Oriental Daily Interview: Current Healthcare Concerns in Malaysia

Current Healthcare Concerns in Malaysia

Interview with Ms Piong Tsuey Yin, Senior Reporter, Oriental Daily (29 Dec 2009)

1. The Government is considering paying a portion of the bill for treatment at private clinics under a proposed healthcare reform plan which is expected to be ready next year. “The plan is to pay a portion of the bill but there is a cap to the amount, the public will pay the remaining amount.”said Health Minister Dato' Sri Liow Tiong Lai.

What’s your opinion on this?

The MMA welcomes any forward looking mechanism to improve the delivery of primary health care (i.e. GP or family clinics) to the rakyat. There is actually a glut of GP clinics in urban areas many of which are under-utilised, some seeing only a handful of patients a day. Many of these clinics are suffering economic hardship, many are manned by locums only who are paid poorly.

So, if the MOH can offer a mechanism to distribute some patients who are using the overcrowded government clinics, then this will be welcome. Perhaps a quantum of payment per patient can be agreed upon, but this cannot be so little as to be meaningless.

Medications can of course be obtained at government pharmacies which will help to reduce costs, but may inconvenience the patients. If the public can help co-pay a little then this will also be very good.

2. Dato' Sri Liow said the ministry was studying several models implemented in other countries such as paying medical bills through deduction from the Employees Provident Fund or a tri-parte payment scheme were medical cost would be borne by the patient, his employer and the government. Which way do you think Government prefer? (EPF,medical coupons or compulsory insurance?)

At present it is very difficult to withdraw money from the EPF, therefore this is not a very practical approach for outpatient doctor visits. Using medical coupons or insurance may be better.

However, the paper work should not be so much that it cripples the system. Also insurance companies tend to deny treatment and screen without seeing the patient's needs, and this will be very hard in simpler illnesses. Medical coupons may be difficult to keep a tab on, and have a potential to be abused.

It appears premature that any form of mechanism can just be rolled out anytime soon. The MOH must engage the medical profession and work out a win-win partnership to ensure the best benefits and convenience for the rakyat.

3. Is “unified government and private hospital charges”policy a prelude to implementation of national health insurance? 

This may be the best way forward. a genuine partnership/integration of the public-private sector especially for primary health care services.

We need a portable system of reimbursement mechanism or payment scheme where the rakyat in need of primary medical services can access any clinic whether in the government or private sector, where each Malaysian is guaranteed access to this service. This is called universal access to healthcare where many countries believe is a human right, and this is also endorsed by the WHO and UN.

The National Health Insurance or Financing Scheme is still being worked out. So far, there are many hurdles, because exactly how much each one worker or self-employer contribute is debated.

There are too few income tax payers or employee provident fund contributors, which would make this group community-rate insurance affordable to all. What about those with family members, how do we calculate the quantum of contribution?

How would the government choose or afford to pay for its own civil servants and families, and would this dilute the community pooling of risks for the insurance to work optimally?

There is talk that is around 5 to 6% of basic salary, with the employee paying half, and the employer the other half, with a cap on ceiling of total contribution per year, but nothing has been finalised yet.

4. Had the government announced the implementation details of national health insurance? What is the main key to make judgement toward the implementation details by public? Is it the transparency and detail of the implementation?

→If the government does not announce the details and open for public discussions, do you think the results of the implementation of national health insurance will be good?

I have discussed some of these unresolved issues above. It is true that the government needs to engage with more stakeholders to work out a better mechanism which is agreeable to most parties. Greater transparency in the details would be welcomed and with greater input by more people, this could be a more robust system which ultimately affects all Malaysians.

Therefore the MMA fully supports greater discussions and public input. I suspect not everyone will agree to this scheme, but in any major policy change, it is to be expected.

Look at how the huge health reform bill in the USA had turned out with great partisan debate and recriminations, but at least nearly everyone has a say--this is how a democracy functions, with the majority gaining the final say with modifying input from the dissenting minority, and not just bulldozing a policy down the throats of the citizens!.

5.If our government practise national health insurance by unified the charges, do you agree with this? Why?

Common charges will have to be agreed upon, but this does not mean that the charges are identical in the public or private sector.

Some basic charges will be acceptable and reimbursed on both systems, but at the private sector hospitals, some form of 'luxury' or better facility copayments may be necessary, unless the government wants to nationalise the entire health care system and make it a state concern.

But the MMA does not see the second option happening because we believe that the government still practices a free market economy. A group of common diseases and emergency care will be provided for all, including catastrophic illness such as cancers, chronic illness, but more than that, other agreed upon mechanisms of extra payment will be dependent on public or private options.

6. Most people think that health care reform is good. What is your opinion toward Malaysia's privatization policy in the past?

It is difficult to gauge what had actually happened in the past. It is true that since the 1980s there had been a flurry of new private sector clinics and hospitals being developed. But this is consistent with the economic trends of the era.

There has been some unfortunate misplacement of privatisation of some state-owned health care concerns (e.g. cleaning maintenance services, government pharmacy, etc.) into the hands of political cronies--these patronage is unproductive and lead to wastage of public funds.

However, privatisation helps to modernise and upgrade some of the services and provide a form of competition for the public health services sector too. It allows good doctors to expand their expertise locally albeit in the private sector, without  being lost to overseas, e.g. Singapore or Australia; although of late we are experiencing some out-migration of professionals again.

But of course privatisation always leads to loss of expertise and specialists away from the public sector and in a way undermine the capacity of the government hospitals and clinics. Better incentives are needed to keep our government doctors and personnel happy in service.

7. Liow said the proposed healthcare reform would also see the Government introducing the national health financing scheme.

Some people worry that national health insurance may create a way of embezzle. How do you think about this?

The National health financing scheme is unlikely to be made policy by the next 1 to 2 years. There are many other problems which have not been resolved.

The MMA is not actually concerned that the national health insurance would lead to embezzlement. We are more concerned that the national authority overseeing this fund (which may run into billions of ringgit) be properly applied and used--this must be a government or parliament empowered authority and not privatised.

Also the administrative costs should be kep to a minimal as is seen in the USA's Medicare or MediAid, which only uses 5-6% on clerical, administrative work, and the rest for actual health care needs.

Private insurances tend to be very wasteful, with as much as one third (33%) going to administrative matters, which means only 65 sen to the ringgit is actually left for real health care concerns! The government or parliament must have a very tight control over the use or expenditure of this fund.

8. Do you think national health insurance is able to solve the problems which are created by privatization?   Will it create new problems, such as the government can control the private health sector easier than before?

The MMA does not think that privatisation is the cause of problems in the health care system.

Globally, health care costs have gone up exponentially because of greater medical advances and also patient empowerment and increased demands for the best, the fastest and the most cutting edge medicine. People are living much longer, and thus are having more diseases which are linked to lifestyle, and older age.

No country in the world except perhaps communist Cuba has a state controlled health system. Even Britain's NHS is more and more privatised, although basic to secondary care are still guaranteed as a universal right. But most people (at least in the past) have been quite willing to wait their turn for some therapies or surgeries, which is part and parcel of a national health care system. Australia, Canada, Taiwan and even northern European countries also have wait times, but huge social-health-education compulsory contributions/taxes, some upwards of 20 to 35%  of their wages.

If Malaysians are willing to pay such taxes, then our health care system will almost surely run better, but not when everyone expects free or very cheap health care costs. There is no free lunch in health care. But in Malaysia, the government has been subsidising health care for so long that everyone expects this. For simple primary care may be this is possible, but for more advanced and up-to-date care, this will no longer be affordable for any government.

Malaysians have to wise up to the fact that as much as 10 to 15% of their savings have to be allocated for healthcare, at some stage of their lives. By having a mechanism to cater to some basic healthcare needs, this will help streamline a more efficient and perhaps cost-saving method of health care.

But Malaysians must expect some form of rationing and waiting. Health service on demand or immediately, will never be possible for any state funded system of national health insurance. For that extra luxury service, then some co-payment for these privileges will still be needed.

But in a nationally guaranteed health care system, all health or medical emergencies will always be provided for, without unnecessary delay.

9. I heard that private hospital group intends to open clinics, how do you think about this?

 In principle, the MMA is against the setting up of primary care clinics by private hospitals because they have an unfair advantage over GPs. There has been a moratorium on this in the Private healthcare services and facilities regulations which prohibit the setting up of such clinics in the private hospital vicinities.

However, many are now setting up such clinics as feeder clinics to channel such patients to their own private hospitals which would limit choice and may encourage over-utilisation of amenities such as x-rays or CT scans etc. The MMA is opposed to such practices.

10. What direction should Malaysia's healthcare reform move towards? Specifically, what should our government do?

→How can we solve the shortage of doctors in government hospitals?

 Our current 'shortage' of doctors in the country is due to poor and lopsided distribution of doctors around the country. For most towns and cities, we do have enough doctors, most urban locations in Malaysia already have a doctor-population ratio of 1:400 to 1:600, a WHO mark/standard of adequacy of health care..

If there is better allocation planning and career-path plans/hardship allowances for younger doctors, these problems may be solved, with most doctors being willing to go to more remote and inaccessible areas in the country such as in the interiors of Sarawak and Sabah.

There will soon be sufficient doctors in the country, if not a very serious glut and oversupply. We have to date, 23 medical schools in the country producing some 1500 doctors with another 1000 to 2000 graduates returning from overseas! We understand that another 6 medical schools have been approved but not yet functioning.

At this rate of medical graduate production, we will reach 35,000 to 45,000 doctors by 2015, when there will be too many for our system to absorb, and many doctors will be unemployed, even by the government's MOH! We must not become a diploma mill producing nation with dubious quality medical graduates!! We need to knock some sense into our authorities, quickest possible!

There are simply too many private medical schools in the country, with too little oversight as to the final quality of the medical graduates produced. There will be a need to check the quality and the quantity of the medical graduates, otherwise many may soon not be having a job to go to, as already happening in countries such as the Philippines, Indonesia or even India.

We do need an urgent health care reform agenda, but we must all participate in formulating one that is best for the country, starting with the need for guaranteeing universal access to health for all. But the mechanism for payment and reimbursing health care costs has to be streamlined and improved upon to contain the escalating cost and wastage.

Basic and catastrophic or emergency care should be affordable or insurable for all, with some form of leeway for quicker access and more luxury care for those who purchase a premium service, because like it or not, we are a free-market consumer driven society, and cannot shy away from these demands. But we must be careful about too much wastage from either excessive demand, administrative or patronage-connected (crony or rentier economic) leakages.

Dr David KL Quek

President MMA

NST: MEDICAL FACILITIES: Rethink 1Malaysia clinic move

MEDICAL FACILITIES: Rethink 1Malaysia clinic move

New Straits Times, 2009/12/24

DR DAVID K.L. QUEK, President, Malaysian Medical Association 

WHEN the government announced in the 2010 Budget the setting up of 50 1Malaysia clinics in urban areas, the Malaysian Medical Association was perplexed.

That these clinics are to be be set up at all is perhaps a good move by the government that must have genuinely felt the need to offer some much-needed goodwill to the urban folk, especially the poor and the marginalised.

However, what is disturbing is the plan to have these clinics run by medical assistants and nurses, which in effect places the standard of these clinics at the level of Third World countries, where there is a real shortage of registered physicians.

The MMA is gravely concerned that such a major shift in policy with regard to public sector healthcare should be implemented without sufficient input from and discourse with stakeholders, such as medical practitioners and perhaps even Health Ministry officials.

It has been suggested that even some health officials were taken aback by this announcement, but they have been instructed to implement the decision next month.

Firstly, let me reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also concerned about our patients, that is, the rakyat who are our reason to exist, our raison d'etre.


We welcome the government's concern about the health needs of the people. We also recognise that for many urban poor, the only recourse to healthcare is that offered by the ministry's overcrowded and understaffed outpatient clinics. That there has been much queuing and long waiting times is regrettable and wasteful in terms of productivity. Certainly, we should do better.

We also know that new ministry directives have been employed to shorten waiting time to less than 30 minutes: this has been included as part of the Key Performance Indicators or Key Result Areas announced by the government.

