Monday, October 26, 2009

MMA: Treading between Advocacy & Professional Balance

MMA: Treading between Advocacy & Professional Balance

President's Page, MMA News, October 2009

“There is no career nobler than that of the physician.  The progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession than with the status of any other class...” ~ Elizabeth Blackwell, M.D., 1889

Medical Professionalism and our Caring Vocation
As medical professionals, our patients should be our raison d’être, our sine qua non for existing.

However, as is becoming more evident, daily societal developments pose severe challenges to our medical profession. Our role as physicians sometimes appears to come into conflict or competition with society’s other demands—some social, while others, political.

Yet, we must choose a careful path, treading a thin line between strident but necessary advocacy and rational professional balance on the other. Above all, we must remain steadfast as our patients’ strongest advocate—their health interests must precede all others. 

During the start of my term of office, I had highlighted that I would emphasise the more humane aspects of the medical professional, that kindlier face of the doctor as we interact daily with our patients. As physicians, we must strive to always practice our craft without that edgy touch of cynicism, jadedness and/or burnout.

We must project that long-forgotten intimate encounter which makes us the most trusted and respected amongst professionals. We must re-ignite that fervour to make this a daily reality for our patients and all those whom we connect with through all walks of life.

But this must be through one’s personal conscious effort—it does not come naturally to most of us… The good thing is that we can learn and adapt until this becomes a part of our attitude, our persona.

My personal daily goal is to see if I could get each and every one of my patients to leave my consultation room with a contented smile; yes, despite the fees, the test results and burden of illness. The hospitalized patient poses a rather more difficult problem—many are too ill or too discomfited to be satisfied, but he or she can usually be consoled, especially when we show that we care. And most patients can actually sense our sincerity and our empathy.

But this is by no means a given. We all have our off-days, days when we are troubled by our own unresolved nagging tribulations and private burdens. Just to shake off these deep-rooted weights would make most of us sullen, poorly communicative people, who would not normally be expected to make good counsellors or empathetic muses!

Yet, that is expected of us, to perform even in the midst of personal distress and overbearing internal conflicts. I have striven to do this for some years now, but sometimes this just isn’t possible. Undoubtedly, this will increase our stress level which is now recognized even by our own citizens! In a recent poll, Malaysians had voted doctors as the second most stressful job among the professions, the PM's position being the one to beat!

How do we inform seriously ill patients that their ailment is life threatening, or even terminal? How do we get the patients and their loved ones to come to grips with the dire prognoses, the possible huge treatment costs, and the uncertain outcomes for some illness? How do we sometimes admit our limitations that even we do not have all the answers?

Yet on the more mundane aspects, how do we continue to inculcate a sense of shared intervention and commitment to some therapeutic regimen for some chronic ailments such as hypertension, diabetes, etc.? We need to constantly urge even ‘gently berate’ our patients to stay on treatment for the best outcomes in the long term, especially when the symptoms are covert, apparently nonexistent, or even silent?

As doctors, we must regularly remind ourselves that among the professions, we are perhaps the only one that demands a caring value system. We must constantly remind ourselves of this duty.

Yet again there are other issues, which demand our action and our input, at least this is what I have pledged to do. There are problems with some of our health care services such as our forensic service, which has been under the spotlight recently.

Careless and callous attention to detail has created great public uncertainty, dismay and disbelief, which undermines the critical function of our forensic pathology services. The MMA naturally would stress that forensic health care is every bit as essential for the final truth and professional determination of causation of death or injury, especially of anyone under detention—as is demanded of us the medical professional, in WMA’s Declarations of Tokyo and Istanbul.

Let us practice the noble art of medicine as has been enjoined upon us from time immemorial.  Let us engage more meaningfully and help shape the kind of medical practice that we would all be proud of. 

Ongoing Challenges
Just 4 months into the fiscal year, and the MMA continues to face new or resurgent challenges. Some of these are simply perennial issues, which surface periodically when political awakenings rekindle them into topical issues of importance of the day. Others are the result of unforeseen or poorly planned policies that have now come home to roost with outcomes that seriously impact our profession and our practice.

1. Competition is becoming more intense than ever. We continue to have complaints of community pharmacies posing as clinics, providing discounted medicines to unsuspecting patients who have elected to purchase their medications without prescription. This continues to take place, despite MMA’s consistently vocal stance that safety issues and laws have been breached.

We also have the understanding from the Malaysian Pharmaceutical Society that it is trying hard to rein in their pharmacies, their members. But the MPS has also repeatedly called for a greater if total separation of duties—to let each professional earn his/her true value and worth.  The MPS continues to urge that perhaps doctors can start by being a little more transparent in their prescribing and dispensing habits. We are trying to resolve some common interests through greater dialogue, which may benefit both parties as a win-win approach—but we are a long way off a final agreement or compromise.

