Sunday, December 6, 2009


Dato' Dr Ronald S. McCoy

Medicine had its origins in ancient Greece in the 7th 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 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
5th December 2009 on behalf of the Malaysian Medical Association.

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