The South African Medical Quandary

Events over the last few years have made me increasingly disenchanted with the South African health profession in general. From blatant over management to a complete lack of consistency between professionals, the world of medicine is a torrid one to navigate. The following serves as an guide to members of the public in the hope it will assist them in making informed decisions regarding their medical management.

As a physiotherapist we are interestingly poised as health professionals in South Africa. We are first line practitioners and will often come into contact with patients who have been managed by other health professionals (including physio) for either the problem they are presenting with or others and also have the added benefit of typically spending more time with patients than the majority of medical practitioners. This, alas, frequently brings us into contact with patients that have been very poorly managed.

South Africa’s private medical framework is based on a system of financial rewards for intervention. Simply put we receive direct financial compensation for services rendered. The more patients I see daily, the more I earn. The more total hip replacements and orthopaedic surgeon performs per week, the more he / she earns. In no way do I suggest health professionals should not be excellently remunerated but this policy of pay as you treat (more intervention more income) coupled with the fact specialists can effectively pick a figure of x times medical aid rates has to create major conflicts of interest in terms of ethical management of patients. Testament to this is the rather ridiculous notion of Gap Cover (which I incidentally have) whereby we are covered by another policy for medical insurance shortfalls due to specialists charging 5 times medical aid rates!

South Africans are also extremely biased towards the notion of ‘the doctor knowing best’. While intensive entrance criteria, years of study and rigorous specialisation examinations certainly ensure a certain calibre of person, this does not mean that they are always correct or always have 100% your best interest at heart. While the majority of educated people will dogmatically investigate potential investment strategies they will commonly allow invasive surgery with no investigation or query whatsoever.

In the following I will discuss three hypothetical cases loosely based on reality in order to highlight and further discus pitfalls. In my professional capacity I deal largely with musculoskeletal injuries and ailments and hence in this article, the examples will all be related to such. The ideas and concepts are however readily transferable to other medical issues

Patient One: 23 year old female who rolled her ankle trail running. The ankle swelled rapidly but she could weight bear immediately. She did not seek any medical assistance initially and over a period of weeks the swelling subsided and the pain reduced but at around 6 weeks she was left with ongoing stiffness, mild occasional discomfort and a frequent non-painful click. On the recommendation of a friend she consulted an orthopaedic surgeon.

Medical management: X-rays (no fracture), MRI (grade 1 lateral ankle sprain), surgical intervention to stabilise lateral ligaments. Boot and crutches for 6 weeks. Numerous physiotherapy sessions. Period to functional recovery 3 months. Return to sport 6 months. Medical costs > R50000

Evidence based management of Gr1 Ankle Sprain: No x-ray required, crutches if necessary for 2-3 days, speed brace derivative worn constantly initially (around 1 week) and then only during sport for up to 9 months, 2 – 3 physio sessions incorporating progressive weight bearing rehab. Period to return to sport 3 – 4 weeks. Medical costs < R3000.

This is a worst case scenario but one that has been personally witnessed in various guises and pertaining to various areas of the body. The above situation can however readily be avoided. While it is unfortunate that the patient was extremely poorly managed by a specialist at the end of the day the responsibility is with the patient to make an informed decision with the information they are presented with.

Investigate: if your injury / ailment is not of sufficient severity to land you immediately in hospital, you have the time and ability to read and investigate. Look for solid, evidence based publications.
Choose the correct professional: Baring once again severe trauma, a specialist is often not the best place to start your medical journey. (You don’t start with an ENT for a sore throat). A skilled physio is typically a good clinical diagnostician and will thereafter be able to assess and guide if further investigation is required. It will be cheaper, they will spend more time with you and if further intervention is required they will be able to refer you to the right person for the job. if referral is required, don’t take their word for it. Always investigate the specialist and choose the right person for the job. An ankle and foot specialist for an ankle injury rather than a general surgeon!
Question: Always voice your concerns and questions. If somebody dismisses questions and fails to take a few minutes to adequately explain the necessity for an invasive procedure and associated risks and outcome are they the right person for the job?
Don’t settle: particularly with surgical interventions, if all does not completely add up get another or multiple opinions. The additional initial expense will offset the substantial expense and risk of uneccesary surgery.

Over management definitely does not only occur in the realm of surgeons.

Patient 2: a 35 year old male was playing 6 down touch with his friends. He accelerated rapidly for the ball and felt a solid snap at the back of his thigh. It was extremely painful initially and he had difficulty walking the next day. He went to physiotherapy 1 day post injury.

