Recently, there was some debate in the local press regarding the need for marathon runners to submit letters from their doctors, certifying fitness to participate.
I don't have a copy of the Straits Times article, but a Google search produced this statement on NTUC's website.
I'd like to highlight the following comment:
"While a medical certification does not guarantee that medical emergencies would not happen during a run, we believe that the doctor would be best placed to screen and advise the would-be participant on whether he is fit enough to do a physically demanding run."
I have a few burning questions:
1) Can any doctor - including GPs - write this potentially incriminating letter, or are only "experts", i.e. cardiologists, allowed to do so?
2) What are the criteria for certifying someone "fit enough to do a physically demanding run"? A normal general medical examination? A normal ECG? A negative treadmill stress test / CT angiogram? Perhaps a normal coronary angiogram ( also fraught with its own risks, and hardly inexpensive )?
3) What are the predictive values of negative cardiac stress tests / imaging studies? Literature has shown that no investigation - not even a coronary angiogram ( considered the gold standard in detecting coronary artery disease ) - is 100% accurate in predicting future adverse events.
Meaning: You may have a completely normal coronary angiogram, and still die from a heart attack shortly after that.
There's also a significant number of people with undiagnosed cardiac disease whose very first presentation comes in the form of catastrophic events - i.e. massive heart attacks, sudden deaths - with no preceding warning signs or symptoms whatsoever.
These are the same people who may exercise regularly without difficulty, but develop problems under severe duress - that's right, when pushing themselves too hard during marathons.
4) Did NTUC bother to consult any experts before implementing this questionable protocol?
5) What are the implications if someone who's certified fit by his / her doctor kicks the bucket during the run? Will the family decide to sue the physician for negligence? How will the SMC respond?
A medical expert from the U.S., who specializes in emergency cardiac care, recently visited Singapore and delivered a series of excellent lectures on the dilemma faced by doctors who manage patients with possible underlying cardiac disease. A couple of interesting - and rather alarming - anecdotes he shared include:
1) A 12-year-old who suffered an actual heart attack, caused by vasospasm of the coronary arteries, and
2) An adult male who dramatically collapsed at the door of a hospital, just after a myocardial perfusion scan was performed and found to be NEGATIVE. In fact, the poor chap was found clutching the normal report in his hand as doctors resuscitated him.
True stories.
Let's face it - a doctor's letter is woefully insufficient, designed only to protect the organizers, not the participants. It instils runners with over-confidence, and may even result in more deaths if they think it's okay to push themselves beyond safe limits.
Is there anything wrong with signing declaration and indemnity forms?
Your comments, please.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.
It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble."
(full article here)
An interesting article in Medscape tells us something which most doctors already know: patient satisfaction does not always equate to quality healthcare - in fact, if this study is correct, the most satisfied patients are also the ones who "have the highest mortality rate and the highest hospital admission and healthcare expenditure rates".
In case you can't access the article, here are some abstracts:
"[A]n overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes," write Joshua J. Fenton...
The prospective cohort study followed-up 51,946 respondents to the 2000 through 2007 Medical Expenditure Panel Survey (MEPS) and included 2 consecutive annual surveys for each patient. ... Mortality outcomes during a mean follow-up of 3.9 years were available for a subset of 36,428 respondents.
Patient satisfaction was assessed with the Consumer Assessment of Health Plans Survey; specifically, with 4 items pertaining to physician communication (which is strongly correlated with global satisfaction) and a fifth item that allowed patients to rate their care from all physicians and healthcare providers.
After adjusting for sociodemographics, health behaviors, healthcare access, propensity to use healthcare, and health status, the authors determined that the odds of any ED visit were lower among patients in the more satisfied quartiles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.84 - 1.00; P = .06), whereas the odds of inpatient admission were higher among the most satisfied patients (aOR, 1.12; 95% CI, 1.02 - 1.23; P = .02).Similarly, patients who were the most satisfied had 8.8% more health expenditures (95% CI, 1.6% - 16.6%; P = .02) in the second year, as well as 9.1% more drug expenditures (95% CI, 2.3% - 16.4%; P = .01) and a 26% greater mortality risk (adjusted hazard ratio, 1.26; 95% CI, 1.05 - 1.53; P = .02), compared with patients who were least satisfied.
...
