MAY 30 — In writing this article I have sought the opinion of several colleagues (both medical and non-medical) and I thank them for their advice and opinions. Well-meaning friends have advised that I should show restraint in my writings as this is meant for the general public, to keep it simple and avoid technicalities.

My wife of 40 years was blunt — she told me to get off my moral high horse and be fair and balanced in my writing.

So I have unsaddled and attempted to accommodate as much as I can without losing the initial flavour or intent of the original purpose of this project.

Let me begin by saying in all sincerity that most doctors want to do their best for their patients; we all want them to recover from their illness and suffering and return them to their homes and loved ones.

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Along the way, however, some of us forget why we chose to do medicine; the long hours, sleepless nights, the stress of looking after very ill patients hovering between life and death can get to everyone; some become cynical of the callings of this great humanitarian profession and get distracted by the financial remunerations that come with the job — we become the few bad apples that taint the sincere work that our colleagues do.

This article is thus an attempt to set right some of the misdoings in our profession. Its purpose is not sensational expose but rather to inform and educate the lay public to enable them to make educated choices in their health care.

Stents save lives, if implanted for the correct indication — in patients with unstable heart conditions, heart attacks and in those with accelerating, progressively worsening chest pains due to coronary disease — but not in patients who are stable and especially in those who are asymptomatic.

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A recent British study, though debateable, showed no symptomatic benefit in stable patients who were stented. Stents may have a small role in asymptomatic patients who have severe lesions in arteries supplying a large area of heart muscle.

I admit sometimes, decisions are hard to make — these are times when getting second and if necessary third opinions from fellow interventional cardiology colleagues will save the day.

Recent studies have shown that stents can cause trouble even years after they are implanted (“Incident Myocardial Infarction” and “Very Late Stent Thrombosis in Outpatients With Stable Coronary Artery Disease” — Journal of the American College of Cardiology Volume 69, Issue 17, May 2017 ).

Thus the decision to implant a stent in a patient carries onerous responsibilities. Besides risks inherent in stents themselves, patients are also exposed to the potential risks of bleeding with antiplatelet drugs that need to be taken as the stents heal.

The presence of stents may also prevent surgical procedures and investigations like MRI examinations. Anti-platelet agents also interfere with treatment of dengue fever — an illness endemic in our country. Thus risk versus benefit has to be carefully balanced and considered.

A middle aged lady with no risk factors (no diabetes, no hypertension, never smoked and no significant family history ) presents to her cardiologist complaining of chest pain. He does a treadmill test — she is asymptomatic but ECG changes during the test are abnormal.

The cardiologist advises that an invasive coronary angiogram be done immediately — a 50 per cent narrowing of a branch vessel is detected — the cardiologist advises that a stent be implanted immediately, the patient panics and gives her consent.

She returns a week later for her follow up — her pains are no better! An unusual scenario? Hardly — all cardiologists will have in their follow up several patients who have been similarly wronged by others, and thus have chosen to change their doctors.

So what went wrong — the error was in a suboptimal history taken by the cardiologist, careful interrogation of the patient revealed intermittent pricking chest pains aggravated by local chest wall pressure and chest wall movements, most likely costochondritis — a benign inflammation of the costochondral joints — definitely not life threatening, which no stent in the world would cure.

Due diligence by the cardiologist would have avoided the patient an unnecessary invasive procedure, major medical expenses (PTCA with implant of a single stent will set you back by about RM25K) and even more important the implant of an unnecessary foreign body into the body with its attendant risks.

Except in rare occasions, generally speaking, depending upon the area of heart muscle served, a 50 per cent coronary stenosis in a branch vessel would be considered haemodynamically insignificant — meaning it will not hinder blood flow and thus will not cause symptoms.

Special methods are currently available using fine wires to assess parameters called FFR which measure the functional significance of these lesions — this was unfortunately not carried out in this patient. So what is the root cause?

There are some doctors whose professional skills or decisions or conduct has been marred by the distractions of private medicine. The fault probably goes back to a defective educational system where ethics and character building were not adequately emphasised.

I have been reminded that a senior dean of medicine once labelled private practice as the prostitution of medicine with all its nefarious attractions. It is likely that they learnt their bad habits from their seniors and mentors who obviously failed as role models and teachers.