In most urban centres, there is a glut of side-by-side clinics, thereby causing intense competition for patients both from self-paying patients as well as for panel contracts or even third party payer MCOs, which are demanding depressingly low capitation fees for services.

Latterly, there were reports of some private medical centres/hospitals expanding their coverage with feeder clinics and wellness centres. Undoubtedly, these are patently to recruit more patients for their services, their laboratories and their hospital facilities. 

We have recently sent notice of our displeasure to the press, and urge the authorities to nip these practices in the bud!


2. ‘1Malaysia Clinics’ & Task Shifting
There have been some global trends toward professional task shifting, now increasingly contemplated and advocated worldwide following WHO initiatives to reach out to very poor countries, which lack properly trained medical personnel.

This essentially means that so-called ‘simpler’ healthcare responsibilities would be shifted down to lesser (more specifically and focussed) trained, cheaper to maintain personnel e.g. nurse physicians, medical assistants, pharmacist assistants, etc.

And now during the recent Budget 2010, we received yet another shockwave to the equanimity of our urban GPs—the just announced ‘1Malaysia clinics’ to be manned by medical assistants! One would have thought that this model is a relic of the past!

In the pre-1980s, it is true that we had utilized medical assistants and ‘jururawat desa’ to help out in more remote rural clinics. They certainly provided a great much needed service then.

But, these are now increasingly scaled down so that doctors can oversee more and more of these services to enhance greater quality and service even to our rural or more remote locales.

Therefore, MMA has immediately opposed what we feel is a hugely retrogressive approach to health care. We are saddened that this approach had been suddenly sprung upon us. We understand that sometimes ‘pork-barrel’ goodies need to be dished out, but we envision these so-called ‘1Malaysia clinics’ as simply exercises to exude political goodwill. This may temporarily salve some very poor urbanites, but we fear that in the longer term, this exercise may be shortchanging the less discerning marginalized public. Regulatory and medico-legal aspects, potential abuses and unethical practices remain to be ironed out.

However, we have counter-offered that our already very available and plentiful GP clinics be tapped to help provide these outsourced MOH initiatives, as more suitable alternatives. We are made to understand that the Minister of Health sympathises with us in this, although it would appear that the MOH has to contend with other Cabinet portfolios for ‘public service’ projects and financial resources…

For our country, which continues to produce so many new doctors—some 2500 per annum, this will be catastrophic for our younger graduates, who might in future not have enough jobs to function, and whose remuneration may be sharply reduced. We need to enlighten the government that this may not be the best approach. Standards of health care cannot be compromised or made expedient just to accommodate to some economic or short-term considerations.

3. CPD/CME & MSQH Accreditation Standards
Another issue regarding professional standards has also to be resolved. As doctors, we must constantly be upgrading our standard of care and professionalism, as well as our currency of our medical knowledge, i.e. we must keep up with CPD/CME activities.

Our clinics and amenities must be enhanced and modernized in keeping with public expectations, keeping cost-cutting measures at a minimum so as not to jeopardize the public perceptions that GPs are only mercenary and venal, and too profit-orientated!

The Malaysian Society for Quality in Health (MSQH) has been set up to help modernize the standards of health care in Malaysia. As a very dynamic entity, it has been working hard to enhance its value by being a lot bolder in its push for more if not all clinics to be accredited as of sufficient quality. This aggressive approach may pose yet another round of regulatory burden on us, the private medical practitioner.

As an initial founding partner, the MMA appears to have been rather silent, in the past. Perhaps to be fair, some of these exercises and progress of the MSQH reach have been hitherto understated, and its potential for burdening the GPs not fully realised. As president just recently exposed to the intricacies of the MSQH exercise, I will work to address such concerns so that doctors will not be subject to any more regulations and new Acts.

Furthermore, we need to work with the Academy of Family Physicians (AFPM) to see if we can re-organise the frame of reference of upgrading and updating our GP/FP practices. At the most, we will accept MSQH as a reference standard purely on a voluntary basis, which should in no way reduce our acceptance with any distribution of work or panels or third party payer contracts or business opportunities.

Most importantly, the MMA needs all your support and members must all come forward to be bold in defending this stand.

Let’s work together to ensure that we provide the best to our patients without overburdening our capacity to cope. Let’s come together to self-regulate and engage in self-improvement techniques, credentialing exercises and standards attainment, which are the hallmarks of mature medical systems the world over.

In this way, we can together persuade the authorities and policy makers that we can be trusted to provide the best and most professional healthcare for all our patients without fear or favour, and certainly not at our professional expense!

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