Letters to the Editor
TOWARDS NEW MEDICINE
Surreptitiously, amoeboid changes have taken place in the last 100 years since Western medicine has organised itself into a systematic body of knowledge and skills. What lies ahead in the coming century?
The long shadow of non-communicable diseases
The advent of effective medical care, particularly, the ability to deal with infections have reduced morbidity and mortality. Coupled with public health measures on hygiene, sanitation and preventive health like immunisation and adequate nutrition, the life expectancy has increased from 30 to 40 years in the middle ages to 80 - 90 in the Western developed countries today. This is a remarkable achievement.
With the curtailment of infectious diseases, non communicable diseases like ischaemic heart disease, strokes and cancer have come in to take the top places as causes of death vacated by the infectious diseases, diarrhoeal diseases, pneumonias and pulmonary tuberculosis. The non-communicable diseases have longer shadows than the infectious ones in terms of health care delivery costs and salvageability. One either die from an infection or recover and survive, often with as good health as before. With heart attacks, strokes and cancer, life is more likely to be never the same again. Of course, there are exceptions with some diseases of antiquity, such as the ravages of tuberculous meningitis or poliomyelitis. By and large, modern medicine has substituted the more easily resolved problems with less easily resolved ones with longer shadows of morbidity and with it continuing need to spend for health care. More than ever, we need cost-effective care.
New paradigm needed for old people
Surreptiously, we are dealing with people at an age that we have not dealt before in increasing numbers namely, older and older people. Now, old people are not the same as young people on which most of modern medicine have based its experience.
A couple of examples will illustrate this amoeboid change. For instance,
we are all taught about the need to put all symptoms into one diagnosis
- the so-called Oram's razor. Try that with the elderly patient. One is
likely to be wrong. These multiple diseases are likely to interact with
one another. What is the clinical significance of this? Apart from the
dilemma and the need to decide which is the one that needs management and
which can be left alone, there is the revelation that
small improvements in many of the problems can result in large improvements even if the conditions are not all curable. Take dementia for example. It is not curable. But the confusion is made worse by chest infection, anaemia and new environment. Much then can be done to improve the mental status of that demented patient by timely attention to the chest infection, the anaemia and making sure that there are sufficient links with that person with what is familiar in his environment
Another observation is that in the elderly, the symptoms often do not refer to the system that is the seat of disease. Take thyrotoxicosis for example. In the young patient, the classical triad of proptosis, tremors and thyroid enlargement is a familiar paradigm to us all. In the elderly, the same condition manifests as what is called apathetic thyrotoxicosis - heart failure, lethargy and weakness or even confusion. Pursuing the heart will not find the diagnosis! How can this be explained as a paradigm? This is the paradigm of "homeostenosis", a concept described by Professor Neil Resnick from Harvard. This is described in Harrison's Textbook of Internal Medicine in its 1994 edition. In a gist, the body systems age surreptitiously from about 30 years onwards. What happens is the loss of functional reserve. The organs systems lose their functional reserves at different rates in the same person and in different persons, the same organ system may lose its functional reserve at different rates. This loss of functional reserve is an amoeboid change and the elderly is able to function normally but he is less likely to be able to withstand any stress that threatens his homeostasis. This is the idea behind the word "homeostenosis". Thus, the hyperthyroid state in the example cited in the elderly person above may stretch the limits of functional reserve of the cardiovascular system before it reaches the limits of the other systems. The elderly person then manifests his thyrotoxic state as heart failure. In the young person, all systems have large functional reserves so the organ system with the least reserve will be that of the seat of disease namely, the neck swelling. The proptosis and tremors help to pinpoint the thyrotoxic state. What is the clinical significance of this? Unless all doctors are aware that the elderly can present "atypically", wrong diagnosis will be made. Indeed, in the elderly, confusion and incontinence may well be the common manifestations of many serious problems e.g. chest infection. To look for an answer in the neurological system or in the urinary tract will be futile if not dangerous, to say the least.