Perhaps this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution, has prompted this new approach.

But we also urge the government to recognise that throughout the country, there are many general practitio-ner (GP) clinics available in almost every urban block of shophouses and business complexes.

There is a severe glut of GPs in urban areas, such as Klang Valley, Penang, Johor Baru, Malacca, Ipoh and other major towns. In these cities, the ratio of doctor to population is 1:400 -- better than the World Health Organisation's recommended ratio of 1:600.

While some GPs have been successful, the great majority of them simply eke out a mediocre living. Most GPs see less than 20 patients per day and are, therefore, under-utilised. This is grossly unproductive and wasteful.

The problem is learning how to manage the distribution of the doctor-patient function more efficiently.

It is with this in mind that for several years now, the MMA and the ministry have been seeking an efficient public-private partnership in shaping a better healthcare system for the country.

Unfortunately, because of the differential system of fee and/or payment mechanisms, it is proving to be rather tricky to bring about a cohesive transferable system.


Thus, there have been talks about integrating the public-private sector for primary care medical services.
This will hopefully integrate all the GPs into a primary care medical service, whereby the public can seek treatment at either the public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will, undoubtedly, be the way forward.

Of course, quite a few discrepancies need to be addressed, for example, differing expectations and amenities available. But this can be worked out and we are establishing common areas of standardisation which will ensure that the public can be assured of as high a standard of healthcare as possible.

In this context, the establishment of the new 1Malaysia clinics appears to be unnecessary. If the government feels that these clinics should be set up despite the protests of the medical profession, then the least it should do is to ensure that these clinics are manned by registered medical doctors.

The standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is unbecoming to offer a lesser level of care to citizens just because they cannot afford to pay to see a doctor.

Employing medical assistants and nurses to do a doctor's job is called task-shifting, a practice employed mainly in Third World countries, where there is a severe shortage of doctors. To do so in this country would be a major step backwards and, in the MMA's view, unnecessary.

Do we have enough doctors? Of course, we do. It is just the poor distribution and logistics that need to be addressed.

Recently, more than 2,500 new doctors joined the public service as house officers. It is learnt that many of them are under-employed in various government hospitals.

Owing to the mushrooming of medical schools (23 as of this year) in Malaysia and medical graduates returning from abroad, we will have some 2,000 to 3,000 new doctors returning to our shores annually.

We can certainly tap into this resource to help run our public clinics more efficiently. At the very least, the public will be better served by registered medical doctors.

Although they may only have a probationary medical licence, the fact remains that they have had sufficient training and knowledge. Medical officers, registrars and specialists can supervise these doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioners?

Because under the Medical Act 1971, this is illegal. Because doctors who employ such unregistered persons have been charged and penalised for unprofessional conduct. Because medical assistants cannot prescribe any more than some simple medicines, cannot sign any medical leave chits or write any reports, and would become subject to medico-legal challenges with no precedents.

There should not be one law for some and another for others, even if it is approved by the government or the ministry. The MMA believes that setting up 1Malaysia clinics in urban locales is redundant, wasteful and shortchanges the rakyat. Utilising the existing GP clinics would be the better way forward.

Furthermore, the manning of these clinics by non-registered medical doctors is wrong and undermines the healthcare service, leading to a possibly poorer standard of care and many uncharted legal problems.

We urge a rethink on this project, and for the ministry to seriously look into the implications of this poorly advised move. The MMA will strive to work with the ministry to help raise the standard of healthcare for Malaysians, but not by compromising on the quality of care.

The Star: MMA: 1Malaysia community clinics a step backward

MMA: 1Malaysia community clinics a step backward

The Star, Thursday December 24, 2009

PETALING JAYA: The Malaysian Medical Association (MMA) has ex­pressed grave concern over the set­­­t­ing up of the 1Malaysia community clinics as stipulated in Budget 2010.

It said the 50 clinics which were to be set up would be similar to those in Third World countries as they would be run by medical assistants and nurses.

“This in effect places their standards on the level of countries that have a scarcity of fully-registered physicians,” said MMA president Dr David K.L. Quek in a statement.

He said this was certainly a major step backwards for a progressive nation such as Malaysia.
Dr Quek said it was illegal for medical assistants or other unregistered medical practitioners to run a clinic under the Medical Act 1971.

“Furthermore, having them man these clinics undermines the healthcare service which will lead to possibly poorer standard of healthcare,” he said.

The policy, he added, also did not have sufficient input from stakeholders such as medical practitioners and even Health Ministry officials.

The clinics will begin operations next month to offer outpatient services like dressing for wounds as well as treatment for simple colds, coughs and headaches for urban residents.

Dr Quek said there were many “under-utilised” general practitioner clinics to cater for these needs.
“If the Government feels the 1Malaysia clinics have to be established, the least it could do is ensure these clinics are manned by registered medical doctors,” he said.

The Sun Newspaper: MMA slams 1Malaysia clinics

This article is from Sun2Surf
Article's URL: http://www.sun2surf.com/article.cfm?id=41557
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MMA slams 1Malaysia clinics
By: by Meena L. Ramadas (The Sun, Tue, 22 Dec 2009)


PETALING JAYA (Dec 22, 2009) : The Malaysian Medical Association (MMA) has criticised the government’s decision to implement 1Malaysia clinics which are to be manned by medical assistants and nurses, calling it "wasteful" and "illegal".

"The MMA believes such clinics in urban areas would be redundant and shortchange the rakyat," its president Dr David K.L. Quek said in a statement today.

"Furthermore, getting unregistered medical doctors to man these clinics is also wrong and undermines the healthcare service which leads to a possible poorer standard of care," he said.

Quek said the employment of medical assistants and nurses to man clinics is against the Medical Act 1971 which prohibits medical assistants from prescribing “any more than some very simple medicines”.

Last week, Bernama quoted Health Minister Datuk Seri Liow Tiong Lai as saying the clinics would be allowed to prescribe medicine for minor illnesses like fever, cough or minor cuts and could also handle referral cases.

A total of 50 1Malaysia community clinics will begin operation next month to provide basic health treatment for urban residents.

However, Quek said there are already many “under-utilised” general practitioner clinics.

He said there are many doctors in the country but they are poorly distributed.

"If the government feels the 1Malaysia clinics have to be established, the least it could do is ensure these clinics are manned by registered medical doctors,” he said.

“The standard of medical care should not be compromised."

Prime Minister Najib Abdul Razak recently announced an allocation of RM10 million under Budget 2010 for the clinics.

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COMMENT (DQ):
As of today only the Sun newspaper and malaysiakini has published edited versions of our press release. Thus is the state of our press. When the issue raised appears to be too sensitive, they are deemed unworthy of being published and simply filed away in the dust-covered archives of 'lost' news.

MMA vs. MMC: Don't muddle their roles

MMA vs. MMC: Don't muddle their roles

David KL Quek, malaysiakini, 22 Dec 2009, 11.08am

comment I sense great disquiet and anguish that many doctors appear so helpless in the wake of several issues which appear to have emasculated the medical profession and make the practice that much more onerous and perhaps a tad nit-picky.

I will not touch on the political slants and the many possibly hearsay implications of one writer's perspective regarding the director-general (DG) or ministers of health, past and present. That is his right.

However, it must be clarified that the Malaysian Medical Association (MMA) is not synonymous with the Malaysian Medical Council (MMC). The MMA does not form part of the MMC and does not have any influence on it, or vice-versa.

The MMA was formed nearly 50 years ago to represent the interests of the medical practitioners. Our motto reads Jasa Utama which translates into 'Service First'. This necessarily implies that our interests must rest with our service to our patients first and foremost.

Conversely, the MMC is the regulatory body formed by an Act of Parliament, which governs the spectrum of medical practice, including formal registration of all medical professionals, as well as meting out disciplinary action against errant doctors, after due processes of inquiry, fully enshrined in the Medical Act 1971.

Every country (and some states in the US) has such a governing disciplinary board or council, because professional matters can become contentious and sometimes tinged with poor and unethical practices, which we call 'professional misconduct'.

Of course, no doctor would like to be hauled up for inquiry into professional conduct, because this process can be very unnerving and stressful. Their jobs and right to practice are literally on the line.

In every profession, there will always be those who come perilously close to the edge of propriety in their dealings with patients. This is especially so in the usually quite asymmetric patient-doctor relationship, where faith and trust in the doctor clearly is more one-sided than the other way round.

The MMA also operates on an independent code of ethics. It deals with complaints about errant doctors from the public and occasionally from our own doctor members. We do not actively search for possible wrongdoing by doctors. But we owe it to our patients to help answer some of their grievances, which may have an ethical basis or misunderstanding.

The ethics committee conducts investigations, which include asking the doctor involved to help answer the charges - there is always a right of reply, where even the right to engage legal counsel is allowed. The complaints are then resolved amicably, or are referred to the MMC if no agreement is reached.

Previously the MMA has taken the role of complainant against errant doctors at MMC hearings, but these days we have tried to persuade the complainant to directly represent him or herself for greater clarity and purpose.

Referral to the MMC for further action or possibly a full inquiry is based purely on what we consider to be possible breach of professional conduct, but not medical negligence. Professional misconduct has more to do with the medical profession's expectations as physicians under our Code of Ethics. It has no legal basis, although the connotations are as ponderous.

Every doctor understands his or her ethical boundaries, which are clearly spelt out in several documents either by the MMA or the MMC (Code of Professional Conduct). No doctor can claim this is an archaic practice and thus choose not to abide by these, otherwise, he or she has no right to continue being a part of the profession which has survived since the time of Hippocrates.

You may not like these ethical constricts, but you will have to toe the line, to protect both our august profession and more importantly, the patient and the public at large.

MMC decisions

The fact that I have been elected as a MMC member since 2004 is not exactly a secret. I was elected as one of 11 MMC members by all Malaysian registered doctors, and not just by MMA members - although only about 15-20 percent actually exercise this right through a nationwide postal ballot.

Some of the elected members have been re-elected for many terms because these doctors are stalwarts of the profession. They are respected by almost every doctor as holding the profession in its highest regard and to the best standards. One senior clinician and past president of the MMA has been an elected MMC member successively (every three years) for more than 25 years.

The DG of Health is president of the MMC under the Medical Act, while the other members are appointed from the universities or the Health Ministry.

As councillors, we generally have the interests of medical doctors and professionalism at heart, but our foremost role is to protect the rights and interests of patients. We cannot be and just are not partial toward protecting our 'own kind' so to speak - that is not our remit.

Conversely, it is untrue to imply that the MMC is bent on arbitrarily punishing doctors for trivial issues. Legal representation is almost always encouraged and due process always given extended leeway to arrive at the truth of every dispute.

A minimum of nine councillors must be present to form a quorum to decide on any full inquiry, which is a form of jury of our peers. A decision to sanction or to acquit any doctor is taken very seriously and only after much discussion and debate, as well as an internal discourse with our own conscience, experience and moral underpinnings.

Most decisions are made by majority vote, but very often on unanimity, which underscores the commonality of purpose and ethical compass, which everyone pledge to perform as MMC member. We all understand the seriousness of our collective decisions. Making a decision is not at all a frivolous exercise of misguided power play, as implied by the letter writer.

Although some MMC findings have been overturned by the High Court due to procedural lapses - long delays and more rarely, misunderstandings on exact expectations of legal interpretations - the MMC as a regulatory body stands by its collective disciplinary decisions.

The decisions are, by and large, representative of quite serious misconduct applicable to doctors the world over, such as causing harm due to callous disregard to one's training and expertise; yes, employing unregistered persons to act as 'doctors' in helping to run their clinics; dishing out drugs without seeing or examining patients; or sometimes acting as high-class drug pushers for drug addicts; or selling medical chits.

Please don't confuse the MMA with the MMC. The MMA does not have the power to suspend, deregister or to reprimand any doctor under the law. We may however, help facilitate some complaint mechanism for further action.

