Sunday, January 3, 2010

1M Clinics: Recent Commentaries from some of our MMA members...

Recent Commentaries from some of our MMA members...

Dr Vithylingam:
You have given a fair view of the situation.
   Action must be taken to show MMA's concern of this grave injustice to the private practitioners esp Primary care doctors. It is a blatant disregard to the Medical Act. Exco must take a collective decision to pacify the angry GPs. A repeat of what the Schomos did, without fear, in the 80s. Doctors must cooperate and take the necessary action otherwise it may be embarrassing for the Exco.

Alternatively, MMA can have a press conference on the 10th before the Council meeting. All the state reps will be there. In the meantime a Nationwide signature campaign can be carried out and presented on  the 10th Jan.All the Primary care doctors can be present as a show of protest.PPS Chairman can call all the PPS reps on 10th to show solidarity and demo within the compound of MMA.
 Hope good sense will prevail.

Dr Milton Lum's email Points

In addressing this issue, can I suggest that you and Council consider the following:
1. the law i.e. not only the Medical Act but also the Medical Assistants (MA) Act, Nurses Act, Midwives Act
2. the current scope of clinical responsibilities of MAs, nurses and midwives in the public sector, and to some extent, in the private sector
3. the proposed scope of practice in the 1Malaysia clinics and its standard operating procedures
4. the numbers of patients treated by MAs, nurses and midwives in the public sector relative to the numbers treated by doctors.
5. what are the objectives of proposed actions
6. alternatives to the actions stated in your email
7. whether the public will be supportive of actions taken by MMA
8. whether doctors will support MMA's actions
9. whether other professional medical organizations are supportive of MMA's position
10. timing

Whilst the anger expressed by some doctors is understandable, any action taken should be based on sound rationale that can withstand public scrutiny.

Dr Ashok: 
It may be difficult to halt these clinics now, with the momentum and politicians behind it. We
should register our opposition and reasons for such in a letter to the MOH. Perhaps we
should monitor the progress of these clinics closely, noting the inevitable problems that will
crop up.

My feeling is that as the MOH fills up with more and more young doctors, they may replace
MAs at these clinics - and that won't be too far in the future. For GPs, the strongest point is
their personal relationship with the patient, their experience and their patient management

Prof KH Sim:

We must never forget for MMA to remain relevant, for the medical profession to still be considered as a noble profession, we must have the 3 main objectives
·         to remain respected by the community
·         to remain as the partner of health to the government
·         to remain relevant to our younger colleagues

Our medical profession will need to adapt and have the courage to take leadership above self interest for the healthcare of the community, the nation and lastly for our medical profession (our younger newly graduated colleagues will out numbers the older colleagues very soon. It will change the whole political dynamic within MMA and the medical profession).    

Sun Zi - military philosophy   
©      “know the terrain before know the weather”
©      “know your enemy before know yourself”

Suggest we plan and aim to win the war rather than win the battle and lose the war.  The best is to win the battle and the war of cause.

 Dato' Dr Sarjeet S Sidhu

The DG has put up a credible case for the setting up of 1M clinics (1MC); and as a very senior Civil Servant one cannot expect any less from him. He has given a good explanation of the rationale for the setting of these 1MCs: as I said made a credible case.

But “that this approach is really shortchanging the urban poor in the long term”  will not be realised by the citizens at large at this stage.

"Suggesting that the ministry had acted in haste and is being retrogressive in its approach clearly reflects their lack of understanding of the role of the 1Malaysia clinics."

From the above it appears that the MOH did NOT act in haste, and it may well be so. But it cannot be denied that the MMA and all doctors were caught unawares. Shouldn’t the doctors (via MMA, etc) have been consulted? Strange that such an important step was taken without so much as a consultation with the doctors and without any debate. Why were we kept out of the loop when such decisions were being made?

"Rural Malaysians receive better healthcare than their poorer urban counterparts."

And many rural poor (interior of Sabah and Sarawak, for example) receive even poorer healthcare than the urban poor.

Anyway it’s a little late to stop the setting up of the 50 1MCs, and as the DG persuasively says “…having the 1Malaysia clinics, just 50 of them throughout the country (three or four in each state) is not going to dent the purse of our doctors…”

What needs to be done at this stage is to make a detailed and reasoned case as to why we oppose such a move. It will not cause the 50 clinics to be “undone” but may persuade the Govt to not expand further.

As Dr Ashok says “It may be difficult to halt these clinics now, with the momentum and politicians behind it. We should register our opposition and reasons for such in a letter to the MOH. Perhaps we should monitor the progress of these clinics closely, noting the inevitable problems that will crop up.”

By the same token IF the 50 clinics should turn out to be a success story, and we have no real reason beyond the fact that it will affect the earning capacity of GPs, we will be obliged to withdraw our protests (if any).

As Ashok says it may well be “that as the MOH fills up with more and more young doctors, they may replace MAs at these clinics - and that won't be too far in the future. For GPs, the strongest point is their personal relationship with the patient, their experience and their patient management skills”. 