Changing social regard for the doctor
Another amoeboid change is the changing social regard for the doctor from saint to shopkeeper. This causes tension between the doctor and the patient. The patient values the ability to buy what he wants more than accepting what the doctor feels is good for him. He may even doubt or suspect his doctor's good intentions. This of course can be a culture shock to the doctor. The doctor must not surrender and degenerate into a businessman.
The subspecialisation trend that started with the 1960s appears to have
reached a turning point. The negative impact of fragmentation of care is
beginning to be jarring. Suspecialisation is likely to lead to submaximisation
of health goals and to train doctors who are myopic and incomplete, particularly
if they are not exposed to a stint of general work in the early part of
their specialised training. Operationally, subspecialisation consumes health
manpower numbers particularly if every subspecialty wants to subsist on
its own. This may in part account for the short fall of doctor manpower.
Professionally, posting to subspecialty units may not meet the training
needs and satisfaction of the young doctor in training. To the patient,
fragmentation of his body into body parts often leave much to be desired.
There is one more drawback. With the multiple system disorders that we
will be encountering in the older population, subspecialisation can be
a problem. As was pointed out earlier, old people present with symptoms
that do not reflect the system that is diseased.
The solution appears to turn back to general departments again. Certainly, the Americans have discovered the wisdom of this and one needs to read current debate in its journals to appreciate this. This is something for health policy makers to seriously consider.
Empower general practice
General practice too has its amoeboid changes. Today, patients are discharged
earlier home and often to their family doctors. Also, with the fragmentation
of care by the subspecialty hospital system, more than ever there is a
need for a co-ordinator of care. Professors Nigel Stott and Harvard Davis
from UK wrote about the potential in each primary care consultation in
a paper in the Journal of RCGP (J RCGP, Apr 1979:201). They noted that
the potential of the consultation to be in 4 areas: (A) management of presenting
problems (B) modification of help seeking behaviour e.g. dissuading patient
with a clinical viral infection from wanting antibiotics, (C) management
problems, and (D) opportunistic health promotion.
For doctors to be able to practise beyond area (A), time is needed to raise, discuss and explain the issues in areas (B), (C), and (D). The desired consultation time for general practice has moved from 6 minutes to 10 minutes for the UK setting. As patients become empowered to participate in health care, more time may be needed in the consultation.
There is thus a need for doctors to gear up to the ameoboid changes of the patient's expectations and societal demands. Singapore has developed its family medicine programme. To be effective, the training programme needs to reach out to all doctors in practice. This will require a critical mass of practicing family medicine teachers in and out of the University. For the GP to remain relevant, there must a re-think of what the GP community sees as encroachment of its turf. Restructured hospitals are setting up clinics in the community. With the unequal strength, they are likely to prevail. In the long run it can only erode the position of the GP. We end up with the specialists trying to do what the GP should be doing. This cannot be cost effective.
Make managed care win-win
Managed care is a confusing label to mean different kinds of financial arrangements and cost containment. There are basically three principles, namely, the agreement to (1) deliver specified services for (2) a defined sum of money called the capitation, and the doctor now takes on (3) varying degree of risk in allocating resources for the patient. For it to work there are the following big things to be satisfied: (a) the capitation must be enough for the doctor to provide the specified level of care, (b) the patient and doctor must be clear the level of care to be provided, and (c) it needs to be an open system. The AIA Mediguard scheme for instance has increased its consultation fee from $8.50 to $15.00 over the past year to pay doctors at a more realistic level: this is a step in the right direction. Patients may be used to expensive drugs when a more cost effective one may do as well. Of course, like all things, there are the outliers – the exceptions. So the system must be able to cater for the these. At the bottom of it all, for managed care to work there must be a mutual trust and support between the managed care provider (eg NTUC, AIA), the doctor and the patient. There is a need to teach everyone that managed care must not degenerate into a system where the three parties try to take advantage of one another. It must be a win-win situation.
We can ignore the changing world and practise medicine that will be increasingly irrelevant to people and disatisfying to ourselves. We can make changes towards the new medicine of the twenty-first century. The choice is ours.