Tuesday, December 22, 2009

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.

medical doctorsThe 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.

medical doctors in malaysia 120106Every 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 are not just blindly 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.

methadone-drugsThe 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.

swine flu sungai buloh hospitalMost 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.

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