Middle path

The MMA has already expressed dismay about the 1Malaysia clinics to be run by medical assistants instead of doctors. We are taking steps to see how we can influence its unwelcome direction. Although we understand that this may be a preliminary step - just 50 clinics in urban areas, this move may be a starting point to further extend this exercise, which will demoralise the profession of doctors, and worse would undermine the standard of health care for our less- than-informed rakyat.

We are working unfortunately behind the scenes to try and ameliorate its fallout, failing which, some greater collective action may be called for. Holding an EGM or conducting signature campaigns or even protest rallies may be just some of the options that we may contemplate.

We are likely to begin with a signature campaign to enlighten the ministry and the premier that most, if not all, doctors are really opposed to this move. However, it is clear that different doctors will see different actions as appropriate, while others will not. We will still strive for a middle path.

Unlike the British or German Medical Association, the MMA was not registered as a trade union, and thus our approach cannot be the same. Nevertheless, the MMA has been acting as a de facto professional body, which does look after the welfare and the various benefits for our members and doctors.

Most of the many perks, wage gains, overtime reimbursement, and promotion prospects of public service doctors have been won through the arduous efforts and campaigns led by the MMA, through its Section Concerning House Officers, Medical Officers and Specialists. Clearly we cannot have everything we want to be accepted wholesale, by any authority, let alone the government.

We have been successful in many ways, but weaker in others such as private GP concerns. This may be because many GPs choose to be rather apathetic and reactive unless issues impinge upon their practices.

Most GPs also are disjointedly single-minded, and not as cohesive as the public service doctors. We recognise some of these weaknesses and are working hard to rectify these so that we can be better represented at crucial dialogues with the ministry and the government.

With regard to doctors being able to pool funds to protect their rights, this is a fool's paradise! We have problems even asking doctors to be members of the MMA, when our annual dues are just below RM300.

When we finally looked into our membership rolls (previously more than 13,000), we had to delist some 4,000 doctors for defaulting on membership fees. We now have 8,200 members in benefit, from a total of around 27,000 registered doctors as at 2009.

Go figure! How strong can we be when most doctors are only interested in their own narrowly prescribed world? And no, there is no compulsion for any doctor to be part of the MMA, unlike the Bar Council (all lawyers are mandated to be a member), although this may be the way forward should the government accede to our request to bring this about!

The German and some western medical associations are compulsory for all registered doctors, and their fees are usually commensurate with their status.

Under such constraints, of course, the MMA is doing its best to cope with all these challenges, which will differ in style and approach with every leadership. My own position is to engage and influence without fear or favour.

But on the surface, this is harder to appreciate because contrary to what many members choose to perceive, not all or any of our press releases or communiqués are likely to see the light of day. We do not control the media, and neither can we control their prerogative to publish or to slant their headlines.

Under the best of circumstances, the mainstream media and the authorities may choose to ignore the best of our intentions. But plod on, we must, and we do the best we can.


DR DAVID KL QUEK was editor-in-chief of MMA News (bulletin of the Malaysian Medical Association) for 11 years and is currently president of the MMA.

Malaysiakini Letter: PHFS: No 'ambulance' to rescue harassed doctors

PHFS: No 'ambulance' to rescue harassed doctors
Malaysiakini Letter: RS, Dec 21, 09, 4:46pm

I refer to the Malaysiakini article 1Malaysia Clinics: An exercise in futility and the continuing nationwide harassment of general practitioners especially in the state of Penang by elements at the health ministry led by its controversial director-general, Ismail Merican.. The current fault where private practitioners are now being treated as quasi-criminals by the health authorities and continue to do so must decidedly lie with these doctors themselves.

Unlike the majority of post-2008 Malaysians, they have chosen to remain silent and must now, like all unregistered voters, pay that proverbial high price for remaining cloistered in their shells.

Their grouse, the Private Health Facilities and Services Act (PHFSA) is the demonic brainchild of consumer groups. Doctors at the health ministry put together a disparate chunk of ambiguous edicts from various different countries and called it the PHFSA.

These doctors who tried to do a hard sell on the then health minister, Chua Jui Meng, throughout his tenure failed when, Jui Meng, being a trained lawyer, refused to buy it. For starters, he knew both of them had obstructed discussion of the proposed legislation by blocking inputs from the very doctors it was going to be applied upon by lumping all discussions pertaining to the act under the Official Secrets Act.

Secondly, Jui Meng, now a stalwart with Pakatan Rakyat, discovered their motives for wanting to force doctors to purchase equipment peddled or attend courses driven by health ministry cronies as the main reason behind the application of the OSA on a medical law. However, these doctors realised their opportunity when an ignorant Chua Soi Lek walked into the picture. This time their sales pitch worked.

Appalled doctors who realised the gravity of their connivance and implications of the proposed law threatened to march to Parliament but were let down when their own representatives sold them out lock, stock and barrel to Chua. The PHFSA became a reality and soon enough despite all of Chua's pronouncements (who himself was proven to be untrustworthy by subsequent video revelations at a Batu Pahat hotel) engulfed a bona fide, unsuspecting doctor from USM, Dr Basmullah Khan who did not even have the financial means to engage counsel.

Despite ambiguity virtually popping out of every line of the Act, a judge decided to throw Basmullah into the slammer instead of reading the PHFSA together with that of the duties of a medical practitioner as outlined in the Medical Act 1971.

Malaysia Medical Association (MMA) doctors who were stung by his jailing, tried to sign-up for an EGM to discuss this issue but yet again were foiled by their own brethren at the MMA who instead of focusing on the gravity of such a law on the profession, instead chose to split hairs regarding the inadequate number of members who had asked for the EGM (apparently, some had not paid their subscriptions on time and therefore not eligible to call for an EGM, let alone vote).

The MMA, from whom much was expected for something to be done about this law, remains quiescent and ineffective to say the least. The MMA has failed in two very important tasks. One is its role in the Malaysian Medical Council (MMC). It has been part and parcel of MMC hearings involving the suspensions or reprimanding of six leading specialists and 10 senior GPs, one of whom was suspended for employing a 'Medical Assistant' (now glamorously called 'Assistant Medical Officer' – the types that don't do housemanship and take only three years to graduate after Form 5 and appear today as possible stand-ins for the urban run '1Malaysia' clinics proposed by the government).What irony.

A significant number of these doctors lost their clinical rights based on an archaic misdemeanor called infamous conduct. What's that? The MMA, by being an active member in prosecuting and doling out 'punishments' by taking away doctor's livelihoods in hearings led by a hopelessly biased government establishment unschooled or poorly advised on medical litigation matters has no business representing private doctors anymore.

Of great disappointment is that almost all the doctors suspended, reprimanded or struck off are from the private sector, the very doctors whom the MMA purportedly represent. Despite the health ministry being the ministry with one of the highest number of complaints this government has ever had to face, why isn't there even one single doctor from the government sector struck off, reprimanded or suspended?

Legal advisors to the Malaysian Medical Counsel (MMC) have complained about the blatant abuse of PIC heads and the health ministry DG himself in not following legal procedures but who choose to become judge, jury and executioner against all legal advice despite evidence to the contrary. Some of these advisors have even walked out in protest.

But the MMA remains silent. Shouldn't the MMA, like the British Medical Association, be wearing the other shoe and taking the MMC to task or even to court instead of being part of this shameful charade?

But more ominous is the complete lack of action regarding the PHFSA. Clearly the harassment continues unabated. Doctors in Penang are up in arms, some even considering leaving the profession as the ministry's 'enforcement officers' who clearly have nothing better to do continue to prey on their practice. Meanwhile, the road side pile jabbers and 'sin seh' peddling leaves and acupuncture continue to do roaring business, no thanks to the ministry's endorsement of traditional medicine. Further, the '1Malaysia' clinics run by 'Assistant Medical Doctors'- a lobby far more powerful then the impotent MMA, are now threatening to come on aboard.

By now, the MMA should have written to every private practitioner if they want an EGM to discuss the PHFSA. By now, they should have consulted a team of lawyers to seek leave to look into a judicial review and stay all further actions of this acrimonious act. By now, they should have gone to the ground and provided legal assistance to doctors severely harassed by enforcement authorities.

By now, they should have pooled funds from all GPs affected and sued any authority who acted or trespassed clinics illegally or have contravened in the legal restitution of medical care to the infirm by qualified doctors.

By now, they should have decided whether they are up to the mark in delivering and discharging their duties to the very doctors who (and to those who didn't) put them in-charge. All future MMA presidential hopefuls should perhaps note that if they want to be 'yes men' like many of our Court of Appeal judges, then they should just perhaps focus on their practice instead of assuming an office from which they very well know they cannot discharge their duties effectively.

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COMMENTS (DQ):

Obviously, here is a doctor who has some ideas as to what has been happening but also confused as to the exact roles of MMA and MMC. Furthermore, his suggestion that private doctors are erroneously charged and victimised by the MMC, using archaic rules of professional misconduct, is probably ill-advised and quite inaccurate. 

His blanket acceptance that all those charged by the MMC are innocent victims is also disturbing and not based on facts. Most if not all these complaints arise from disgruntled patients, with some where the MMA simply act as a conduit for the complaint towards the MMC because of inability to resolve the issues to the satisfaction of both parties. And no, not all MMC members are yes-men. MMA leaders likewise are not to be tarred with the same brush. 

But this letter provides some food for thought.

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

When Prime Minister Najib Razak announced in the Budget 2010, the setting up of 50 1Malaysia clinics in urban areas, the MMA was dumbfounded and perplexed.

That these clinics be set up at all, is perhaps a good exercise in public relations for our Prime Minister, who must have genuinely felt the need to offer some much needed goodwill to the urban folks, especially the poor and the marginalised.

However, what is more disturbing is the plan to have these clinics run by medical assistants and/or nurses, which in effect places the standard of these clinics at the level of third world countries, where there is a real scarcity of fully-registered physicians. It is certainly a major step backwards for a progressive nation such as Malaysia, which aspires to be fully developed by 2020, just 10 years away.

The Malaysian Medical Association (MMA) is gravely concerned that such a major shift in policy with regards public sector healthcare should be so implemented without sufficient input and discourse with stakeholders, such as the medical practitioners and perhaps even with officials of the Ministry of Health. It has been suggested that some health officials were also taken aback by this announcement, but they have been made to implement this as a directive, come January 2010. (I stand to be corrected on this fact.) It appears that this plan was brought about by fiat, rather than by persuasive rationale or long-term planning.

Firstly, let us reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also always concerned about our patients, i.e. the rakyat out there, who are our reason to exist, our raison d’être.

We welcome the government’s concern about our rakyat’s health needs. We also recognize that for many urban poor, their only recourse to health care is that offered by the overcrowded and understaffed MOH outpatient clinics. That there have been much queuing and long waiting times is notorious and wasteful in terms of productivity. Certainly we should do better.

We also know that new health ministry directives have been employed to try to shorten waiting times to less than 30 minutes; this has been included as part of the KPI/KRA so proudly announced by the government. Perhaps because of this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution has prompted this new approach.

But we also urge the government to recognize that throughout the country, in urban areas, there are already in place many GP clinics, some only a few doors away from each other in almost every urban block of shop-houses or complexes.

There is a severe glut of GPs in urban areas, where in the Klang Valley, Penang, Johor Bahru, Melaka, Ipoh and other major towns. In all these townships and cities, the ratio of doctor to population is around 1 in 400, more than the WHO recommendation of 1 in 600.

While some GPs have been very successful, the great majority is simply ekeing out a meagre and mediocre living, many GPs are seeing less than 20 patients per day and so are under-utilised. This is grossly unproductive and wasteful when seen in the context of the long arduous training and huge expense required for producing any one doctor, whether locally or abroad.

Our problem is learning how to manage the distribution of the doctor-patient function better and more efficiently. It is with this in mind that for several years now, the MMA and the Ministry of Health have been seeking a better public-private partnership in shaping a better health care system for the country.

Unfortunately because of the differential system of fee and/or payment mechanisms, this is proving rather tricky to bring about a cohesive transferable system. Thus, there has even been growing talks about integrating the public-private sector for primary care medical services. This will hopefully seamlessly integrate the use of almost all GPs into a primary care network where the public can register and seek treatment at either public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will undoubtedly be the way forward.

