More in opinion


Friday, 21 April 2017 | MYT 12:00 AM

High fees for a tiny appendix

I SHARE the pride and happiness of A Doctor in “Technology cannot replace doctors” (The Star, April 17). When the doctor’s clinical skill beats the CT scanner, the feeling can be exhilarating.

There are more interesting stories behind the little appendix which paints out the big picture of technology in medicine.

All through the 1960s and into the early 1980s, the rate of “lily-white” appendicectomies (normal appendix which were operated on due to wrong clinical diagnosis) was commonly used in many countries to gauge the performance of hospitals. Diagnostic accuracy of 85% and above would place the performance of the hospital into the top level.

Today, the MRI or CT scanner machines have replaced clinical diagnostic accuracy (also known as the doctor) for this same purpose.

An experienced clinician or surgeon would have a diagnostic accuracy rate of 90% or more. If doubtful cases were admitted, and observed and examined regularly for 24 to 48 hours, this can be further improved to over 95%.

In 1998, an editorial in the New England Journal of Medicine by Professor Ian McColl (N Engl J Med 1998; 338:190-191) suggested that spiral CT had a sensitivity of 97%, a specificity of 98%, and an accuracy of 98% in suspected appendicitis. This was followed by many other studies, culminating in a study from Harvard-affiliated Massachusetts General Hospital by Erik K. Paulson et al.(N Engl J Med 2003; 348:236-242).

Powerful reports from top institutions around the world soon changed the management of suspected appendicitis: a battery of biochemical blood and urine tests, endoscopies, ultrasound and spiral CT scanning before laparoscopic surgery have now become almost routine. And somebody must pay for these.

In the early 1990s in Kuala Lumpur, we used to be able to do an appendicectomy for under RM3,000 overall. Today, it is not uncommon for the hospital bill to lie between RM20,000 and RM30,000, a more than 10 fold (1,000%) increase. The surgeon’s fee is capped and remains the same at RM1,500. Where does the rest of the money go?

With average incidence of appendicitis of about 1 in 2,000 population a year, this represents a whopping cost increase of RM375mil a year in Malaysia. We have to pay this cost to achieve an improvement in accuracy rate of 5% or less (=750 cases, which works out to an excess payment of half a million ringgit per case).

And that is where A Doctor in Malacca’s pride must come in. There must be careful selection of cases based on sound clinical criteria. Technology is only helpful in doubtful cases but it can never replace the doctor without an unbearable cost.

A good clinician is the prime cost-saving factor, and clinical judgement and experience must reign superior to technology and not the other way round.

On the same token, the de-professionalisation and marginalisation of doctors in decisions on healthcare provision is an important cause of the spiralling rise in healthcare cost.


Consultant Surgeon

Kuala Lumpur