... the authors... suggest a possible explanation for the findings.
"Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services," they write, adding that "discretionary services may lead to iatrogenic harm via overtreatment, labeling, or other causal pathways."
"The authors infer that efforts to cater to patient satisfaction may be ill guided," writes Brenda Sirovich, MD... "There is, however, reason to question the validity of the inference," she continued. "[T]he likelihood of an unmeasured confounder remains high. One nomination is that a patient's strong sense of connection to the health care system, related perhaps to (unmeasured) vulnerability or frailty, might predict more satisfaction, hospitalization, and death.
"And yet, the inference is entirely believable — and cause for concern," she adds.
"Practicing physicians have learned — from reimbursement systems, the medical liability environment, and clinical performance scorekeepers — that they will be rewarded for excess and penalized if they risk not doing enough.... It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."
The authors of this blog will not be surprised at all by these findings - in fact, some have warned against such a phenomenon. Fact is, healthcare is a confidence goods, and what you want (or think you want), what makes you feel good, is oftentimes not what *is* good for you.
Until patients and payers (the "scorekeepers") alike wise up to the fact that it is not the criteria they set but the ones the clinicians set which are likely to have real health outcome significance, and until they are willing to incentivise clinicians for doing what the clinicians *know* and not they (the "customers") *think* is right, the situation will persist.
[ FYI, the title of this post is a playful tribute to the National Museum's current Impressionist painting exhibit. ]
Yes, dear readers, Singapore MD is attempting to resurrect itself from a 6-month-long slumber.
And no, our silence is not the result of The Powers That Be shutting us down. That usually entails an actual deletion of the blog, which clearly hasn't occurred here.
Still, one requires some form of inspiration in order to keep a blog running, and I found mine today.
Ironically, thanks to the MOH, muah-ha-ha-ha-ha... :)
A fellow colleague who worked the afternoon shift in the A&E yesterday described a bizarre phone conversation with someone who identified himself as part of the MOH administration's $$$ department. ( p.s. The symbols $$$ were chosen semi-randomly. )
Mr. $$$ asked what our waiting times were like, because he was contemplating arranging for our department to "help see Hospital X's A&E patients". Hospital X being another public institution belonging to the same cluster, but located in another corner of the island, i.e. far far away.
When my friend answered the call, she was up to her neck in cases, with patient trolleys crammed into every available nook, including the corridor just outside the P2 area. She very wisely told Mr. $$$ to speak to our HOD, after which she didn't hear from him again.
Here're a few burning questions for Mr. $$$ and/or the MOH:
1) Why didn't the query go through "proper channels" - i.e. boss to boss? Who in the world is this mysterious Mr. $$$, and why did he call the busy senior doctor on duty, when he should have called an administrative staff ( e.g. our HOD, or at the very least, department manager ) instead?
2) Shouldn't our hospital's own Powers That Be be consulted as well? Shunting A&E patients from one place to another doesn't isolate the problem to the A&E. What if they need admission? Surgery? High dependency or intensive care management? Do we have the capacity to accomodate transfers when we're already bursting at the seams?
3) Does the MOH really think waiting times accurately reflect an A&E's ability to handle patient loads? Short waiting times don't equal low attendances. Perhaps the turnover rate is high because our doctors are pushing themselves to the limit, skipping meals and toilet breaks in order to clear the queues? Most patients who have been seen don't leave the department quickly either. They hang around waiting for test results, specialist consults, procedures, admissions, and the A&E doctors who first attended to them also need to stop their queues frequently for reviews.
Plus, the limited space poses a huge problem for those in the P2 / critical care area. Such cases are usually seen within an hour, but once the observation ward fills up - trust me, this happens daily - the trolleys have nowhere to go, and walking routes become non-existent.
4) What is the exact reason Mr. $$$ feels compelled to ask us to help Hospital X? What is the casemix of the backlog there? P3 walkers, P2 trolleys or P1 sickies? If it's the first, make them wait! If the second or third, redistribute your MOs and make the P3 cases wait even longer ( or just tell them to see their GPs / polyclinics if their complaints are minor ). Or how about sourcing for ward MOs to come down and help? Short of a mini-mass casualty or worse, diversion should be considered the last resort.
MOH and our cluster / hospital's Powers That Be, for your attention please.