Of course quite a few discrepancies need to be addressed, e.g. differing expectations, possibly standards of every aspect of care, variable amenities available, level of support staff, etc. But these can be worked out, and we are establishing common areas of standardisation, which will then ensure that the public can be assured of and experience as high a standard of health care as possible.

So, in this context, the hurried establishment of the new 1Malaysia Clinics appear irrational and un-called for. If the government feels genuinely that these have to be carried out regardless of the medical profession protestations, then the minimum that it should do, is to ensure that these clinics are duly manned by registered medical doctors, fully in charge of all aspects of the clinics. This standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is quite unbecoming to offer a lesser level of care to those citizens just because they cannot afford to pay to see a doctor. Employing medical assistants and nurses to do a doctor’s job is called task-shifting, which is employed mainly in third world countries where there is severe shortage of doctors. To do so in this country would be a major step backwards and in our MMA’s view, shameful and unnecessary.

Do we have enough doctors? Of course we do. It is just the mal-distribution and poor logistics, which need to be addressed. Recently, more than 2,500 new doctors joined the public service as house officers. It is understood that many of these are under-deployed in the various departments of the government hospitals.

Due to the mushrooming of so many medical schools (23 as of this year) in the country, and medical graduates returning from abroad, we will continue to have some 2,000 to 3,000 new doctors returning to our shores annually!

We can certainly tap into this growing number of doctors to help make our public service clinics more efficient. At the very least the public will be better served by some recognized registered medical doctor, although they may just have probationary medical licence—the fact remains that they have had sufficient training and learning. Medical officers, registrars and specialist, (who can also be deployed to enrich the public sector healthcare service, if need be), can supervise these younger doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.

Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or deregistered!

Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.

Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.

There should not be one law for some and another for others, even if approved by the government or the MOH.

Two wrongs do not make a right.

The MMA believes that setting up 1Malaysia Clinics in urban locales is wasteful, redundant and shortchanging the rakyat. Utilising the already many GP clinics would be the better way forward. 

Furthermore, manning these clinics by other than registered medical doctors is also wrong and undermines the health care service, which leads to a possibly poorer standard of care, which can lead to many uncharted medico-legal problems.

We urge a rethink about this project, and for the MOH to seriously look into the implications of this poorly advised move.

The MMA will strive to work together earnestly with the MOH to help raise the level of healthcare for Malaysians, but not by compromising on the standard of care, or of shortchanging the uninformed rakyat.

Dr David KL Quek, President MMA

BMJ: Looking young for age linked to longer life... ahem!

Looking young for your age linked to longer life
(Research: Perceived age as a clinically useful biomarker of ageing: cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b5262


People who look young for their age enjoy a longer life than those who look older than their years, finds a study in the Christmas issue published on bmj.com today.

Doctors often use perceived age as a general indication of a patient's health, but research on its validity has been sparse. So a team of researchers, led by Professor Kaare Christensen from the University of Southern Denmark, examined whether perceived age is linked with survival and important age related traits, such as physical and mental (cognitive) functioning and a molecular biomarker of ageing (leukocyte telomere length).

Telomere length indicates the ability of cells to replicate. Shorter length is associated with a host of diseases related to ageing, lifestyle factors and death.

In spring 2001, 1,826 Danish twins aged 70 years and over underwent physical and cognitive tests and had their faces photographed.

Three groups of assessors (20 female geriatric nurses aged 25-46, 10 male student teachers aged 22-37, and 11 older women aged 70-87) rated the perceived age of the twins from the facial photographs. The assessors did not know the age range of the twins, and each twin of a pair had their age assessed on different days.

Death records were then used to track the survival of the twins over a seven year period.

Perceived age was significantly associated with survival, even after adjusting for chronological age, sex, and the environment in which each pair of twins grew up. Perceived age, adjusted for chronological age and sex, also correlated with physical and cognitive functioning as well as leukocyte telomere length.

And the bigger the difference in perceived age within a twin pair, the more likely it was that the older looking twin died first.

The age, sex and professional background of the assessors made no difference to any of the results.
Perceived age based on facial photographs is a robust biomarker of ageing that predicts survival among people aged 70 years and over and correlates with important functional and molecular age related characteristics, conclude the authors.

They point to common genetic factors influencing both survival and perceived age to help explain these results.

Contact:
Professor Kaare Christensen, The Danish Twin Registry and The Danish Aging Research Centre, Institute of Public Health, University of Southern Denmark, Odense, Denmark
Email: kchristensen@health.sdu.dk 

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Comments (DQ)

It is interesting to note that perceived youthful looks may be associated with improved longevity. Perhaps, it's not all in the genes, since this study was conducted using paired twins. 

More important is the manner in which we respond to living and all its attendant stressors and challenges. When we cope poorly even if outwardly calm and collected, if within we are ridden by angst, ruffled conscience and unresolved stresses, then it is likely that our cells and our organs will suffer for it, our telomeres shorten at a faster rate, maybe by more rapid replication and changeover of cells... 

Note that almost every US president gray prematurely and rapidly, although with excellent healthcare, most have survived far longer than their peers! Contrast this with our politicians who sometimes resort to ridiculous make-overs to look younger, while acquiring younger wives to inflate their already overblown egos--a recent MP comes to mind!

1 Malaysia Clinics appear set to take off despite MMA's Concerns

Below is a recent letter to the MMA Exco from a MMA Leader, Dr Jeganathan from Kota Bharu, who has expressed serious concerns as the continued push to start of 1Malaysia Clinics by the MOH. Please consider seriously the implications, and whether we should urgently convene a signature campaign, opposing the move.

"Dear All,

I was hoping there would be a favorable response from the Ministry about the one Malaysia clinic, but from today's news looks like we have failed to convince them.

The very detailed article article by the President Dr. David Quek and the other one by Dr. Sarjeet should have been sufficient to convince them, but I think it has not reached the decision makers. I suggest these articles be published in the newspapers so the public is also aware of the issues, and maybe indirectly reach those who can make decisions. The council should take the lead in this matter,

The problem now is real we have to makedecisions because  the idea of having MAs operating clinics in urban areas will ruin the  moraleand  the spirit  of the profession as a whole.Is this what MMA the Largest Ass of Doctors going to allow to happen. If the Govt feels private practise should abolished then nationalize all over clinics,but not to insult us and break our spirit as Doctors. I will not go into all the details why this should not happen but what we can do to relocate this clinics.

We have 20,000 Doctors to the few whom i spoke no one is for the 1 malaysia clinic in urban areas so

1. Find ways to meet the PM and to start this one Malaysia clinics in rural areas.

2. Form a emergency committe to and draft a letter stating all the reasons why the 1 Malaysia should not operate at its present form, and collect signatures first from the Doctors in MMC and then all the 20,000 doctors who are registered  and submit it to the relevant authorities and also the PMS dept. Please don't think it cant be done: appoint a few in each state and get them to sign, don't force them, everyone whom I have talked to is willing. WE had done this for the private health. Dr.Tharma should be able to brief you on that.

3. Ask all the states to have a meeting and decide what other action should be taken because as far as i know none of the doctors are happy.

4. Have a Forum on this issue urgently and get other ideas from members and non members.

5. Can we email this to all our State Reps and have their input.

If what 20,000 Doctors dont think it is right to implement this in its present form and if we cant do anything about it ,then there is something reallywrong with us .

Urgent decision is required; for KB I Can organize the signatures once the letter is ready, please make the letters short so doctors can read it before signing it.

Regards

Jega (Dr N. Jeganathan, Kota Bharu)"

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Earlier Dato' Dr Norul Ameen has this to say:

Dear All,

 

I read with disgust about the so called 1 Malaysia clinic not because it is a ridiculous concept but because I don't understand the 1 Malaysia concept itself.  To me it is nothing but a political hype like the astronaut fiasco. Who is going to benefit from this. Millions were spent to sent one person up to space and at the end of the day how did the citizen of this country benefit.  Like wise who is ultimately  going to benefit from this 1 Malaysia clinic or more aptly who are going to be the losers.

 

I wonder who came up with this 1 Malaysia clinic, as the writer of the article has correctly said the government should be looking at providing better accessibility to health care to the rural people and not to the urban people. The government should be looking at proving tertiary care which is becoming more and more costly than spending money to develop primary care and more so in urban areas. something is fundamentally wrong with the Ministry of health's plan in providing health care to it's citizens.

 

The success is measured by how the government has made health care accessible to all level of citizen's than to come up with programs to increase accessibility of health care to that population which is adequately covered. I think the joint forum of all Medical organizations must come out very forcefully to denounce this absurd idea.

 

Those of us who been around long enough will know nothing is going to come out of this 1 Malaysia concept. If the government is truly interested in promoting 1 Malaysia it can be done without spending any money, and that is when parents go to register their child in the registration department to register the birth of their child they should be allowed to write the RACE of the child as MALAYSIAN. If they continue to have the column of Race to be filled up how can we ever be 1 Malaysia.

 

Dr Ameen

Journal Watch Cardiology Alert: Updated Guidelines for Perioperative Beta-Blockade

Updated Guidelines for Perioperative Beta-Blockade
Clinical Practice Guideline Watch

Revisions include a new recommendation against routine initiation of fixed-dose beta-blockers before noncardiac surgery in low-risk settings.

Sponsoring Organizations: American College of Cardiology, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery

Background and Purpose: In response to publication of the POISE trial results (JW Cardiol May 14 2008), this focused update of the 2007 American College of Cardiology/American Heart Association guidelines addresses the prophylactic use of beta-blockers to minimize cardiac risk during surgery. The update is meant for surgeons, anesthesiologists, patients' primary caregivers, and cardiology consultants. In addition to revised recommendations, the update provides a comprehensive summary of the literature on perioperative beta-blocker therapy.

Key Points:
1. Beta-blockers should be continued in patients undergoing surgery who are currently taking beta-blockers for treatment of indicated conditions (Class I).

2. Beta-blockers titrated to heart rate and blood pressure can be beneficial in patients undergoing vascular surgery who have coronary artery disease or cardiac ischemia identified during preoperative assessment (Class IIa).

3. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing vascular surgery who have >1 clinical risk factor for CAD identified during preoperative assessment (Class IIa)

4. Beta-blockers titrated to heart rate and blood pressure are reasonable in patients undergoing intermediate-risk surgery who have CAD or >1 clinical risk factor identified during preoperative assessment (Class IIa).

5. In patients undergoing intermediate-risk or vascular surgery with a single clinical risk factor identified during preoperative assessment, the usefulness of beta-blockers is uncertain (Class IIb).

6. In patients undergoing vascular surgery who are not currently taking beta-blockers and have no clinical risk factors, the usefulness of beta-blockers is uncertain (Class IIb).

7. In patients undergoing noncardiac surgery who are not currently taking beta-blockers, routine administration of high-dose, untitrated perioperative beta-blockers is not recommended (Class III).

8. Perioperative withdrawal of beta-blockers should be avoided unless absolutely necessary.

9. In general, beta-blockers should be started well in advance of a planned procedure and carefully titrated perioperatively to achieve adequate heart rate control.

Comment: This focused update elucidates the role of prophylactic perioperative beta-blocker therapy in different clinical scenarios. Patients already taking a beta-blocker should continue taking it. In patients who would benefit from a beta-blocker, it should be started well in advance of the surgical procedure and titrated to heart rate and blood pressure. Beta-blocker therapy should be neither initiated on the day of surgery nor stopped abruptly peri- or postoperatively.
— Joel M. Gore, MD
Published in Journal Watch Cardiology December 16, 2009

H1N1 Influenza not really so Benign...

H1N1 Influenza not really so Benign... 

[A recent journal of biology article highlights what is currently known about the (A)H1N1 influenza pandemic & its not so benign course-DQ]

Animal experiments indicate that influenza A(H1N1) 2009 causes relatively severe disease, yet the human disease has been reported as generally relatively mild. How can this discrepancy be explained?
First of all, although initial reports suggest that most human cases of influenza A (H1N1) 2009 infection are mild, particularly in the developed world, this is somewhat misleading as the symptoms are generally reminiscent of those observed with seasonal influenza infection (fever associated with upper respiratory tract illness) and even seasonal influenza is estimated to cause 250,000 to 500,000 deaths worldwide each year.

