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The issue is that the patient wants the best care, but he is not willing to pay for it. Society does not want to pay for it. We have to balance this. 

Professor Eugene Braunwald was in Singapore to give a lecture on Updates in Hyperlipidaemia Therapy on 3 January 1997. He is the Distinguished Hersey Professor of Medicine, Harvard Medical School and Faculty Dean of Academic Programmes, Birgham Women's & Massachusetts General Hospitals. He is a prominent cardiologist and in his extensive curriculum vitae is stated that he is the co-editor of Harrison's Principles of Internal Medicine since 1966. It was with great pleasure that the SMA News managed to interview him during his short stay. 

Q. Could you tell us a bit more on your role as the co-editor of Harrisons, which is the "bible" for all medical students? 

A. I became involved in the publication since 1966 and worked on the 6th edition and we are now finishing work on the 14th edition. I was editor-in-chief of the I Ith and will be editor-in-chief of the 15th. 

Q. Over the years, there have been changes to the "bible" to make it more portable and readable; but with information so rapidly evolving, is it possible that it becomes outdated even as it is in print? 

A. Well, there is a certain amount of core information, that people need to be able to refer to, and I don't think the textbook should be the only source of information and I think your question is a very important one. It brings us to the point on how we should communicate in medicine. We are now putting the Harrisons on CD ROM, and we are producing updates twice a year, instead of waiting 4 years in between editions. I think that a combination of the written text and electronic journalism will be the way to transmit medical information. 

Q. In view of this vast amount of information available, how would you advise the present day practitioner to keep himself abreast of this? 

A. I think it is important to have a good textbook that you can refer to, but you don't read it from cover to cover. I don't advise that. I think that the general medical journals are excellent. Their quality has improved over the last 10 years and they are more user-friendly. The best general journals in internal medicine are the New England Journal, The Lancet, the JAMA, Annals of Internal Medicine and BMJ. You have to devote time, a certain number of hours every week, to read. There is no shortcut. It does not mean you have to read every article. 

Q. How about attending conferences and teaching sessions? 

A. Of course, they are relevant, but they tend to be passive learning. Passive learning is not as good as active learning. I know that if I sit in a lecture, my mind tends to wander. 

Q. But doesn't it help, when the information presented in these sessions have been pre selected from the field? 

A. Yes, I don't think you can rely on one thing alone. A text book is terrific, but it is not as current, and that is why we are playing with things like CD ROM. Journals are even more up to date but it takes a long time to read them. If the lecture is good, it is OK, but people's retention is not as good, if they are in a passive mode. It is better if you have read an article and then you hear a lecture on the same topic. One more thing is this. I tell you what I tell my students; if they have encountered an interesting patient, something they don't see everyday, that is the time to actively read about it. Read through the text book review the pathophysiology of it. 

Q. Would you advocate that the medical practitioner have clinical attachments and have hands on encounters? 

A. Absolutely. 

Q. How often would you recommend it? 

A. I think that continuity is important. It is impractical to drop what they are doing;  they can devote time to attend grand rounds in hospitals and see some patients in the clinics, give 10% of their time perhaps. 

Q. What do you think of the role of electronic communication between the individual practitioner and the hospital teaching centres? 

A. Well, I think that we are now in the intermediate phase. Ten years from now, we will be on line and you can get Harrisons everyday. Thus, it will be easy to purge all information, and we will deal only with electronic information. But we are not there yet. 

Q. Do you think that in future the medical practitioner may become irrelevant and a machine would take over the function? 

A. No. As a matter of fact, the practitioner will be much more relevant. The machine will be a tool to help him or her. But I think for most illnesses, taking a history and doing a clinical examination is all you need to do. The hands on and the doctor-patient relationship, the fears that a patient has; all these cannot be replaced by machines. CT scans, MRIs and computers can assist a doctor in his treatment and diagnosis but can in no way replace him. 

