling out perhaps initially more disabling bypass surgery. too many unwarranted tests and therapies, which could arguably satisfy our egotistical self and enrich us personally, Most cardiologists these days appear to have become certainly more so than our patients. We fail to be our patient’s singularly coronary artery disease (CAD) experts, but not much best advocates, whose interests should really be our more, sadly. Almost every young aspirant in cardiology wishes unwritten if expected ethical compass. 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 Patients’ Interests—First and Foremost least, it seems that way. It has been well described that an injection (even if of sham medicine), surgery or any Have we failed in our duty to place our patients first and foremost, by possibly sacrificing their dignity, their interests, intervention gives greater effects or is p13erceived of as being thereby undermining their safety and long-‐term health even? more efficacious than some simple pill. 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 11 patients?
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 Yet, perhaps this statement is too harsh as an indictment to (e.g. cardiac surgeon, or heart failure expert) more capable, our dilemma as specialist healthcare givers. more adequately, or more appropriately trained than Let us return to practical considerations as we re-‐examine our ourselves? roles as cardiovascular physicians. Increasingly we have been cast as unwitting but willing diagnostic as well as gate-‐keeping Consider the recent findings of the extended follow-‐up OAT cohort that showed that delayed routine revascularization therapists all rolled into one. Some have even labeled us as during the subacute phase, gave no greater benefit. Long-‐term unremitting purveyors of ever-‐newer medical devices: clinical events were not reduced after routine PCI in stable expensive drugs, balloons, stents, pacemakers, etc. Cardiac patients with a totally occluded infarct-‐related artery, if there surgeons have rightfully questioned our objectivity, that we 14 might have unfairly usurped our unique position to sequester was no severe inducible ischemia. all manner of revascularisation therapies, particularly It is also important to note that performing such PCI in the emphasizing PCI to the detrimental exclusion of CABG. non-‐ACS setting, for patients who are symptom-‐free (silent ischemic heart disease, SIHD) just because of some ECG or Perhaps the increasing development and use of appropriateness and organizational care pathways, consensus imaging changes during stress testing would not be associated with survival benefits or even lessening of potential CV events. cardiology-‐cardiothoracic team approach, of hybrid For most scenarios of angiographic stenoses (other than procedures and global budget or diagnostic-‐related groups significant LMS and/or proximal LAD disease) the (DRGs) remuneration models, can reduce the tendency for 15 individual physician decision-‐making, which tends to bias the recommendations are Class IIB or even III. 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.
PCI versus medical therapy in stable CAD can be summarized 15 as follows: • PCI reduces the incidence of angina • PCI has not been demonstrated to improve survival in 16 stable patients 16,17 • PCI may increase the short-‐term risk of MI 18 • PCI does not lower the long-‐term risk of MI
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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 15 program that routinely: 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.
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 ( 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 23 years).
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
“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 24 high-intensity exercise.” 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 25 patients for whom supervised exercise training is warranted.
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Discussion
toward more procedures, devices and interventions than perhaps what might truly be necessary medical care, no My malaise with these newer perplexing recommendations or matter how promising or how technically beguiling these restrictions is not intended to curb or straitjacket medical or appear to be! cardiovascular practice. But, it is perhaps timely for us to seriously reconsider our own trajectory of clinical practice and This includes even pharmaceutical junkets, which invariably professionalism. encourage greater use of newer, more expensive drugs among physicians. But this is not to say that we have to revert back Are we not somewhat complicit in inventing some new into being Luddites, opposing everything that is new and entities of health ailments, i.e. increasingly medicalising good. We just have to be more circumspect, judicious, be health? What are we trying to achieve as we push the really objective and evidence-‐based! We should be imbued boundaries and contemplate expanding such concepts as pre-‐ with a healthier dose of common-‐sense skepticism! diabetes, pre-‐hypertension and lower and lower acceptable levels of serum LDL-‐cholesterol, as we tag along more The former editor of the British Medical Journal, Dr Richard biological markers such as hs-‐CRP, hs-‐TNT, BNP, etc.? Already, Smith had this to say when he reviewed the life and work of many other entities such as serum homocysteine, fibrinogen, Ivan Illich following the latter’s death in 2002 from debilitating lipoprotein (a), PSA (arguably), have fallen by the wayside of cancer: “Technology can help, but modern medicine has gone too far — launching onto a godlike battle to eradicate death, pain and bumf rather than useful reliable knowledge! sickness. In doing so, it turns people into consumers or objects, Who indeed do we serve as we trundle along with exciting if 26 destroying their capacity for health.” unproven new devices, new paradigms of interventionist procedures, as we become increasingly invasive even as we We must re-‐engage with our patients more candidly and miniaturize our techniques and devices? Does the spirit of transparently, and place them and their interests first and medical adventurism justify medicine’s push for cutting-‐edge foremost; after all truth telling is one of the universally innovation and advances? Does potential future benefits and accepted pillars of ethics and professionalism. We should ends for the many, justify the experimental risks as a means inform more openly and widely (to include risks, especially for a few and the now? material risks peculiar to this or that patient). We should also propose and discuss alternative models of therapies and What about that ‘life sentence’ of medications for life or for as lifestyle modifications, so that we allow patients to decide on long as deemed necessary? Yes we appear to have many long-‐ their own, which options to choose from and live by. This is term prognostic outcome data that implies sustained perhaps the modern expectation of patient empowerment therapies for the best effect — extending this or that survival and choice. by perhaps weeks or months, on a statistical basis. Already there is declining trust and belief in physicians. We But, how much of our patients’ lives are we interfering with have to reclaim our trust. Dr Alice Jacobs, president of the and for what quantum of greater good or longer-‐term AHA in 2005 stated that: “This issue is the erosion of trust. Lack of benefits, the possible lost opportunity costs and the inconvenience, that background intrusion into their lives? It is 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 precisely this expropriation of health that philosopher Ivan 3 public. Trust is a vital, unseen, and essential element in diagnosis, Illich had lamented. Has health become such a scarce even elusive commodity that the common man now has to “depend 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 upon the consumption of Ambrosia”? 27 all do to rebuild trust in our profession.” But perhaps more importantly, we need to reignite our “A 2005 U.S. News and World Report cover stated: ‘Who Needs medical professionalism. We must become more critical and Doctors? Your next doctor may not be an MD and you may be better discerning, as we embrace change and development. We must off.’ Have we finally come this far, where the human touch of the learn to stand back from and reappraise the increasing use of physician can be replaced by healthcare reduced to guidelines, tests, industry-‐sponsored spectacles of ‘show-‐and-‐tell’ ‘live’ 28 algorithms, procedures, and drugs?” demonstration courses. We must re-‐evaluate the allure 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 + Ambrosia — the divine potion, which gave the gods unending life. Internet or email consultations, video computer-‐assisted
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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
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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.
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