Internal Medicine: Out of the hamster wheel!

Many are worried about the possible dangers of surgeries, therapies and diagnostics being cancelled or postponed due to the pandemic. Prof. Dr. Sebastian Schellong explains in an interview which health policy improvement potentials the pandemic is currently revealing.

Many are currently worried about the possible dangers of cancelled or postponed operations, therapies and diagnostics due to the pandemic. The German Society for Internal Medicine (Deutsche Gesellschaft für Innere Medizin, DGIM) is turning the tables with its thoughts: What is not being done now without causing damage is part of the medical overuse that has been complained about for a long time. Prof. Dr. Sebastian Schellong, Chief Physician of the II Medical Clinic of the Dresden Municipal Hospital and President of the DGIM explains in an esanum interview which health policy improvement potentials the pandemic is currently revealing.

esanum: Prof. Schellong, you recently said: The pandemic makes unnecessary medicine visible. What makes you say that?

Schellong: The fact that we have medical overuse in various places is not new. That is why there is the "less is more", the "choosing wisely" initiative and others. And in the USA there is the term "low value medicine". These are medical procedures that have a low value, not because they are cheap, but because they have little or no benefit for the patient. And there is the scientific preoccupation with the fact that certain examinations trigger whole cascades of additional examinations and possibly result in procedures that harm the patient.

esanum: And now these weak points are coming into the spotlight?

Schellong: The pandemic acts as a cognitive tool, so to speak. Of course, the topic sits in a minefield of interests, because with every achievement someone also secures his or her livelihood. But now we have this totally exciting time in which both service providers and those seeking services have cut back a lot. Patients have asked themselves: Is this so important that I absolutely have to go to the doctor now? And doctors said to themselves: We can't offer everything now, so we have to do what seems most important to us. All of a sudden, prioritisation was practised, a project that had previously been frowned upon - at least in Germany. It was said that prioritisation was rationing, that one wanted to take something away from the patients.

esanum: But you see it as an opportunity?

Schellong: It is a huge social experiment in health care that is being forced on us by this virus. You can use this experiment by having everyone put their expertise into it and reformulate their needs. We can see what has actually been done less. It shows very precisely which services were billed less. This can therefore not only be quantified, but also qualified according to the type of service. And then you have to look at what harmed the patients? If, for example, tumors are discovered later, if heart attacks are treated too late, that is obvious. But it can also be that services have been omitted that no one really misses.

esanum: What exactly are you thinking about?

Schellong: Various services have long been suspected of being done too often: Hip, knee, spine, cardiac catheterisation. It is of course explosive to name specific services here. As a vascular physician, however, I see two service areas, for example, of which I, like many others, know quite specifically that they are overprovided. One is procedures on varicose veins. You can often reassure patients and say that it doesn't look very nice, but it's not dangerous at all. In this way, perhaps 80% of all varicose vein procedures could be left undone - or at least removed as a cosmetic procedure from the health insurers' obligation to provide services. A second area I see is operations on the carotid artery to prevent strokes. In Denmark, such operations are only performed if there have already been minimal signs of a stroke. In Germany we do 75% of these operations without such signs and the incidence of strokes in Denmark is no higher.

esanum: The whole thing always has an economic dimension, too.

Schellong: Of course. If services are discontinued, turnover drops. And my hospital might go bankrupt. Or the specialist in private practice realises that he is missing part of his income. But the amount of health services should be geared to medical needs. To enable or maintain the economic health of the service providers is the task of the political framework.

esanum: Where does the conflict between medicine and economics actually come from?

Schellong: It is well known that in Germany - as in Austria, for example - we have many more hospital beds than other countries. And health politicians have long been looking for ways to bring the hospital landscape into line with the OECD comparison. But they don't have the guts to do any real planning. It is colossally unpopular with the voters to merge locations, to qualify service areas in one place and close them elsewhere.
So this absurdity arises, that hospitals are brought into competition against each other, in the hope that some will not make it economically, so that they voluntarily leave the market.

esanum: But the market doesn't fix it?

Schellong: On the contrary, everyone is providing more and more services in order to survive in the market. That is why we see an increase in the amount of services and the impression is created that we have too few nurses and too few doctors. That is not what the policy actually wanted.

esanum: How did you come to this very critical point of view?

Schellong: I am the head physician of an internal medicine hospital department. As at most other institutions, we feel that we are forced to retain patients in the competition between hospitals so that the services we offer can be provided to the economically necessary extent. The usual situation in medicine is: The patient seeks out the doctor. In many places today we do the opposite: Service providers seek out their customers. We must now change the direction of travel and try to change that.

esanum: And then?

Schellong: Then we no longer try to provide as many services as possible, but subject ourselves to a certain planning that focuses as much as possible on what is scientifically proven to be necessary.

esanum: With this in mind, who is supposed to accurately determine the damage or non-damage under corona conditions?

Schellong: First and foremost the health insurance companies. They see all the bills. And they have the follow-up data for the patients. Of course, this is a longer phase that has to be followed up. As a scientific professional society, we would like this process to be guided by medical experts. For this, colleagues have to contribute their expertise to this project, where it is a question of which services can be dispensed with. However, doctors don't like to do that. The competition we all face is a big obstacle to changing things together.

esanum: Who are your fellow campaigners?

Schellong: Many colleagues who want to get out of this hamster wheel. And there are already good approaches in politics. In North Rhine-Westphalia there is a project to reorganise the hospital landscape. The state has about as many inhabitants as Holland, but four times as many hospitals. And now the health minister there has commissioned and received a comprehensive report that attempts to identify service areas that can be meaningfully combined in order to gradually work towards a restructuring of the hospital landscape. So the topic has already arrived where it belongs. Because hospital planning in Germany is a matter for the social ministries of the Federal States. The project is meeting with resistance, but it is happening. And hopefully the example will set a precedent.

esanum: And what are you doing about it?

Schellong: We as a professional society are talking more and more about this absurdity of performance competition. We have launched two initiatives: The "Smart Decisions" initiative, which addresses problem areas of overuse with very concrete examples. And the second is the doctors' appeal "Medicine before economics". Here we express that the framework conditions under which we are currently working bring us into conflict with our actual medical mission in many places.