Money?

I thought it was timely that this article came out in the Star.

Many complain of having to pay for unnecessary tests

PETALING JAYA: A retiree seeking treatment at a private hospital was asked to undergo a blood test, X-ray and an ultrasound therapy. He was referred to three specialists an orthopaedic surgeon, a physician and a nephrologist and was admitted for three days. He had gone to the doctor for his gout.
The retiree, who has no medical insurance, claimed he was
eventually discharged with some painkillers and slapped with a RM2,700 bill.

Timely, as I recently became somewhat disillusioned by an incident involving a private hospital. Someone I know recently underwent evaluation for exertional chest discomfort in a private hospital. Now, I can't claim to be a cardiologist as my subspecialty lies in another area, though I am board-certified in internal medicine, and do try to stay up to date with the current guidelines. And I was surprised, that without even recommending something like a stress test, the cardiologist provided two options: a coronary CT scan, or an angiogram. In addition, he ordered a panel of blood tests including VDRL, hepatitis screen, CEA and alpha-fetoprotein.

Now, this confuses me. While many would agree the cardiac CT shows uch promise as a screening tool, all it would show is presence of coronary calcium and plaque; it gives little information (unless the amount of narrowing is unequivocally significant) on whether the calcium you're seeing on the scan is indeed causing ischemia and hence the symptoms. And an angiogram, on the other hand, was like pulling out the big gun, which is invasive and itself may cause an MI and death in rare causes, to work up a hunch.

Perhaps I'm not qualified to comment. Perhaps it's because I'm not a cardiologist, much less a practitioner in Malaysia where systems differ, but here, the first thing one ought to do is to test the hypothesis that the symptoms are indeed angina, from a lack of oxygen to the heart muscle that is accentuated by exercise. Depending on level of suspicion, and patient variables, this may be as simple as an exercise EKG, stress echocardiogram, or one of the many nuclear stress tests. And if things are suspicious, perhaps the angiogram would then be offered. The CT itself is more of a screen (arguably for the rich) and doesn't tell you much unless it's totally clean. In other words, the test has a pretty good negative predictive value. However this would be rare in the older population where you're bound to find coronary calcium in quite a number of patients and you don't really know if this is the cause of the symptoms. Some studies have found a positive predictive value of only 38% with the MSCT coronary angiography with the 64-row CT scanner.

Thankfully, in this case, the CT was negative and so we could lay the matter to rest. Despite that, I could not understand why this cardiologist recommended Clopidogrel, and switched his statin medication from a cheap generic to a nongeneric brand when his LDL ('bad cholesterol') was 69 mg/dL, with his HDL ('good' cholesterol') being even higher at 73 mg/dL. In my patients, arguably many would be happy with an LDL of 130 mg/dL, or less than 100 mg/dL if you have diabetes, or even if you had vascular disease, less than70 mg/dL.

So, maybe it's an assumption on my part, but the only conclusion that I can come up with, is that this was purely financially driven. And no, I'm not accusing all physicians of all private hospitals of being greedy, but for some of them, you do wonder.

As doctors, yes I admit we have to make some money. We have families to feed, mortgage, loans and maybe even some to spend on 'toys'. Like any occupation, making money is a necessity though in doctors' cases the patient-doctor relationship and sacred trust is a bonus. It's a priviledge that another human being lets you look (somethings literally!) into them, and to share every intimate part of their health with you. You look to the doctor and you trust that he has your best health interest in mind. It's a leap of faith.
But when you get the sense that the doctor sitting across the table is suggesting certain testing based primarily on financial motives, then it really leaves a bad taste in the mouth.