Second, up to 40% of infected individuals present with vomiting and gastrointestinal (GI) symptoms, which is higher than for seasonal influenza, and while there is no evidence as yet, this may be indicative of more extensive viral replication. This is actually consistent with three recent studies on the pathogenesis and transmission of influenza A (H1N1) 2009 in ferret models of infection [8,11,12].

All three studies showed that the pandemic strains exhibit more extensive replication in the respiratory tract, particularly the lower respiratory tract, of infected ferrets, as well as in mice [11,12], non-human primates and pigs [11]. Moreover, Maines and colleagues were able to isolate virus from the GI tract of infected ferrets, suggesting an explanation for the increased incidence of GI distress in infected people [12], although no virus has yet been detected in the GI tract of human cases.

All three studies also showed that influenza A (H1N1) 2009 caused more tissue damage in the lower respiratory tract than do typical seasonal influenza strains.

So are you saying the human disease actually isn’t mild?

In some cases, certainly it isn’t. It is important to note that the (H1N1) 2009 virus does cause severe infection in some people, including those who are otherwise healthy. While some fatal cases have been attributed to secondary bacterial infections or exacerbation of other health conditions, as is commonly seen in fatal cases of seasonal influenza in the elderly, an unusual feature of influenza A (H1N1) 2009 infection is severe viral pneumonitis, leading to acute respiratory distress syndrome, prolonged stays in intensive care units and extended use of mechanical ventilation or extracorporeal membrane oxygenation (ECMO) [13,14]. It is unclear what predisposes some people to mild versus severe complications.

And the tissue damage shown in the animal experiments? Isn’t that also indicative of severity?

That is not clear for humans. Although the animal experiments show that influenza A (H1N1) 2009 infection causes more extensive tissue damage than seasonal influenza infection, this could be relatively minor in humans, possibly because of the relatively low binding affinity of the influenza
A (H1N1) 2009 viral HA for human receptors. Human influenza viruses bind their target cells through recognition by the viral HA of cell surface glycoproteins that have sialic acid moieties linked to galactose in a α2,6 configuration.

When Maines and colleagues used a glycan array to compare glycan binding of HAs from influenza A (H1N1) 2009 and 1918 Spanish influenza [12], both showed the same binding specificity and pattern, but the influenza A (H1N1) 2009 HA bound with lower affinity than did the 1918 virus HA. This was attributed to amino acid differ ences in the HA binding site.

Lower binding affinity could affect the degree of inflammation and pathology caused by (H1N1) 2009 infection, so that although the virus seems to cause more tissue damage, the pathology may not be as extensive as that seen in infection with the more virulent 1918 Spanish influenza virus or highly pathogenic H5N1 viruses.

MALAYSIA’S DOCTOR OF TOMORROW - Dato' Dr Ronald McCoy

MALAYSIA’S DOCTOR OF TOMORROW

Dato' Dr Ronald S. McCoy

Introduction

Medicine had its origins in ancient Greece in the 7^th century BC and is one of the oldest and most respected professions in the world. Medicine is an exquisite blend of science and art – the science of preventing, diagnosing and treating disease, based on scientific evidence, and the art of healing, which goes beyond diagnostic, therapeutic and technological skills.

Western medicine is based on mastering a core of knowledge, a code of ethics, and a scientific, systematic approach to decision-making, based on a predetermined model of disease. 

There is both an overt curriculum, made up of factual subject matter, and a hidden curriculum, made up of the high expectations of physicians by fellow physicians and society. It takes daunting years of training and apprenticeship to master the practice of medicine and become providers of competent, effective, appropriate, safe and patient-centred care. In fact, medicine is a life-long learning process and a compliant attitude to continuing professional development is essential.

The profession of medicine is essentially a vocation, distinguished by altruism and a sense of social responsibility. In recent years, medicine seems to have lost its way, lured by modern versions of the Greek mythological Sirens. 

In a rapidly changing world, medicine has sometimes come to resemble a nine-to-five job or a trade or even a business. Perhaps, benign neglect in teaching the philosophy of medicine and medical ethics, before and after graduation, has something to do with it. Perhaps, the lack of good role models is another factor.

Doctors face a shifting medical landscape and have to adapt and respond to changing patterns of disease and new epidemics; address rising costs of health care, growing patient expectations and demands of accountability, expressed in a patient’s charter; adjust to advances in medical and information technology; and consent to clinical governance and regulation.

The paradigms and pressures of the modern world appear to be submerging the core values of medicine. In some countries, there is political interference in the professional independence and integrity of doctors as well as the economic pressures of private enterprise and business, marketing and advertising, profitability and the bottom line. 

These paradigms are being embedded in a dynamic global culture, largely subsumed by the concepts market economics. While medicine cannot change all aspects of culture, nevertheless, the medical profession can and must offer resistance and exert its still considerable influence on society to ensure that negative influences do not degrade medical professionalism or undermine the qualities expected of a doctor. It is in such an environment that the doctor of today stands, gazing into the future.

Medical education in Malaysia

For those who contemplate a career in medicine today, beware the dangers of false expectations and a changing world view of medicine. Medical education in Malaysia sits uneasily on a national health system that is splintered into two and in urgent need of reform – a government-funded public sector for the poor and a separate private sector for the rich. 

Malaysia’s doctor of tomorrow will face many challenges:

·      First, the educational challenge of coping with the consequences of compromised education standards in government primary and secondary schools. In particular, low proficiency in the English language will shape and determine the level of tertiary education, including the teaching of medicine.   

·      Second, the challenge of ensuring that a culture of excellence will nurture medical schools with high standards and that the method of selection will lead to the admission of qualified students, capable of being trained to be competent and ethical doctors. This will depend on several factors:

The standards and requirements of medical education, set by the Malaysian Medical Council (MMC) and the Malaysian Qualifications Agency (MQA) are generally adequate, but there appears to be evidence of failure in implementation in some areas. These shortcomings can and should be rectified by the MMC. This is a particularly important aspect in profit-driven private medical schools and distant foreign medical schools.   

The accreditation of foreign medical schools merits the special attention of the MMC in critically evaluating teaching methods, quality of teachers and learning outcomes. The status of such schools should be closely reviewed and their graduates subject to a common qualifying examination, before they are registered as doctors. Reports from hospital consultants, who supervise the training of housemen, would help in assessing quality.

Education has become a relatively unregulated business in many countries. The damaging impact of agents in enrolling students in suspect foreign medical schools, which teach in a foreign language and have dubious standards, is a matter of great concern.

The problems of recruiting and retaining good clinical teachers and resisting political pressure to lower standards make it difficult to maintain a high standard of undergraduate and postgraduate medical education. The improvement of the doctor-population ratio should not be at the expense of quality.

There is a real danger of mediocre teaching, resulting from the brain drain of senior, experienced clinicians from teaching hospitals to the private sector, owing to the huge differential in income between the two sectors and the government’s misguided health tourism policy.

The separation of university teaching hospitals and government service hospitals should be reviewed and arrangements made to designate some government hospitals and staff as teaching partners.

Teaching methods in medical schools vary and can be problematical. The shift from a traditional curriculum to an integrated curriculum will require a concerted effort to orientate the teachers.

There is a need to regularize and modulate medical curricula in a transparent and accountable manner, as globalization and internationalization are beginning to transform medical education. 

An insightful curriculum will embrace patients and community needs, and equip students with skills to meet postgraduate challenges, including the need for effective use of medical knowledge, appropriate use of medical technology, the development of professionalism and medical ethics, and the need to restructure and redesign the programme for continuing professional development, in the face of an aggressive pharmaceutical industry.

In the medium term, there will be a need to cap the number of medical schools in the country, particularly private medical schools, and gradually reduce student intake to maintain an optimum doctor-population ratio.

Professionalism

Professionalism is an important attribute in any doctor. It is governed by an agreed set of rules and standards of practice and conduct, determined by the profession and society, in the public interest. 

It is important that the medical profession does not interpret professionalism as a licence to serve the interests of the profession itself, rather than the needs of the population it has a duty to serve. 

It also has a duty to maintain professional standards, independent of political or commercial influence, while always being accountable to the public. Apart from knowledge, it is professionalism, ethical practice and compassion that transform a doctor into a healer.

Despite modern health systems and profound advances in medical science and technology, patient-care studies show a steady decline in public satisfaction and trust in the doctor-patient relationship. Although a significant number of patients are satisfied with their individual doctors, there is discontent with the total health care experience. 

This has led to a growing movement towards alternative and complementary medicine. 

A Mori poll in 1999 asked a random selection of the public to say which professionals could be trusted to tell the truth. The results were: doctors 91%, judges 77%, scientists 63%, businessmen 28%, politicians 23%, and journalists 15%.

In recent times, there have been unsettling political trends in Malaysia. We have seen how the independence of the judiciary has been compromised and cowed by executive power. 

We have seen how some members of the medical profession have also been subject to political pressure.  They have recently come under close public scrutiny when they appeared to have succumbed to political pressure when making medical reports on custodial deaths. 

To give you some idea of the problem, between 2003 and 2007, there were 1,535 deaths in prisons, rehabilitation centres and detention centres for illegal immigrants, and very few of those responsible for the safety and well-being of those in custody have been tried or convicted.

The doctor of tomorrow will continue to be under political pressure, unless the medical profession today stands united and firm against the attacks on its professionalism, its independence, and its integrity. 

Until the Malaysian Medical Council (MMC) is reformed and its membership made up of a majority of elected members, it will not be an independent body. It will not feel empowered or inclined to proactively and independently scrutinize the veracity and credibility of medical reports on the causes of strange custodial deaths. In more enlightened countries, not only do national medical councils have a majority of elected members, they also include lay persons.    

Consensus Statement on the Role of the Doctor

In Britain in 2007, Sir John Tooke chaired an Inquiry into Modernising Medical Careers, which called for the profession to speak with a coherent voice and to define the role of the doctor. 

The profession heeded that call by organizing a conference, which issued a Consensus Statement on the Role of the Doctor. Among other things, the statement made the following points:

·      Doctors must be capable of taking ultimate responsibility for difficult decisions, drawing on their scientific knowledge and clinical judgement.

·      It agreed with the International Labour Organisation’s definition of the role of the doctor, namely, that the role of doctors as clinical scientists is to apply the principles and procedures of medicine,

·      supervise the implementation of care and treatment, and conduct medical education and research.

·      All doctors require a set of generic attributes to merit the trust of patients that underpins the therapeutic relationship. These qualities include good communication skills, the ability to work as part of a team, non-judgemental behaviour, empathy and integrity.

·      The nature of these core attributes emphasizes the need to select medical students with appropriate attributes for training.

·      All doctors have a role in the maintenance and promotion of the health of the population, through evidence-based medicine, health education, and health advocacy.

·      Within a world where the capacity to treat is growing but financial resources are finite, doctors have a duty to use resources wisely and effectively and engage in constructive debate about such use.

·      The role of the doctor is changing, alongside the needs and expectations of patients, who are increasingly better informed. The doctor acts as a partner and serves as advisor, interpreter and supporter.

So, there you have it! There is much we have to do in this country to strengthen the medical profession, reform the delivery and financing of health care, and improve medical education for Malaysia’s doctor of tomorrow. And, of course, change the political culture and structure!

Presented at a forum at the International Medical University on

5^th December 2009 on behalf of the Malaysian Medical Association.

1Malaysia Clinics: An Exercise in Futility

My recent article in Malaysiakini Commentary (04 Dec 2009):

Budget 2010 while seemingly benign and nearly forgettable, did not quite please many a doctor or those in the health care system.

The sudden and sneaky introduction of the so-called '1Malaysia clinics' to be manned by medical assistants, instead of doctors, and to be located in urban locales have piqued nearly all private medical practitioners in the country.

The internet and the alternative media are abuzz with recriminations and angry bloggings by doctors and doctor groups, who question why such an obviously retrogressive move has been foisted upon the Malaysian rakyat.

