REPLYING TO STAR. "TESTING THE PATIENT"

I read with great interest and concern, your featured article entitled “ Testing the patient” in Sunday STAR 29^th May 2011. It is written from a purely business angle, with no attempt to understand the medical way to formulate a diagnosis, and also the human body and disease processes. It is so much easier, to know what should have been done when the diagnosis is finally elucidated. But when you are faced with a clinical problem, say fever, you can never know whether it is going to turn out as dengue fever, or malignant fever due to a occult cancerous process. This problem of fever may have to undergo rigorous testing before the diagnosis is made. Once the diagnosis is made, the disease process eradicated, everything is so obvious. In our fraternity, we say that hind sight is always 20 /20.

It is true that as medicine becomes more complex with many new modes of treatment, sometimes clinical test are done, not just for diagnosis but also to stage diseases, so that diseases can be better treated. Different stage of a disease may require a different approach. It is never a one size fits all.

We in the medical fraternity is also very concern about the great number of test that is sometimes done. It is true that to be comprehensive, and to exclude all medical possibilities, sometimes, test to exclude certain conditions that may present unusually, is done. For example, what appears at first as a common headache is rarely due to a brain tumour. But you and I know that brain tumours does cause headache. So brain scans are sometimes done. You may call this approach a defensive approach, or you may call this thoroughness, depending on who you wish to crucify.

What we are more concern about is test instituted routinely by private medical centers, contracturely upon doctors. Meaning that by a doctor’s contract, when he admits a patient, certain test has to be done. So even if the doctors does not order the test ( not necessary ), the staff will do it. Your spokesman from the Private Hospital group should know that, because for many years, he was party to and enforcer for that kind of contract. We are also very concern about routine test for “ Executive screening profile”. It is virtually a licence to charge whatever you wish. We have 25 year old female being subjected to a stress ECG, which to many of us has such a high incidence of false positives that it should never be done routinely.

We are very concern about insurance agents who tell their clients, that they must be admitted to hospital if they wish to claim for certain test, that usually does not require admission, say a stress ECG or a brain scan. This is adding to cost.

We are very much against insurance companies who question a medical judgement to do a test, when they are not qualified to do so. Years ago, insurance companies were staff with staff nurses to vet claims. So we have staff nurses querying doctors as to why they do certain test for certain conditions. One even had the audacity to ask why the neuro-surgeon did the cranial removal of a brain tumour through two separate incisions. Our reply was to get your medical consultant to talk to me, or reject the claim and have the patient sue the insurance. One insurance staff asked me why I did a stress test for a 52 year old lady with a grossly ischemic ECG. That is the standard of many medical insurance companies at the moment.

All these reasons never appear in your article, which seem to imply that doctors are testing patients unnecessarily, adding to cost and discomfort. It is important to note that, 1. Doctors have little to gain when more test are done in private hospital. The hospital does. For example, the doctors fee for stress ECG reporting is RM 100 when the cost of stress ECG is RM 400. Doctor’s professional fees including reporting fees for test are mandated by law. There is nothing to gain for the doctors except for a quicker and better diagnosis, to help the patient get well faster and more completely, with less sequalae. 2. For everything that a doctor does, he is accountable. Doctors have a “face” with the patient. He has to answer all queries and charges. Hospital on the other hand, has “no face”. All complaints are pass on from one station to the next, until the complainant is too fed-up to pursue. Yes, patients can complaint, and a response is forthcoming, but when, and in what form. We call that bureaucratic redtape. 3. Some test are done without the medical consultant’s knowledge, by hospital staff.

What then is the solution? Hospitals must be more accountable. “Routine test” by non-medics ( hospital staff )must stop, by law if necessary. Insurance companies must improve on their insurance models and implementation. More medical professionals must be employed to act as medical consultants to insurance companies, so that when they talk to medics, it makes sense. Doctors of course must be more judicious in their choice and need to do investigations. In an emergency ( life and death situation ), where time is of the essence to save life, he may decide quickly to go ahead, and explain the test to patient / relative later. When lives are not at stake, the doctor must explain all tests to the patient / relatives, especially if test involves cost and risk of procedure. This we are all taught to do. Patients must learn to ask about the purpose and need for a certain test, especially if a test involves cost, pain of procedure and risks. Unless, the patient is satisfy, he / she does not need to agree to the test. Of course, if patient is unhappy, that no satisfactory explanation have been given, he / she always have the recourse of complaining to the medical center ( there is a grievance mechanism in all hospitals ), the ministry of Health or the Malaysian Medical Council. We are quite well regulated. Just like all of you, we do not condone unnecessary testing., but we always know that the word unnecessary is only known when the diagnosis is known and the patient well.Doctors are not perfect, but we do try our best.

It is well for all to remember, no two patients with the same complain are the same. And remember, hind sight 20 / 20, is always better than foresight.