Winter Newsletter 2016 – Editorial – Matthias K. Widmer
“The optimum is better than the maximum”
How do you find the best treatment for your patient, the right measure, in short “the optimum”? Optimum and maximum performance at the hospital, caught between technology, ethics and economy, is a burning issue: it is in this context that the question of third party influence (cost bearers, industry and politics) on the immediate medical activity arises. This current problem and challenge were also the focus of this year’s vascular surgeon congress of Germany, Austria and Switzerland, which took place from October 5 to 8 in Berne. This topic was examined based on classical vascular surgical disease patterns such as the aneurysm of the aorta or intermittent claudication (peripheral arterial disease – PAD).
According to the Health Care Insurance Act, the target is high-quality and appropriate care at the lowest possible cost. Since the introduction of the diagnosis-related groups (SwissDRG) in Switzerland, cost reductions and efficiency enhancements have come to the fore and influenced the clinical routine. Especially in cardiovascular medicine, rapid progress makes today’s optimum appear suboptimal or even outdated tomorrow. This is accompanied by an effort and cost spiral, which is driven not only by research, demography and profits but also by rising demands of informed patients. The responsible patient asks for alternative treatment paths more and more often, and today more than ever demands to be included in the decision-making process. However, when specialists only recommend the treatments they can perform themselves, possible alternative treatments are not even mentioned during consulting hours. In these cases, a second opinion may be a valuable help for the patient. Second opinions have become a trend. Many health care insurance companies point them out to their customers and bear the costs. A good example is the initiative meinezweitmeinung.ch, where patients go online to obtain second opinions from VASCULAR INTERNATIONAL experts in an uncomplicated manner.
Obtaining a second opinion addresses another controversial topic in today’s health care: over-diagnosis (diagnosis of conditions that never become symptomatic) and overtreatment (treatment of over-diagnosed conditions and therapies with minimum or no use). This implies that with a maximum effort by no means an optimum medical quality of results is strived for.
In the discussion about the optimum of patient care, the question what the perfect measure of medical services is that can be rendered reasonably in a society is raised inevitably. Wouldn’t it be better to rank the quality of treatments higher than the quantity of the performed interventions?
Today, several specialist disciplines are competing for the vascular surgical patient. Vascular surgeons, angiologists, interventional radiologists and cardiologists vie for the patient with intermittent claudication (peripheral arterial disease – PAD). Who shall the confused patient address with his medical conditions? If the patient was presented all full treatment paths in one single consultation meeting, he could decide more easily and his confidence in medical institutions would be increased. However, this requires that the involved disciplines hold one common consultation hour. Already developed models where vascular surgeons, angiologists and radiologists cooperate and share one budget, staff and equipment are the future and must be promoted.
Clinical ethicists may help in the decision-making process in this dilemma – especially when the situation also involves moral-ethical conflicts of values. The optimum need not always be the maximum. On a case-by-case basis, the optimum could even be that there is no medical intervention at all if it is not what the patients want in their particular life situations. In order to give patients the opportunity to make good decisions, the attending physicians must explain in detail what kind of disease they are dealing with and what kind of therapy options are possible. This requires that prior to talking to the patient, the treatment team has already made a decision on the optimum medical procedure. However, in particular in complex decisions the team is often unsure about the most appropriate way. It is not the ethicist’s task to make these decisions but to support their finding by introducing legal and ethical justifications and insecurities in addition to medical facts to the discussion and reflecting them.
With its activities, VASCULAR INTERNATIONAL tries to influence today’s developments and to promote the conversation culture and the interdisciplinary cooperation among specialists in addition to skills. Please support us in these efforts.
Matthias K. Widmer
Senior physician, vascular surgery, University Clinic for Cardiac and Vascular Surgery, Inselspital, University Hospital Berne