Yet surprisingly, not a few public-minded readers of main stream media had only open praises for the government for proposing these new supposedly 'free' clinics for urban dwellers, as evidenced by the letters of support in their interactive columns.

Clearly, many such supporters feel that recent health care costs have become too much for them to afford, although, this is quite unsupported by the facts on the ground.

Our private health care costs are quite reasonable and of acceptably high standards when compared with our neighbouring countries, in terms of purchasing parity or inflationary terms.

Most city clinics charge a reasonable sum of between 25 to 40 ringgit for physician consultation including medications. This works out to be less than a usual meal for 2 or 3 people.

Yet we understand that for some people, this may prove to be too expensive. These urban poor would usually be those who utilise the public sector clinics in government establishments.

It is likely that for too long the government has been offering practically free health care services to nearly everyone on demand, that not too many people bother to plan or budget for any such 'extra' expenses. Perhaps, many now believe that health care should be an expected right of every citizen.

Whichever is the case preferred, our rakyat must make their stance clear to the government. Which system do they want? A command state-controlled public-driven national health system, or the current dual-tier system of a market-driven free choice private system, working in tandem with a 'safety net' mechanism funded by the public purse?

However, like it or not, ours is not a single-payer National Health Service as yet. Our tax base is actually very small (1.2 million taxpayers, and probably 6-7 million current provident fund contributors), and there have really been no preferential or special social/health taxes to cater specially for this in our national health plan.

The latest national budget 2010 has indeed shrunk the health care allocation from the public purse, down some 4.8 percent to just over 13 billion ringgit. The government expects the private sector to take up the slack and push the overall health expenditure to a respectable 7 percent of our GDP, instead of the current 4.9 percent.

The reduced public service expenditure is not enough to cater for this. So it appears that the government wants to move toward improved efficiencies and reduced expenditure, rather than simply continuing with more of the same, unsustainable model.

So what's the logic of the public sector putting in such piecemeal local projects such as 1Malaysia clinics? In terms of quantum and social impact, the 10 million ringgit for 50 urban 1Malaysia clinics does not make much sense, except perhaps to assuage some misguided ego-boosting government agency or two.

More importantly, do we really need these clinics?! Do we want such questionable lower standard of care just because it is superficially cheaper to maintain?

Isn't the shortage more in remote and rural areas, especially in the interiors of Sabah and Sarawak, where the doctor-population ratio is so wretchedly large, and the health care facilities so sparse and sporadic?

It is especially ironic because in towns and cities, there are enough doctors to cater to the health needs of most, if not all urban dwellers. In the Klang Valley itself the doctor-population ratio is around 1 in 380, more than enough for even the most developed nations.

This is also true of most towns and cities in the country (around 1 in 600). There is therefore, really no shortage of health services or personnel in such urban areas.

Health care can never be a free lunch

In fact, due to some skewed sense of urban penchant, doctors especially GPs, continue to vie with each other, ever so competitively by locating in inner-city sprawls, with many now just eking out paltry livelihoods.

So why, it begs the question, would the government see fit to jostle for such overcrowded spaces, if not to spite the medical profession?

Perhaps, there is that misguided thought that by offering urbanites some goodies, no matter how inane, citizens might be persuaded to look upon the federal government more favourably, considering that almost all metropolitan parliamentary political representatives are from the opposition parties!

Nevertheless, notwithstanding the possibly noble intentions of the authorities, we seriously question the rationale and the sudden move, which we feel are at best

misguided and not too well-thought of.

We understand that because for a very long time, we have had tax dollars paying for our nearly free public health care services, a large number of our citizens have come to expect that this should continue indefinitely.

However, one to five ringgit for seeing a doctor in the public health care sector, hugely subsidised or free investigations and therapies, and months of free medications, (totalling only 2 percent copayment for public health care expenditure), cannot be a sustainable option.

The current realisation is that most countries in the world cannot sustainably afford socialised medical system, unless there are accompanying high statutory contributions or taxes.

Yet despite such high social taxes, some upwards of 40 percent, there are unavoidable glitches with enforced rationing, prolonged waiting times, diagnostic and therapeutic delays and even deliberate choice reductions, and even to systematically exclude new, cutting-edge or really expensive therapies.

In other words, something's got to give. Health care can never be a free lunch! Infinite health care needs always outstrip finite resources.

But, we are aware that some the less endowed of our populace actually depend and benefit from such a much needed service. Thus, we feel this service cannot be done without, no matter the pressing need to revamp the system.

It is estimated that one-third or so of the rakyat are looked after by some 10-12 percent of pimary care physicians now left in the public sector service, which explains the overcrowding, long queues and waiting times.

But we have to consider a different mechanism to respond to such needs. I believe the medical profession will wholeheartedly support a reform of a properly considered alternative mechanism(s), but these should be undertaken with in-depth input from all stakeholders and which would require great political will and planning.

Should we then be embarking on such a drastic paradigm shift with such haste? Perhaps sooner rather than later as some health economists might suggest. Yet, different agencies of the government appear haphazard in their approaches to the health care 'industry'.

They have promoted and continue to push private healthcare initiatives and insurances; new hospitals and medical centres are mushrooming; and we are targeting and enlarging our medical tourism incentives, which leads to a 'schizophrenic' scenario as to what we truly want!

Sadly this has excluded sufficient public discourse and debate - these opinions might be quite different from what the government imagines it knows. Instead of boosting and improving healthcare services and access, we appear to be taking the cheaper but possibly mediocre approach; worse, at taxpayers' expense on the one hand, and paradoxically encouraging super-duper specialist private sector growth on the other!

It cannot be denied that by having economists dictate some of these market driven policies, we inadvertently but invariably encourage and push even greater public-to-private sector expertise migration, thereby undermining the public services even more...

Adding insult to injury

Perhaps, this exercise is just another political posturing which had been hurriedly pieced together to extract some cheap brownie points on a perceivably weak government, whose popularity needed some wagging-the-dog boosts!

To add salt to the wound, these so-called '1Malaysia' clinics would compete with the already overly cutthroat urban clinics; but to be manned by 'medical assistants'. That notion of not too subtly shifting the task downward by possibly non-health personnel bureaucrats is what takes the cake of adding insult to injury!

In one fell swoop, it would appear that the authorities had "ambushed" (as voiced by one angry doctor) the medical professionals once again, by proposing newfangled schemes which are arbitrary, uncalled-for and possibly 'illegal', especially when viewed vis-a-vis the Private Healthcare Facilities and Services Act/Regulations and the Medical Act.

It is pointedly clear that any and every clinic should be manned by a registered medical practitioner. To do so otherwise would be to go against the law no matter the fact that there may be supervision from a medical practitioner from afar.

Whatever mechanism of oversight now employed would appear to be an afterthought justification, which is convenient but probably still illegitimate.

In fact, the Ministry of Health and the law has prosecuted and indeed fined and jailed medical practitioners for employing under-qualified or unqualified people just for such unprofessional practices. Now it appears that one law is to be applied differentially for the private sector clinics, and

another for those operated by the Ministry of Health!

So it is not surprising that many medical practitioners are up in arms, that such a move by the government once again undermines the bittersweet equanimity of our already beleaguered medical practices, just recently reeling from the imposition of the private health care facilities and services Regulations in 2006.

Still, perhaps it is good for more of us medical professionals to feel the need and the want to do something and at last, to resort to some form of collective action. When push comes to shove, at least some have been moved to take action, to have become agitated, angry and perhaps finally, willing to take some action, belatedly as the case may be.

Sadly, such reactive knee-jerk reflexes are only triggered whenever doctors' purse strings appear to be at risks, their livelihoods at stake. In such a light doctors often come across as venal and mercenary. Yet the reality is more complex than that.

As physicians we have been advocating for greater professionalism and higher standards of clinical care. As doctors we believe that our patients expect a higher better standard of care, too. As we move up the quality ladder, we should not be resorting to possibly lower standards just for quirky convenience or political purposes.

The current concept of '1Malaysia' clinics just do not gel, and are uncalled for. What the authorities can do instead, is to tap into the hugely available GP clinics which are already crying out for more patients and greater public-private partnership. Let's work together rather than waste public funds for questionable standards of care, and shortchanging our less discerning rakyat.

Dr David KL Quek was the editor-in-chief of 'MMA News' (bulletin of the Malaysian Medical Association) for 11 years. He is currently president of the MMA.

1Malaysia Clinics: President's Response, 27 Nov 2009

My latest response to Dato' Dr Thuraiappah and Dr Xavier (27 Nov 2009)

Dear Dato Thurai and Xavier,

I'm sorry if I sounded quite brusque the last time. Personally I concur with both of you and many others who feel that the GPs need to boost their capacity to be more full fledged and perhaps arguably more complete and competent primary care physicians, and that the only way forwards is to ensure that everyone undergoes CPD lifelong.

However, the reality of the ground is that most GPs are totally averse to more regulations and prescriptions of more rules which dictate what each should do to benefit from supposedly wider disbursement of primary care services.

Last night we just had a National Health Policy committee meeting, and we heard from 2 GPs, Dr Tan and Dr Krishnamurthy who were vocalising their unease with any more restrictions on their services and their livelihood.

They represent some GPs on the ground who feel that the OPD services of MOH is far worse than their anecdotal cases they have looked after. Conversely the MOH feels that our GP services thus far is also below bar. we have to find the truth in between, finding the strengths of each rather than just the weaknesses.

It is in this context that I think the MMA have to present a collective front of consensus. There are just too many disagreements right now and we all have to work towards a more persuasive atmosphere of voluntary CPD including the AFPM QIP which I have actually encouraged for some time.

But if we at all individually begin to suggest that stringent and restrictive requirements for GP involvement in the MOH distribution of its primary care patients, then we can lead to impasse and a lot of GP unhappiness, even outright revolt. So I welcome all discussions on this, but please let's have internal dialogue and try and find a way forward--some compromise will be needed on a win-win basis.

Cheers and best wishes!

Can I encourage you both to join our MyHealth Matters-MMA 2009-2011 facebook chat site?I would also include your emails for further discussions by others.

1Malaysia Clinics and AFPM: Dato Dr DM Thuraiappah's Comments

Dato Dr DM Thuraiappah's Comments 27 Nov 2009

Dear Dr David Quek,

I have read with interest the many replies to Dr Xavier’s mail with interest. I feel there has been some misunderstanding of Dr Xavier’s letter.

Firstly the concept of ‘One Malaysia Clinics’ was the Prime Minister’s proposal that twenty odd clinics be opened to be manned by HA’s or equivalent to manage simple outpatient illnesses with standard prescriptions by a visiting medical officer and these clinics are to be located in heavily populated areas in Malaysia with budget of about RM200,000.00 and to be opened by January, 2010. This is indeed a tall order and whether this will be realised is questionable.  This idea is good for patients who currently use the public primary care system.    

Secondly, the proposal by the MOH to enable general practitioners to care for chronic diseases in order to reduce the workload of Kelinik Kesihhatan and public hospital outpatient departments was the point which Dr Xavier was making. For this to happen, to be fair to all concerned, although it will be good for the general practitioner there are several prerequisites to be in place. 

1. There has to be a referral system in place from the general practitioner to the consultant and returned to the care of the general practitioner. In order for this process to happen, the consultant has to be confident that such care can be continued in the general practitioner set-up. Here, various definitions have to be clear and precise.
2. That the patients will have to be able to receive the same investigations, procedures and prescriptions from the general practitioner as they receive from the public sector. How the mechanism for payment for such services rendered will take place will only take effect when the national health financing mechanism is in place or any other mode of payments is established.
3. Currently there is concern whether the investigations, procedures or prescriptions can be uniform among all general practitioners. The concern has arisen that some clinics may lack some essential items to carry out acceptable methods of care.
4. The nature of general practice is family care but some clinics may not have some essential equipment and do not practice a variety of services such as pre-employment medical examinations, wellness services, counselling services,  surgical or gynaecological care or procedures. The common chronic diseases which need to be looked at are hypertension, coronary artery disease, metabolic syndrome, screening for cervical cancer, asthma ad mental health.  
5. It is therefore in our interest that these disparities must be discussed among ourselves and we must endeavour to provide the expectations of the public sector so that we can be united by auditing our selves by our own profession.
6. CME may not be sufficient because of its opportunistic in nature. One must look at structured CPD be in place so that doctors can learn skills to equip them in accessible, continuous and comprehensive family oriented care.  
7. The Director General of Health has repeatedly announced at various meetings that general practitioners should be trained to a level of primary care physician, and I think there is a message in his frequent announcements that it may be a requirement in the future.

I hope that Dr Xavier’s mail be taken in the spirit it was written.

Yours truly,

D. M. Thuraiappah, Council Chairman, AFPM        

1Malaysia Clinics: Dato' Dr Tharmaseelan's comments

Dato' Dr Thuraiappah's Comments (AFPM Council Chairman) on our 1Malaysia Clinics

Following this Dato' Dr Tharmaseelan also commented: 21 Nov 2009

Am in total agreement with the President on the matter.

All GPs should be allowed to join the 1care clinics. There should not be conditions imposed on becoming one.

Marginalising a section of the GPs based retrospective regulatory measures in unfair .

I doubt even the MOH would think of such a measure so why propose one unless there are some unseen motives

NKS Tharmaseelan
DATO DR N.K.S.THARMASEELAN

       

1Malaysia Clinics: Response to Dr Xavier's Comments

My Response to Dr Xavier's comments (21 Nov 2009)

Dear Dr Xavier,
I note the concerns in your correspondence.

However, I also wish that you would refrain from suggesting your personal viewpoints which can be discussed within the ambit of national representation in the PPSMMA, but which on their own, may also be misinterpreted by the MOH as policy agreement with your suggestions by the national MMA.

At the current point in time, the MMA is not in favour of any more regulations or imposition of conditions to be appointed GP clinics which can be accredited or accorded practice rights by the MOH.

We are working with the MOH and the Health Minister to see if all our GP clinics can be incorporated into the primary care system which will then benefit all. Of course we encourage self-CPD/CME programs to enhance the quality and standards of care, but we will not wish to be unfair to any GP/FP who may not have the necessary paper diplomas to carry out his due practice and benefits.

We cannot at this juncture jeopardise these efforts by offering only to a few who have these arbitrary paper qualifications. We believe that sufficient time, notice and effort be made, so that more and more GPs will recognise the importance of CPD/CME and thus voluntarily engage more readily into these programs. With the revised Medical Act, sufficient points earned can already be used for APC licensing and thus obviate more regulations which will encumber the GP/FP even more.

So your suggestion to limited recognition based on the FP diploma is at best very personal and premature and probably unfair and discriminatory to a whole lot of GPs out there. I reiterate that I have no personal interests in this, as I am a specialist totally uninvolved in this exercise.

I have been getting feedback from our PPS as well as from a large number of GPs, and recently through the PPSMMA NWC meeting recently. Please try and organise your ideas through the proper channels so that we can have a more collective and concerted united stand.

With best wishes and best of intentions,

Dr David KL Quek, President MMA

--------------------ooooo00000ooooo----------------------------

Dr Xavier's reply 23 Nov 2009:

Dear Dr David Quek

 

I am in favour of 1 Malaysia Clinics to be managed by General Practitioners. I would like the GPs to not only manage 1 Malaysia Clinics but also to manage chronic cases. 

 

For this we must update ourselves to manage these cases well.I have only given two examples of poor management of chronic cases.

 

I will present a paper of pitfalls in management of chronic cases at the next GP meeting and after that you decide for yourself whether a proper update is necessary.

 

This is my own opinion and not that of MMA. I hope i have made my situation very clear and i do not wish to hurt anyone.

 

 

Regards,

Dr.Gnanasegaran Xavier

MBBS FAFP FRACGP CIME AM

1Malaysia Clinics: Letter from Dr Gnanasegaran Xavier, Family Physician Penang

This letter was cc'd to me on 21 Nov 2009

Dear Dato Dr.Teh, (Penang State Director of Health)

Thank you very much for your prompt reply. I think we should do a pilot project amongst GP Clinics interested to become 1 Malaysia Clinics. To become 1 Malaysia Clinics maybe we can request the doctors to at least have a diploma in Family Medicine organized by the Academy of Family Physicians. If the pilot project is a failure we can always discontinue it. But if it is a success I think many people would gain and it would be a win win situation.

For the management of chronic cases these clinics could be used. I had asked about the cost incurred by KKM in managing chronic cases like Diabetes Mellitus during the Nadi Conference. If cost incurred by KKM and the private clinics are going to be similar than we can always use these clinics to manage the chronic cases. This would definitely reduce the work load at the Klinik Kesihatan. I have attached here a Diabetic case. With Amputation of toes and another management of Diabetes Mellitus with gross protein urea.

I also had dissccused with Dato Dr.Christhoper Lee about H1N1 Management by GP Clinics and being reimbursed by KKM. Would management of H1N1 be better if there is combined effort?

At the moment I feel the General Practitioners are neglected and we should bring them into the main stream. KKM can definitely monitor these Clinics and make sure they meet the required standard. I think if we put all our heads together we can have an excellent GP force in the country.

 Mr.Palani ,Dr.Hooi and I are already preparing for the 13^th Teaching Course for GP’s from 23th September 2010 to 26^th September 2010. Attached also is the previous feedback for the 12^th Teaching Course. This course was motivated by our late Dr.M.K Raj Kumar and it is now going to its 13^th year.

I help out the Tzu Chi Dialysis centre at Bagan Ajam (voluntary) and I notice most of the people undergoing Dialysis there are due to end stage renal failure from Diabetes Mellitus. If we can prevent an amputation of a single toe and prevent one Diabetes Mellitus patient from becoming End Stage Renal failure than I believe we have achieved something very great.

1 Malaysia Clinics should not be a political issue but should be a KKM issue.

Regards,

Dr. Gnanasegaran Xavier

MBBS FAFP FRACGP CIME AM

1 Malaysia Clinics: More for the Haves?

1 Malaysia Clinics: More for the Haves?

Dato’ Dr Sarjeet Singh Sidhu

Hon. Dep Secretary, MMA

No sooner had the PM announced the 1 Malaysia Clinics to be set up in urban areas the idea was being lauded by one and (almost) all. 

On the surface it does seem to be a good idea. I mean who can quarrel with the idea that now more (Govt) clinics will be within striking distance for the urban folk in our over-extended, sprawling cities? 

No more long distance travels and no more long waits and the poorer sections of the rakyat can get the same treatment as their better-off counterparts who will be visiting the private clinics to avoid long waits at the Govt hospitals. That in essence, I think, is how most people will understand the concept. But no, some people have a different, if flawed understanding.

With the concept of 1Malaysia still quite nebulous in most citizens’ minds it is inevitable there be some confusion. The 1Malaysia concept is understood by some to be a vision wherein we (Malaysians) will think along non-ethnic lines, and by some to mean there will be a cross-section of ethnicities represented in every (Govt) department and in every phase of the nations development, that all Malaysians will have equal access to Govt funds (scholarships for example).

In general (hopefully) most Malaysians think it means or must mean “1 Malaysia policy should serve all and equitably” [1] or as some voices on one forum [2] said: “1Malaysia to me is Malaysia for Malaysians... 1 Country regardless of race” or “1Malaysia... A country of equal opportunities...  And ethnocentrism is a thing of the past.”

Whatever each individual’s perception of the concept the PM says that “the 1Malaysia concept’s ultimate objective is to achieve national unity among its people. He said "In other words, 1Malaysia is a concept to foster unity in Malaysians of all races based on several important values which should become the practice of every Malaysian””. [3]

Here is one more Malaysian who does not quite know what it all means; he asks: “Can someone enlighten me why there are plans to have "1Malaysia Clinic"? Do you mean that the clinic have Malay, Chinese, Indian and other doctors operating in? Do you mean that other clinics are not par with 1Malaysia theme? where clinics are not open for all? Do you think this "1Malaysia" tagline is over-used?” [4]

So now that we are sure that many Malaysians are unsure as to what 1Malaysia means perhaps we can take a look at the shortcomings in relation to the 1Malaysia clinics.

The World Medical Association (WMA) and the United Nations encourage “Task-Shifting” (TS) in specific situations. The WMA Resolution on TS [5], adopted by the WMA General Assembly, New Delhi, India, October 2009 describes it TS as “a situation where a task normally performed by a physician is transferred to a health professional with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without having a formal health education” (my emphasis). It further states “A major factor leading to task shifting is the shortage of qualified workers... The rationale behind the transferring of these tasks is that the alternative would be no service to those in need” (again emphasis added). The WMA does, however, caution that “This may be appropriate in countries where the alternative to task shifting is no care at all but should not be extended to countries with different circumstances”; in other words TS is not for places where there is already available quality healthcare provided by doctors.

Clearly, in our situation where the stated reason for opening these 1M clinics is “to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics” [6] the care will be provided by less skilled personnel (“manned by medical assistants or paramedics”). It would be difficult to oppose the plan if the 1M clinics were actually manned by doctors, but that is not the case here.

To my mind the obvious flaws in the IM clinics plan are:

1. These will provide service by less qualified personnel to that segment of Malaysians.
2. Not withstanding the above, these clinics will provide additional services to those who already possess such services by qualified personnel.
3. What is the standard of care that the courts will expect from these 1M clinics? If a lower standard is expected (i.e. commensurate with the training and expertise of the MAs) then this is clearly a case of providing lower standard of care in areas (urban) where a better standard of care is already established via the plethora of GP clinics in urban areas.
4. What will be the legal liabilities arising out of medical mishaps consequent upon the use of “medical assistants or paramedics”? And mishaps will arise sooner or later.

As Dr Mary Cardoza pointed out in an email correspondence “the concept of "bringing the service to the people" is good but there are already many GP clinics in the towns (to) provide this service to people.  The obvious areas where these IM clinics will be of better use are areas where NO service at all is available for now. Examples that spring to mind are the Orang Asli settlements (especially if far from towns), and the deep interiors of Sabah and Sarawak.

Every year Malaysia is set to get 3000 new doctors entering service (half from local universities and half from overseas universities). Already we have insufficient places for their housemanship training; many will be quickly released and enter private practice. How are all the current GPs and the new ones expected to come in going to make ends meet?

According to a Bernama report Penang is already looking at sites for these clinics [7] and this despite the knowledge that Penang already has so many GPs and Private hospitals in such a small area. This is again a case of providing even more benefits (IF there is any benefit to be derived from treatment by less qualified personnel) to those who already have more than ample access to healthcare whilst leaving out those who have NO access to healthcare.

It’s been reported that “For a start… an allocation of RM10 million will be provided to set up 50 clinics in selected areas” [6]. That works out to RM 200,000 per clinic per year. Now if the REAL aim of the 1M Clinics is “to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics” [6] then it will be far more prudent and convenient to spend that money by roping in the GPs who already dot the entire landscape of most cities and towns. Again as Dr Mary Cardoza points out in her mail “MMA has offered the services of its members for this purpose many years ago and was told that this was accepted in principle; however, nothing concrete has materialised”.

I, for one, cannot fathom how 10 clinics, strategically located in overpopulated areas of our cities, with ample quality care available can be a move forward because they will now have even more clinics, run by less qualified personnel, to make life easier for them, whilst large areas with no or inadequate healthcare will remain so for some time more? 

Is it because these areas are under-populated? 

Am I missing something: more for the ‘haves’ and less for the ‘have-nots’?

