Published on 8 May 2023Over-investigation may harm the patient and burden our healthcare system
Professor Joseph Sung
Dean, Lee Kong Chian School of Medicine
I have been practising clinical medicine in Singapore for almost two years now. It struck me that some of our young clinicians are too quick to book CT/MRI, endoscopy, a suite of blood tests and sometimes even invasive procedures upon seeing the first signs of malady in our patients. When perhaps it is best to listen closely to the patients’ complaints, conduct a physical examination meticulously and look carefully into their charts to really understand what they are going through.
A middle-aged lady was found incidentally to have some cystic structure in the right lobe of her liver. Within minutes in the clinic, she was booked for a tri-phasic CT scan to rule out hepatocellular carcinoma. A man in his mid 40’s presented with dyspepsia for years entered the clinic. There was no sign of anemia, no weight loss or dysphagia. Patient was offered a second-look gastroscopy within 12 months. Yet another gentleman complained of diarrhea and abdominal cramps, which usually came in the morning and as an intestinal rush after eating. He was offered colonoscopy before stool culture and test of occult blood. A woman diagnosed to have fibroid of the uterus was sent for ultrasound (second time in one year) to confirm the lesion is benign. I have seen MRI (or MRCP) ordered for a mild elevation of liver enzyme even before he was checked for stigmata of chronic liver disease. In some clinics, auto-antibody, thyroid function test, cancer markers (e.g. CA 125, CA 19.9) are booked almost as a routine for a variety of symptoms.
I ask myself, are these tests necessary? Are we offering our patients good service, or are we doing things mechanically, like a routine? Would these tests solve the patients’ problems or would they cause more worry and trouble, such as producing false positive results requiring further investigations? Would colonoscopy or other invasive procedures lead to complications or cause harm to the advance-aged patients? Could this liberal ordering of expensive tests and investigations be one reason why our healthcare budget is going through the ceiling with little marked improvement in the health outcomes of the population? Finally, are our young graduates from medical schools using their clinical skills and exercising their professional discretion, and if not, why do we still need to teach history taking and physical examination in the medical curriculum?
Last year, Health Minister Ong Ye Kung had pointed to the ageing of our population and this is driving healthcare cost increases . Government healthcare expenditure tripled over the last 10 years, and is set to triple in the next decade. To that end, we need to relook at the way we are sending patients for procedures and tests.
I appreciate our young doctors spending hours and hours at night to review the chart of patients that they are going to see the next day and preparing to order “necessary” tests before seeing patients. Isn’t that putting the cart before the horse? Asking the right questions, hearing intently the complaints of our patients, putting our hands on their abdomen and listening to their heart sounds and breathing, these are the basis for good medicine. If we lose these steps in our consultation at the clinic; if we focus on typing the “clinical findings” in the electronic medical record; if we spend all the time on the computer monitor and not get a brief look of our patient’s worried face, where is the humanity in Medicine?
I understand that we don’t want to miss a serious diagnosis such as an occult malignancy, an insidious deterioration of the liver or kidney functions, a foetus with abnormality undetected until after birth, or missing anything that could lead to medical-legal consequences. Yet, there are numerous guidelines and consensus out there to direct the most appropriate action and the right investigation to reach a diagnosis. These guidelines are drawn up by the most experienced clinicians and authoritative experts, sponsored by professional societies around the world based on evidence that is so richly displayed in the literature. If we follow these guidelines, and still miss one or two cases (out of thousands or millions) of diagnoses, our action should be defendable. Besides, as a senior in our specialty, we should guide, support and advise our junior doctors when and what we should do when it comes to difficult decisions.
I am perplexed that after spending so much time teaching and training our medical students and young doctors the right way to perform physical examinations, they are not using these skills well in their daily practice. I have seen palpation of the abdomen like dancing fingers on the belly. I have seen doctors listening to the heart and chest for murmurs and abnormal breath sounds with the stethoscope placed on the shirts of the patients. As an examiner for MBBS finals and MRCP PACES for many years, I am perturbed that we are teaching people how to ‘cook’, but many opt for fast-food and order something that does not require their hard-earned skills. All those hours of teaching and examining going to waste.
This blog is not meant to point fingers at anyone, especially not the junior doctors. Besides venting some of my frustrations, this is trying to point out that the art of Medicine should be maintained. The art of communication between doctors and patients, the art of choosing the right steps in diagnosis and assessment instead of taking a short cut for everything, the art of practising evidence-based Medicine using clinical judgement at the same time. As senior clinicians in hospitals and clinics, we should support our juniors to do the right thing, and not to do just about everything. As trainers and educators in Medicine, we should emphasise that Medicine is both an art as well as science. As leaders in hospital and healthcare service, we should prepare to stand behind our young doctors when they practise evidence-based clinical judgement.
If we are doing everything routinely and mechanically, without looking at individual needs, we are certainly no better than AI and robots. In that case, we should be worried that one day, we will indeed be replaced by AI and robots.
 Speech at the Ministry of Health Committee of Supply Debate 2022 https://www.moh.gov.sg/news-highlights/details/speech-by-mr-ong-ye-kung-minister-for-health-at-the-ministry-of-health-committee-of-supply-debate-2022