“Make sure you shop around before deciding, OK?”

Huh? A new concept in health tourism? Not really.

Mr X had gallbladder disease and consulted Dr K. After appropriate tests, Dr K explained the management options and recommended surgery to remove the gallbladder. Mr X left and after 5 days returned to Dr K for surgery. In the intervening 5 days, Mr X had visited another surgeon who performed further tests and said there was nothing wrong with the gallbladder. While feeling relieved to be told his gallbladder was blameless, Mr X was still unsure and visited another doctor. The physician told Mr X he definitely had gallbladder disease and needed surgery. After surgery by Dr K, the pathology of the removed gallbladder confirmed that it was diseased. Dr K asked Mr X and family why they had seen two other doctors before coming back for surgery.  They told Dr K that “in our country you do not trust the first doctor you see, you always see a few doctors and verify that the majority of the doctors are telling you the same thing.”  Personally, I am saddened by this.

The doctor-patient relationship is based on trust. The patient must trust that his doctor is truthful in his diagnosis and management recommendations. In an environment where there are doubts about the impartiality of the information / recommendations given, this trust is broken. The patient and family are thus conditioned to distrust all doctors in and outside their country.

In both public and private settings, a doctor’s practice can be influenced by many factors. In a public institution, the desire to try out a new treatment modality may ‘induce’ the doctor to recommend this over the conventional approach. The pressure to recruit patients for a study can influence the way in which a doctor presents and discusses treatment options. In private practice, the doctor may be motivated to over-investigate or ‘expand’ the indications for treating a condition for personal gain.

In order for the public to have implicit trust in the health care system, the industry must be regulated to a high standard. The existence of stringent rules and regulations within a health institution will reassure the public. A transparent, strong and impartial professional body will give confidence to the public that the conduct and practice of the doctors are tightly controlled. Those who stray will be brought to account.

While the above will help to ensure ethical and good heath care and restore trust in the doctor-patient relationship, to me, the most reliable gatekeeper for achieving this is still the doctor himself. If the doctor practices with scruples and principles, the patient can rest assured that he will be properly looked after.

]]> http://www.ckleow.md/news/2011/12/trust/feed/ http://www.ckleow.md/news/2011/08/metabolic-syndrome-hepatobiliary-cancer/ http://www.ckleow.md/news/2011/08/metabolic-syndrome-hepatobiliary-cancer/#comments Sun, 07 Aug 2011 03:50:36 +0000 Dr. CK Leow http://www.ckleow.md/news/?p=434 In the United States the incidence of hepatocellular carcinoma (HCC, primary liver cancer) and intrahepatic cholangiocarcinoma (ICC, bile duct cancer) is increasing. While metabolic syndrome is recognized as a risk factor for HCC and is postulated as one for ICC, the exact risk in the population has not been quantified.

Using the Surveillance, Epidemiology and End Results (SEER) – Medicare database, researchers from the National Cancer Institute in USA examined the association between metabolic syndrome and the development of HCC and ICC in the US population (Hepatology 2011; 54: 463 – 471). They found 3649 HCC cases, 743 ICC cases and 195,953 comparison persons meeting the study criteria. The study found that metabolic syndrome was significantly more common among individuals who developed HCC (37.1%) and ICC (29.7%) than among the comparison, non-cancer group (17.1%, p < 0.0001). This means that, if you have metabolic syndrome, the risk of developing HCC is significantly increased by 113%, while the risk of developing ICC is significantly increased by 56% (p < 0.0001).

People with metabolic syndrome tend to be overweight or obese. With this habitus they are at increased risk of developing steatosis (fatty liver), steatohepatitis (inflammation within a fatty liver), diabetes mellitus, heart disease, hypertension, joint problems and certain type of cancers, such as colorectal, endometrial, breast and hepatocellular carcinoma.

In my practice the following scenario during a consultation is common:-

Mr X, having just been told that he has to eat healthily, reduce his food portion, partake in daily exercise and gradually reduce weight for his fatty liver,  would retort ‘Just give me some pills!’. After explaining that at present there are no magic pills for treating fatty liver, Mr X  looks incredulously at me, thinking ‘You have to be kidding me or you must be a useless doctor’.

Indeed many patients do not believe that there is no approved and effective medicine at the moment for treating fatty liver worldwide. If you control your food intake, you can control your weight. If you don’t get overweight or obese, your risk of developing metabolic syndrome is greatly reduced. It’s up to you!

HCC is a known and dreaded complication for a chronic HBV carrier. HCC usually occurs on a background of liver cirrhosis (hardened liver) but it can occur in a relatively normal liver too. HBV carriers have an increased risk of developing HCC because of the virus itself and also because of the development of liver cirrhosis. Once HCC is diagnosed, the only curative treatment is complete surgical removal of the cancer. Despite a curative liver resection, these patients still have a chance of cancer recurrence because of the underlying HBV infection and / or liver cirrhosis. At present there is no effective treatment to reverse liver cirrhosis. However, we do have drugs to suppress the virus.

A recent study from Hong Kong University examined the impact of anti-viral therapy on the overall and disease-free survival of chronic HBV carriers who had had curative liver resection for HCC (Arch Surg 2011; 146: 675 -681). Between 01/09/2003 and 31/12/2007, 136 patients had major liver resection for HBV-related HCC. Of these, 42 patients received anti-viral therapy (treatment group) and 94 patients did not (control group). The overall and disease-free survival rates of the treatment group were significantly better than those of the control group. The 1-, 3- and 5-year overall survival rates in the treatment group were 88.1%, 79.1% and 71.2% compared to 76.5%, 47.5% and 43.5%, respectively, in the control group (p=0.005). The 1-, 3- and 5-year disease-free survival rates in the treatment group were 66.5%, 51.4% and 51.4% compared to 48.9%, 33.8% and 33.8%, respectively, in the control group (p=0.05). Sub-group analysis showed that anti-viral therapy conferred significant survival benefit in patients with stage I and II HCCs without major venous invasion.

Most HCC patients who have had curative liver surgery die from complications from the underlying liver cirrhosis or from cancer recurrence. There is evidence to suggest that suppressing the virus can reduce the risk of cancer recurrence and may retard the onset or progression of cirrhosis related complications. Some patients like to react to an illness appearing again while others would rather prevent an illness from recurring. Are you the reactionary type or the preventive type? I know what I would rather be. Do you?

Researchers at University of Illinois at Urbana-Champaign performed a meta-analysis on 17 published studies examining the relationship between frequency of shared family mealtimes and nutritional health in children and adolescents (Pediatrics, published online May 2011; doi: 10.1542/peds.2010-1440). A total of 182,836 children and adolescents (mean sample age: 2.8 – 17.3 years) were studied. Children and adolescents who share ≥ 3 family meals / week are more likely to be of normal weight, have healthier dietary and eating patterns and are less likely to engage in disordered eating. The benefits of sharing ≥ 3 family meals expressed in percentage terms are – the odds for being overweight, eating unhealthy foods and disordered eating are reduced by 12%, 20% and 35%. Moreover the chance of the children and adolescents eating healthy foods is increased by 24%.

Having a sit down family meal provides a focal point for the whole family to slow down and catch up with each other’s activities for the day. Parents can ensure that the children have at least one decent nutritious meal a day. At the table, children get a chance to air their grievances about school and boast about their achievements. Parents can glean a lot of information on a child’s behaviour or mood from his / her interaction at the table. The benefits of a shared family meal are innumerable and known to our ancestors / elders. While we do not need scientific proof of the benefits, the study above certainly helps to remind us about the importance of having family meals.

Let us take colonoscopy as an example. Colonoscopy has been shown to be an important and effective preventive procedure for colorectal cancer (CRC). It has been shown that endoscopists who take a longer time to withdraw the scope during endoscopy achieve a higher rate of adenoma polyp detection. (Adenoma polyp, if left untreated, will evolve into colon cancer over time.) Several studies have been done to look at which processes constitute good colonoscopy practice. However, few have been carried out to look at what parts of the practice affects patient outcome. For example, does the type of endoscopist and the setting where the procedure is performed influence patient outcome?

A recent study from University of Toronto studied individuals in Ontario diagnosed with CRC between 2000 and 2005 (Gastroenterology 2011; 140: 65 -72). The researchers determined how many of these individuals with cancer had had complete colonoscopies 7 to 36 months before the diagnosis. These patients were defined as having developed a post colonoscopy colorectal cancer (PCCRC). The researchers then determined if endoscopist factors, such as volume of endoscopy, polypectomy and completion rate, specialization and setting where the procedure was carried out, were associated with PCCRC. A total of 14,064 patients had had a colonoscopy within 36 months. Of these, 1260 (8.95%) had developed a PCCRC. Patients with a proximal cancer were more likely to have a PCCRC than patients with distal cancer. Non-surgeon and non-gastroenterologist endoscopist is associated with PCCRC. When the colonoscopy is performed in a non-hospital based setting, it is associated with PCCRC. Patients undergoing colonoscopy performed by an endoscopist with a completion rate of ≥ 95% were less likely to have a PCCRC than those patients who had colonoscopy by an endoscopist with a < 80% completion rate. For proximal PCCRC, endoscopists with a polypectomy rate ≥ 30% were less likely to have patients with PCCRC. The volume of colonoscopies performed by an endoscopist had no influence on the PCCRC rate.

To me, the study shows that the training of the endoscopist and how meticulously he performs the procedure will impact significantly on the outcome. To be meticulous you cannot be hurried. If you do not want to be hurried, you will take more time to complete the task.

My standard answer to the question ‘How long do you take to perform this procedure / operation?’ is “It will take as long as it is necessary to do a good job”. I will, howeve,r tell the patient a time range but I cannot be precise about how long the procedure will take.

I have had patients who moved onto a different doctor because ‘my time’ is longer than the other doctor’s. A patient has rights and the choice is his / hers.