References:

1. http://dayakbaru.com/weblog08/2009/04/27/re-thinking-one-malaysia-concept/
2. http://recom.org/forum/showthread.php?t=9129
3. http://www.malaysiatoday.com/Latest-News/1malaysia-concept-all-about-unity-pm.html
4. http://blog.thestar.com.my/permalink.asp?id=27428
5. http://www.wma.net/en/30publications/10policies/t4/index.html

6. NST 23 Oct 2009 http://www.nst.com.my/articles/20091023203300/Article/index_html
7. http://malaysia.news.yahoo.com/bnm/20091024/tts-nor-land-bm-993ba14.html

15 November 2009

Post-Script:

After I wrote of the above it was brought to my notice by a politically well-connected individual that there is more to the 1M clinics than meets the eye. It seems that the push for such clinics came from the Medical Assistants (MA), once called Hospital assistants (HA), and recently “promoted” to Assistant Medical Officers (AMO). Evidently the suggestion for such clinics, to be run by the MAs/HAs/ AMOs, came from the MAs themselves. It’s been said that this is one way for some of them to remain in the urban areas (mainly the cities and larger townships) and not get posted out to remote areas. The designation as AMOs gives them better status and, together with the running of the 1M clinics, will add weight to their requests for a jump to a higher level on the pay scale. But why would anyone pay attention to such requests? Well, it’s been said that are many of these MAs, and a great number of them are active (influential?) party members. Makes sense? It does if the story is true.

1Malaysia Clinics: It’s time to get angry, agitated, involved!

1Malaysia Clinics: It’s time to get angry, agitated, involved!

Dr David KL Quek,

drquek@gmail.com

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions  and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”
~ Sir William Osler

Once again the internet and the alternative media are abuzz with recriminations and angry bloggings on why such an obviously regressive move has been foisted upon us, the hapless doctors, especially the GPs in urban locales!

Yet, a few public-minded readers of main stream media had only high praises for the government for proposing these new free clinics for urban dwellers, as evidenced by the letters of support in their interactive columns.

This is not altogether too surprising because, many of these people obviously feel that health care costs have become too costly for them to afford, but which is quite unsupported by the facts on the ground. Our private health care costs are quite reasonable and of high standards when compared with our neighbouring countries, in terms of purchasing parity or inflationary terms.

Perhaps, for too long the government has been offering practically free health care services to nearly everyone, so much so that not many people bother to plan or budget for any such ‘extra’ expenses. Perhaps, we now believe that health care should be an expected right of the citizen.

Like it or not, however, ours is not a single-payer National Health Service. Our tax base is actually very small (1.2 million taxpayers, and probably 6 million provident fund contributors), and there have really been no preferential or special social/health taxes to cater for this in our budget.

The latest national budget 2010 has indeed shrunk the health care allocation from the public purse, down some 4.8% to just over 13 billion ringgit. The government expects the private sector to take up the slack and push the overall health expenditure to a respectable 7% of our GDP, instead of the current 4.9%. Clearly the public service expenditure is not enough to cater for this.

So where is the money coming from, if the public sector puts in piecemeal local projects such as 1Malaysia clinics to compete with urban GP practices? In terms of quantum, the 10 million ringgit for 50 urban 1Malaysia clinics does not make much sense, except perhaps to assuage some misguided ego-boosting government agency or two!

Most importantly, do we really need these clinics?! Isn’t the shortage more in remote and rural areas, especially in the interiors of Sabah and Sarawak, where the doctor-population ratio is so wretchedly large, and the health care facilities so sparse and sporadic?

This is especially ironic because in towns and cities, there are enough doctors to cater to the health needs of most, if not all urban dwellers. In the Klang Valley itself the doctor-population ratio is around 1 in 380, more than enough for even the most developed nations. This is also true of most cities in the country (around 1 in 600). There is therefore, really no shortage of health services or personnel in such urban areas.

In fact, due to some skewed sense of urban penchant, doctors especially GPs, continue to vie with each other, ever so competitively by locating in inner-city sprawls, with many now just eking out paltry livelihoods.

So why, it begs the question, would the government see fit to jostle for such overcrowded spaces, if not to spite the medical profession?!

Perhaps, there is that misguided thought that by offering urbanites some goodies, no matter how inane, citizens might be persuaded to look upon the federal government more favourably, considering that almost all metropolitan parliamentary political representatives are from the opposition parties!

Nevertheless, notwithstanding the possibly noble intentions of the authorities, we seriously question the rationale and the sudden move, which we feel are at best misguided and not too well-thought of.

We understand that because for a very long time, we have had tax dollars paying for our nearly free public health care services, a large number of our citizens have come to expect that this should continue indefinitely. However, one to five ringgit for seeing a doctor in the public health care sector, hugely subsidized or free investigations and therapies, and months of free medications, (totalling only 2% copayment for public health care expenditure), cannot be a sustainable option!

Yet the reality is that this type of system is highly unlikely to be sustainable in the longer term—most countries in the world are finding out that they cannot afford this without enforced rationing, prolonged waiting times, diagnostic and therapeutic delays and even deliberate choice reductions, to exclude new, cutting-edge or really expensive therapies. In other words, something’s got to give!

But, we too are aware that some 35% of our populace (the less endowed) actually depend and benefit from such a much needed service, that we feel this cannot be done without.

But we have to reconsider a different mechanism to respond to such needs—I believe the medical profession will wholeheartedly support a revamp of a properly considered alternative mechanism(s), but these should be undertaken with in-depth input from all stakeholders and which would require great political will and planning!

Should we then be embarking on such a drastic paradigm shift? Perhaps, as some health economists might suggest. Yet, we continue to push private healthcare initiatives and insurances; new hospitals and medical centres are mushrooming; and we are targeting and enlarging our medical tourism incentives, which leads to a schizophrenic scenario as to what we truly want!

Instead of boosting and improving healthcare services and access, we appear to be taking the cheaper but possibly inferior approach; worse, at taxpayers’ expense on the one hand, and paradoxically encouraging super-duper specialist private sector growth on the other! We inadvertently but invariably encourage and push public to private sector expertise migration, thereby undermining the public services even more…

Perhaps, this exercise is just another political posturing which had been hurriedly pieced together to extract some cheap brownie points on a perceivably weak government, whose popularity needed some wagging-the-dog boosts!

To add salt to the wound, these so-called 1Malaysia clinics would compete with the already overly cutthroat urban clinics; but to be manned by medical assistants. That notion of not too subtly shifting the task downward by possibly non-health personnel bureaucrats is what takes the cake of adding insult to injury!

In one fell swoop, it would appear that the MOH had “ambushed” (as voiced by one angry doctor) the medical professionals once again, by proposing newfangled schemes which are arbitrary and even at first glance ‘illegal’, especially when viewed vis-à-vis the Private Healthcare Facilities and Services Act/Regulations and the Medical Act.

It is pointedly clear that any and every clinic should be manned by a registered medical practitioner. To do so otherwise would be to go against the law no matter the fact that there may be supervision from a medical practitioner from afar. Whatever mechanism of oversight now employed would appear to be an afterthought justification, which is convenient but probably still illegitimate.

In fact, the MOH and the law has prosecuted and indeed fined and jailed medical practitioners for employing under-qualified or unqualified people just for such unprofessional practices! Now it appears that one law is to be applied differentially for the private sector clinics, and another for those operated by the Ministry of Health!

Now it appears that many medical practitioners are up in arms, at least vocally, that such a move by the Ministry of Health once again undermines the bittersweet equanimity of our already beleaguered medical practices, just recently reeling from the imposition of the private health care facilities and services Regulations in 2006.

It appears to some doctors, that no medical society seems to care for them and their piled-on plight, and some have expressed their intentions to start another “grouping” to vent just such an opposition to these dastardly moves of the uncaring MOH, and yes, even the MMA! Isn’t this just like trying to re-create the “wheel”?

Still, perhaps it is good for more of us medical professionals to feel the need and the want to do something and at last, to resort to some form of collective action.

That is what and why most societies are formed for—to come together so that as a group representing a common purpose, we can be more effective in pursuing a cause, or to exert pressure against another, which is inimical to the group.

That is what the MMA is all about too, except that many choose to think that the MMA has been too ineffectual, and therefore some have chosen to denigrate and denounce its so-called inaction and ‘useless’ purpose!

They cry “what has the MMA done for me?” while at the same time shamelessly refusing to acknowledge that they have poorly supported the MMA, most by not even becoming members!

How many doctors turn up for rallies when called upon by the MMA leadership? Perhaps a few hundred, whom I fully salute! How many bother to turn up for our Annual General Assembly meetings, year in year out, to debate policies and issues, and yes even to engage in politicking mindlessness and arguments? A dismal two to three hundred!

As of this year, the MMA has just 8100 members in benefit, out of a total registered 26,000 medical practitioners, a paltry 30%! Yet, we are the largest representative body of the medical profession, but we could definitely show a greater strength of purpose and unity. We need more members to join our cause and increase our profile.

We, you have to show greater participation and engagement in our, your association, despite its inherent discordance and splintering interest groups! That is the essence of democracy and participatory membership. That is the essence of being involved, being engaged, wanting to contribute to perhaps influence a change no matter how small, but perhaps also in helping to shape a major policy which will affect our professional lives and livelihood!

But a fair and close scrutiny would immediately expose the truth: our MMA’s public sector arm, SCHOMOS, has been exemplary in catering to the benefits and interests of our public health care doctors. Perhaps our private practitioners section (PPSMMA) can do better, but we have actually been busy working hard on many issues to try and resolve with as many stakeholders as possible, by being as inclusive as we can.

When push comes to shove, at least some have been moved to take action, to have become agitated, angry and perhaps finally, willing to take some action, belatedly as the case may be. Sadly, such reactive knee-jerk reflexes are only triggered whenever our purse strings appear to be at risks, our livelihood’s at stake. In such a light we often come across as venal and mercenary. We should be more professionally-minded while we work hard and unapologetically for our professional interests and practices!

Yet, when it comes to unity of purpose and real positive contribution, these are often met with walls of silence and inaction, even apathy. It is time to come aboard and engage us to make us better, stronger, more meaningful! Come and join us and help us make better changes!

So what have the MMA done these past few weeks?

1. We have set up committees to look into the affairs of GP issues: met with and dialogue with the DG of Health and his MOH directors to share our concerns;
2. The recent National PPS NWC met with Director of Medical Services Dr Nooraini Baba to straighten out some difficulties, i.e. amendments/modification of the PHCFSA/R; private specialist hospitals setting up of feeder clinics, errant dispensing without prescription pharmacies, even the setting up of 1Malaysia clinics in urban areas;
3. We have formed a protem group to address the possible threat and extension of statutory requirements and MSQH accreditation moves for GPs,
4. We are working with the Academy of Family Physicians of Malaysia (AFPM) on developing a QIP programme which will enhance the quality and CPD of GPs/family physicians,
5. We are opposed to any splintering move of GPs into FPs and others,
6. We are opposed to the 1Malaysia Clinics being manned by non-doctors, or even their locations in competition with our urban GPs, and have expressed our concerns directly to the Minister and the MOH;
7. We have been discussing mechanisms on how to integrate our GP services into the overall Primary Care practice to alleviate the overcrowded public health care clinics—the Minister is very interested, but logistics and administrative barriers remain, recent announcement shows some progress;
8. We have worked out more favourable terms with FOMEMA, enlarging to 750 foreign worker examinations quota per annum, and streamlined radiological training for clinics with x-ray facilities
9. We are working with EPU to understand more of how the privatization plans would favour the medical industry;
10. We have worked with the MOH and EPU on understanding and moderating the implications of the ASEAN free trade zone, i.e. MRA and AFAS, when these come on board from next year, with full operational capacity by 2015;
11. We are working with various mass media which will work with us to enhance our profession-public interaction and communication, Astro’s Tamil service will showcase a collaboration with MMA on a series of expert talk shows from late this year or early next year 2010;
12. We are convening and engaging specialists to rethink our national health policy directions; discussing with various groups on case-mix/DRGs mechanisms;
13. We are actively engaging with WHO, Transparency International, ASLI, Human Rights Coalitions, on issues of better governance, better accountability, best practices, and human rights concerns, etc.
14. We are working on how to enhance the image of the medical profession in our run-up to our Golden Jubilee (50^th Anniversary) next year!
15. I have set-up a Facebook group blog strictly for medical professionals to engage more concretely issues, where everyone once registered can input, contribute, share and debate health care concerns (MyHealth Matters-MMA 2009-2011)  http://www.facebook.com/group.php?gid=181442416810