My Comments:

Dear Ashok, Prof Sim and all,
I already know from several inside sources about the 1M clinic being made to prepare for the opening within 30 days. I am fully aware that this is a political move, which the MOH cannot of course acknowledge widely.

Unfortunately, such a move of task-shifting professional matter downwards has grave implications for doctors not only here but also in many countries in the world. So, we have to make a concerted stand, so that this would not be allowed to be further extended into a program where more and more primary care doctors would be marginalised especially those in the private sector. Financial implications is not the only concern, but perhaps most unfortunately obvious.

As pointed out by Dr Alan Teh, governments are only interested in short term goals of seeking good publicity fallout, but some decreased quality issues cannot be excluded and would be bound to occur (missed diagnoses, delayed referral for complicated cases, errors, etc), and unfortunately this would affect the poor first and foremost, with those that can afford paying to see doctors would escape this potential woe.

It is not that doctors are simply against treating the urban poor but, that this approach is really shortchanging the urban poor in the long term. What is most important for us is the medical profession itself, what would become of us, if the government keeps shifting the  goalposts for political or economic ends? The future of so many new medical graduates would also be even more murky and probably made even harder with such arbitrary moves by the government or MOH.

I speak on behalf of the very many GPs who are truly concerned and angered by this move. Personally and professionally, I feel that the very small number of these clinics will impact very little on most GPs even in the urban setting, but this is not the issue. Professionally as a specialist, I will personally not be impacted in the least by these 1M clinics, but because we are elected to represent all MMA members, we have to recognise their plight and the potential major issue behind such moves.

Personally I am not partial to any demonstration or public protests, but if this is the will of the majority of the GPs and the members then this will have to be the stand of MMA. Our personal beliefs must be subsumed within the greater good and will of the majority of our members.

I will of course seek a dialogue and ensure that we get truly represented to give our strongest views to the government, without fear or favour.


Sarjeet and all, it's not all that's explicitly stated by DG.

Pls re-read this MOH FP's posting, which now confirms a few other MOH doctors who were all caught unawares until budget 2010.

"On Sat, Jan 2, 2010 at 1:13 PM, a senior government MOH Family physician wrote:

Agreed with Prof Sim.

It seem that MOH has NO option and has to obey the political need of the country.

MOH has made preparation for the 1Malaysia Clinic in a very short time..I was informed only RM30,000 allocated to initiate service per clinic. So the clinics are meant for very basic medical care. We were also told that MOH budget for next year was cut by about 5%.  Hope the government will provide more since this last year itself, we faced inadequate budget. What more this year where service expanded with another 50 clinics

Currently at government health clinics, we are  facing shortage of this will be aggravated further since we have to send some to work there. Not to forget we still send paramedics for the PLKN.....This will not help our existing clinics since I am sure many patients will ultimately be referred  to the clinics to be seen by doctors.

There are more than 800s health clinics in Malaysia but there are still clinics without resident doctors and being manned by MAs. Even in many clinics with doctors, many patients are being treated by MAs since not enough medical officers and some doctors has to cover certain days to clinics without doctors. Meaning MAs are able running the 1Malaysia clinics though patients actually prefer to see doctors.

Then what about issuing medical certificate?

The clinics will be opened as planned ; all states has been given instruction to make the necessary Dr Ashok said it will be good to monitor the performances. This is a challenge not only to GPs but also to MOH. However I feel the surrounding community near the 1Malaysia clinic welcome the clinics."

Another source confirmed that some of our doctor colleague 'ministers' had proposed expanding similar clinics for urban poor some years ago, for political consideration, but never adopted.

There is another dimension where Dr Denison Jayasooria has been advocating very ardently about alleviating urban poverty, with some touches on marginalised health care concerns, but this again was never a mainstream policy, and why now, quite suddenly...

Also, Dr Hooi, it was precisely a slanderous doctor from Penang who wrote scurrilous ad hominem attacks on me for doing 'nothing' in MalaysiaToday, but which I have elected not to reply despite calls from many friends. If he or she had the guts to climb out of that anonymous pseudonym, then my lawyers will know what to do!

I think everyone has now mellowed to passive acceptance that what has happened is fiat accompli.

The question is what's next? Please give a lot of thought to this.

I am only responding to the majority's wishes to be more vocal in expressing our interests as I have been trying to do without fear or favour thus far, although personally I have more to lose than to gain. But because I have been elected to serve our members, I will do what the majority decides.

However, I do feel that our medical profession has been shortchanged once again. Future doctors' careers may never be the same if this task-shifting is pursued as a tool to keep a check on doctors' salaries or possible future intransigence/disagreements with the government.

Like I said earlier, right now, most of us are not going to be materially affected. As a private specialist, I have no stake in this at all. But what of our GPs and our future doctors?

I will post the WMA statement on Task-shifting so that perhaps more of us can understand the implications and the global dimension of such moves by many health authorities and governments.

No comments: