This letter is a response to Koon Yew Yin's letter, Unnecessary tests for heart problems .

Over the past few weeks, I have been following the progress of an elderly patient who had no cardiac symptoms, and had minimal, non-significant changes on his treadmill test. Nevertheless, the consultant in charge decided to order an angiogram which showed that one of the main arteries of his heart was 98% blocked.

Needless to say, it was a minor miracle that he had not presented any symptoms beforehand and he was extremely lucky to have had his problem diagnosed before any actual ischaemic presentation.

Now, the angiogram might not have been indicated, but if it was not done, the patient's chances of morbidity or mortality would have been a lot higher.

In medicine, guidelines are important insofar as they provide a logarithm in establishing the safest and most cost-effective method of treatment for the majority of patients. There will always be patients who do not fit the standard module, and there will be cases when the doctor will have to make judgements that are not entirely within the box. Unfortunately, there are still many aspects of medicine that are more art rather than a precise science.

Of course, things are placed in a different perspective when the investigations need to be paid for by individuals rather than the state. Individuals who are in dire circumstances (after all, what is more profoundly despairing than knowing your life is at stake?) are the very individuals who will be susceptible to being taken advantage of by malicious individuals who would see it fit to derive a profit from the agony of others.

I agree with Koon's assertion that appropriate monitoring practices should be instilled to weed out the bad apples. I am convinced that the majority of doctors practise with good intentions in mind, and they should not bear the cross that was created by certain individuals.

Perhaps a rating scale can be drawn up to rate individual practices regarding the quality of their care and these can be publicised for the benefit of the general public.

At the end of the day, it would almost certainly boil down to the relationship between the doctor and patient. The amount of information available to the patient, along with the manner in which it is presented would be essential.

Perhaps the relevant ministry could create a database or web portal that would be accessible to all. This would also help prevent the proliferation of misleading information that is the bane of the Internet.