Medical Management: Diagnosed with a grade 2 Biceps Femoris (Hamstring strain). Treated 4 times in the first 2 weeks largely with a combination of electrotherapy (interferential and ultrasound) ice and then heat and a further 5 times over a 6 week period incorporating soft tissue mobilisation, needling and a home stretching program. Return to sport at 8 weeks followed by re-injury 20 mins into first match back. Medical costs: R4500

Evidence Based Management of Grade 2 Hamstring strain: offload and protect initially – crutches until walking pain free (2-3 days), ice, compress and take it easy. Beyond the initially assessment and guidance of what to do and not to do there is very little to be achieved by early ‘treatment’ including electrotherapy (poor evidence). A further 3 sessions spread over a 4 week period included most importantly graded rehab consisting of progressive loading (including eccentric). Graded return to straight-line running culminating in explosive acceleration / deceleration. Successful return to sport at 6 weeks. Medical costs: R2000

Although not as significant, particularly cost wise, as the first example, it is still equally frustrating particularly with a poor end outcome. This example is a tough one as with any soft tissue injury there will be a fairly linear healing process and it will get better if simply left alone. To the uninformed it will therefore appear that the treatment is working. The value in correct treatment lies largely in the management: What to do when and how to condition to 100% and prevent re-injury on return to play. Something I have seen relatively frequently is people having 12 – 14 physio of chiro sessions for treatment of lower back pain with no change whatsoever. This makes absolutely no sense to me from a clinician and patient perspective. For most scenarios I want to have made a difference after 1 session. If i have not changed things (even fractionally) by the 3rd session, I’m missing something or we need to investigate further. There are situations which take longer but the patient will have been informed at session #1. Education is key.

Once again in the scenario:

Investigate: you have a wealth of information at your fingertips. Google and particularly Google Scholar are fantastic resources. Take a bit of time and peruse a number of sites and publications and you will likely see trends emerging with regards to correct management strategies.
Question: Don’t be a passive bystander. If you impart information regarding your injury it forces the professional firstly to think and secondly to qualify what they are doing / achieving from a treatment and management perspective. It also allows you to sneakily evaluate their knowledge base. If not forthcoming, ask early what the person envisages from a management perspective: how many sessions, what needs to be done and likely return to sport.
Don’t settle: If the above does not make sense from what you have read and generally from a common sense perspective get a second opinion early in the game.

Under management (not necessarily from a cost perspective) is also something to beware of

Patient 3: 40 year old male who works in a sedentary environment. He is generally fairly active and goes to gym 2 – 3 x weekly and runs 5km twice a week. 8 weeks previously he started training at a functional training gym. He went 4 x in week 1. Into the second week his right achilles tendon was swollen and intensely painful when walking. He consulted his GP.

Medical Management: Diagnosed with ‘achilles tendinitis’. Given a course of non-steroidal anti-inflammatories and was put in a boot (had one from a previous ankle fracture) for a 6 week period. Was informed to not do any exercise while in the boot. Due to tendon feeling much better after 6 weeks, he went straight back into the high intensity training and after 2 sessions was back to square one.

Investigate: for various reasons, research into tendon pathology is fairly categoric with regards to successful management. Despite this, they remain extremely poorly managed! Nevertheless, with some basic reading, the patient would have realised that tendon pathology is not governed by active inflammation and hence ‘tendinitis’ is not a good term. He would also have realised that long term immobilisation of tendons is catabolic to the tendon structure.
Choose the correct professional: You do not consult your physiotherapist for a bladder infection or sore throat. Find a medical professional who deals with musculoskeletal, sport based injuries on a daily basis.
Question: ‘Is there a way I should ease myself back into activity after 6 weeks of doing nothing?’ or ‘Is there anything else I should potentially do during this time period?’ would have been good questions to ask in this scenario.
Don’t settle: Extreme time periods of immobilisation or time off sport / activity without sufficient logical explanation? Always get another opinion.

The goal of this article rather than to strike fear into your heart or make you shake you head in disgust as to the greed of the medical profession is to alert you to the fact that you are not a passive bystander in the sphere of the health and wellbeing. You can wail and gnash your teeth over how poorly managed you were and often, in all fairness, this is completely out of your control. Nevertheless it is your personal responsibility and obligation to take responsibility and make INFORMED decisions regarding your health. Not every medical opinion requires dogmatic investigation but the more potentially invasive, expensive and life altering the situation the greater the required research.

by Iain Sykes (physiotherapist)

Iain Sykes Physiotherapy

Cape Town South Africa