Q. It brings this then to the other point, how do you suggest maintaining health care at a manageable cost level? 

A. The first thing to do is to give good incentive to the doctor. The doctor should not be paid by the care that he delivers. For example, if you are a cardiologist, you should not make more money if you do more catheterisations. It is not that you will ill advise the patient, but the threshold of doing something expensive is lower. So I think that is the most important thing, if you are given a good salary, your incentive will be to look after the patient and not make more money, that reduces the cost of care. Secondly, I think a doctor should be able to justify, particularly if the procedure is expensive, and there should be a spot-check on the utilisation of expensive facilities and expensive drugs. And the doctor should be at some financial risk. Otherwise, it would be easy to order an infinite number of tests. The more you look, the more you find, the more you find, the more you do and get into a spiral of costs. 

Q. How do you draw the line at the patient's demand for better healthcare? 

A. It is very difficult. The issue is that the patient wants the best care, but he is not willing to pay for it. Society does not want to pay for it. We have to balance this. A good example is the over utilisation in cardiology, such as coronary bypass surgery, which costs US$25,000. There should be a standard requirement for such surgery to be performed. In the US, we are developing practice guidelines for expensive procedures. These guidelines are not absolute laws but if you go beyond them, you will be subject to peer review. There are several issues mixed up together. The most important being the need to realign the doctor's incentive. In the US, I know that if a doctor gets paid more by doing more, the expenses of care will go up, and that does not necessarily mean that the quality of care increases correspondingly. A good example would be the healthcare cost between Canada and the US. The cost of care in Canada is about 50% of the cost in US, and the life expectancy is 1 year longer! 

Q. What else can we learn from your experience in the US? 

A. Of course, one of the things we learn is that the pendulum swings too far. In the effort to reduce cost in the US, some people are being deprived of proper healthcare. There is a law passed, just last week by the government which states that doctors cannot be rewarded for withholding care. In the past, the doctor was rewarded for doing more. For example, a cardiologist will get $500 for each cardiac catheterisation he does; that is a bad incentive to decide who needs a catheterisation. However, the pendulum will swing the other way if you tell the cardiologist that the fewer patients he catheterises, the more money he will make. The government is trying to reduce cost but this should not be done at the expense of our patients. 

Q. Does the medical faculty support these views? 

A. Many doctors in the US are very unhappy at the moment. We have a system in transition; it is very unstable presently. In the US, the system is largely driven by specialists and specialists by definition perform expensive procedures. With this law to cut down cost of care, the generalists will be taking over and the specialists will be losing their jobs. As such, there is a tremendous amount of discouragement. The doctors have lost control of the system to the insurance companies and the payers. 

Q. Will this general unhappiness deprive the patients of good healthcare? 

A. This will not happen. Healthcare is so important to the Americans. They have very different personalities compared to the British. The Canadians are somewhere in the middle. If you tell a patient in the UK who has renal failure, that the National Health Service will not put you on dialysis, he will say. "Yes, sir". If you say this to the American, he will laugh at you; Americans cannot accept anything less than what they are entitled. The trick is to prevent the spiral of costs and at the same time not depriving patients with the best medical care. I think we can do it, as there is a lot of fat in the system. A lot of money is being spent unnecessarily and we can do a better job, without endangering care. For example, stress testing for chronic stable angina. There are many cardiologists who do an annual stress test for such cases. There is no proof that it helps. The only proof is that it makes the cardiologist richer. If somebody can say that the standard of care does not require a stress test once a year, and if that is sanctioned, but you, as a patient, do not agree and still insists on a stress test, you can pay for it. What the insurance company and the government is willing to pay for is perfectly good care; if you want more, you should pay for it. 

Q. What about the rising cost of drugs, how do you suggest dealing with it, as you are on the advisory boards of several drug companies? 

A. It is the same way as for procedures. Drugs should not be used unnecessarily and there should be certain criteria, and the drug should only be given when there is evidence to support its use. Ultimately, it boils down to the practice of evidence-based-medicine. We should not base our treatment on intuition. There should be solid evidence. I think that drugs are expensive but in the US, they amount to 6% of the total cost of medical care. I would say that among the things we do, that is not the top of the list. If we cut the use of drugs by 20%, we will reduce the cost of medical care by 1.5%. 

      Reported by Dr Tan Hooi Hwa