A senior colleague even quoted from the Bible “unless you have not sinned, do not cast the first stone” and I admit I have made my share of mistakes but I do not think I have sinned. In my book savouring the latest pictures in Playboy is not a sin!

But we must make a start to get cardiology back onto the ethical track; to do what is right and correct especially for ill informed, gullible and unsuspecting patients.

Speaking in low whispers or continuing to be the proverbial ostrich will not achieve any result. A first step has to be taken on a long journey to put it right. It is not going to be pleasant.

Reports to the MMC have to be made, with appropriate documents and evidence and the people who sit on the MMC council should have the moral fibre to chastise and reprimand their colleagues in the strongest possible terms so that they do not return to their unethical ways.

Some of us have tried. One head of department faced persecution for trying to improve the standard of practice in his department.

Concerns of the coffers should not be a priority especially in matters of health and survival of patients. Policing of doctors' practice is the responsibility of all — medical societies, hospital administration and Ministry of Health.

My colleague and National Heart Association Malaysia past president Dr Samuel Ong, when delivering the Nik Zainal memorial lecture at the association’s annual meeting last year, noted that after the New York State Department of Health threatened to withhold fees and disbursement for PTCA procedures in patients where the procedure was not indicated, the rate of PTCAs drastically dropped — thus policing if done with due diligence will show results.

Thus this is not a problem confined to Malaysia; reading the medical literature, one realises that this is an international problem.

Reading the statistics, one realises that this is not a problem confined to private hospitals but also in state sponsored institutions — thus money alone is not the only attraction, other factors are also at play here.

Medical societies also have a moral responsibility to ensure that during angioplasty conferences, real world issues are discussed and methods demonstrated; the ego of the cardiologist should not be feted by showing off a difficult technique that would not be carried out in daily practice. The aim must always be safety and good recovery of the patient.

Luckily we have good guidelines. The Appropriate Usage Criteria was penned by several colleagues led by my friends Tan Sri Robayaah Zambahari and Dr Jeyamalar Rajadurai recently and published with the blessings of the Ministry of Health. But sad to say few follow the criteria.

The public is thus warned to remain vigilant especially in the management of their health. Do not hesitate to get second opinions — it may well save your life — it is your right enshrined in law to get another opinion.

I will conclude by quoting ad verbatim the well written last paragraph in Dr Ong’s lecture.

“So, whither the heart of cardiology? I am sure cardiology will continue to advance on multiple fronts, from bench to bedside. But will this scientific and technological march forward be accompanied by integrity and compassion?

“Will our patients see just cold science and hard cash or will they feel the warm heart of medicine. Sick people may have broken hearts but are yet whole persons. They are not just hearts with appendages attached.

“The art of caring for them is not just about protocols, technologies and drugs but also about pain and suffering, fear and doubts, death and separation. A good cardiologist is one who holds science in one hand and art in the other. In the art of medicine, integrity and compassion are paramount. Integrity is about being one (integer) in our values and actions.

“Compassion literally means ‘to suffer together.’ It is the feeling that arises when you are confronted with another’s suffering and feel motivated to relieve that suffering. These traits need to be inculcated from the beginning when doctors are students, and they are certainly better caught than taught.

“So a word to us, teachers and mentors. Even as we seek to impart knowledge and skills to those who come after us, may we also be models of integrity and compassion so that we may be cardiologists with a heart and mind who are ever seeking to do what is best and right for those whom we care for.”

In conclusion, some final take home messages:

  • Coronary stents are like the proverbial two edged sword — they may cause harm if not used appropriately.

  • Cardiologists must exercise caution and spend time and effort to evaluate their patients carefully clinically prior to embarking on invasive procedures. Due diligence must be exercised. This is a moral and medical responsibility.

  • Check and balance is effective and is the responsibility of cardiology peer groups, societies, medical institutions and the ministry of health.

  • Medicine is a partnership between the patient and his or her doctor. Patients should be encouraged to get second opinions whenever necessary, for their health care.

  • Our country is mending via GE14; it is time to set cardiology on the road to recovery too.

* Dr Kannan Pasamanickam is a cardiologist at Sime Darby Medical Centre

** This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail.