Wednesday, April 21, 2010

Physician Malaise, Dwindling Public Trust, Moral Imperative
By Dr David KL Quek
The most recent Readers’ Digest poll on Malaysia found doctors to be third (behind pilots and teachers) in the line of professions whom they can trust (Nichol David, Dr Jemilah Mahmood (MERCY Malaysia), Lee Chong Wei, and Lat were the top 4 eclectic celebrities that Malaysians chose to trust).[1]

This is perhaps not too surprising but maybe a sign of the times. Just a few years ago, doctors were polled as the most trusted profession, so clearly in the interim the public perception has changed somewhat. Have our doctors done anything to deserve this climb down in public trust? If so, how and what has rankled the public?
To be sure if we do scrutinise the above table, there is little to distinguish the top 3 professions. But it is worthwhile scanning down to see that the paramedic, the surgeon, the dentist, the pharmacist and the nurse are now quite high up the hierarchy of public trust from a list of 40 professions. We are now in a highly competitive climate for public trust and regard, and it will get keener with the times!
This became quite clear, when the MMA and many doctors protested the setting up of 1Malaysia clinics to be manned by paramedics in urban centres in January 2010. While the concept of making healthcare access better for urban poor is laudable, our contention that doctors and not just paramedics man these clinics did not receive the expected attention or response that it should.
Medical assistants—now also renamed as “assistant medical officers” and nurses were up in arms that we were belittling their skills and training, when what we intended was to simply state the facts of inequality and disparity in qualifications, schooling, training and possibly standard of care of the 3 professions.
As medical professionals, we maintain that each of the professions has its own niche, task and role. However, without exception, as is stipulated by the Medical Act, all clinics should be fully supervised and manned by doctors.
Nurses and paramedics are clearly indispensable in their respective roles, and we do not dispute that, nor do we wish to denigrate their responsibilities or capabilities. But ultimately, they are there to assist us and carry out certain tasks, but the final responsibilities must rest with doctors, as full supervisors and hopefully not any less!
Sadly, due to political manoeuverings, our authorities have spun a disingenuous tale that we are elitist and uncaring with the full-throttled support and thrust from the mainstream media and a populist public. Perhaps, such run-ins are the stuff that damages our position, unless we choose to quietly abide by the challenges and events, and let them slip by, without comment or debate…
But I think the medical profession cannot afford to keep quiet and let this erosion of our practice issues continue. It is precisely differences of opinions and approaches like these that the MMA must be willing to challenge and question, and expose the fallacy and/or the unacceptability of these moves. Globally, for various reasons, task-shifting is being manipulated mainly on economic grounds, to undermine the scope and practices of the medical profession, and we have to remain vigilant to stall these measures of convenience.
However, perhaps for a growing number of Malaysians there has been a widening schism of trust pertaining to all things authoritative and maybe elitist to some degree. Alas, doctors have sometimes been labelled as such—that we are too patronising, too paternalistic, oftentimes too self-seeking and too all-knowing, that we give too little precious time and trouble to explain more to our patients, the public at large.
The information asymmetry due to the very wide knowledge gap and esoteric nature of medical jargon and terminology only continues to drive a deepening wedge between the medical profession and the public. Our perceived haughty tone also isolate us from the more curious if lesser informed public. Many now hanker for better understanding but because their educational or belief systems are so varied, these create what appears as an unbridgeable divide that makes communication less amiable and severely limits two-way exchanges.
Unfortunately many doctors and medical graduates are never adequately taught to speak and communicate in simple layman’s language. Perhaps this has to be addressed—doctor-speak and ‘medicalese’ vocabulary creates misunderstanding or confusion, which lessens the doctor-patient encounter.
Most doctors tend to find comfort in their own abstruse medical universe. But this clearly must now change. We have to engage the public as never before, we must make ourselves clear and express ourselves better, if we hope to continue to be as meaningful and as trusted by the public. We must give our patients more time and show a greater empathy. We must not be mere business contractors, too busy and too calculating to care.
Paternalistic attitudes of the past when “doctor knows best” are long gone and passé. We must become attuned to the times—we need to re-engage with our more knowledgeable and more inquisitive patient, so that we meet their rising expectations, their trust that we duly deserve.
However, throughout the rest of the world, most people do continue to find doctors most trustworthy. For example, the MORI poll of the United Kingdom has consistently found doctors to be most trusted (with 92% believing that doctors can be trusted to tell the truth), way ahead of politicians (13%), ministers (16%) and journalists (22%).[2]
Expanded Moral Imperative for the Physician
So, in many ways, the Malaysian doctor is now perceived somewhat differently. We are now caught in the crossfire of growing skeptical if flawed sophistic judgement and inquisition by a larger segment of a more discerning public.
Simply put, while we generally still enjoy our much-vaunted position of trust and respect from the general public, we are getting more than the occasional hiccups from bad press and publicity. Perhaps, this trust has dropped a few notches, but there is by and large hope that doctors can rise above the fray of the mundane mediocrity of Malaysian society!
Furthermore, we are exhorted to become more than what we have been accustomed to do thus far—being far too meek, commonly apathetic, conscientiously practice-oriented, and indeed fully focused only on our parochial medical interests, our bread-and-butter humdrum lives and livelihood…
Perhaps, there is greater expectation that as a whole, our usually higher moral standing should buttress a more consistent level of ethics and good societal practices, most of which have taken tumbles from our previously respected lofty heights. Our debilitating institutions and highly questionable state of affairs have cast a shadow of despondency on a large segment of our more enlightened society.
Although many of us traditional doctors are wary of treading on the wrong side of political correctness, there are increasingly greater demands on the astute doctor to act according to his or her expected standard of intellectual and professional standing, training and moral compass—to do the right thing or at least to come right out and say so.
The public demands that doctors stand up to be counted, to emerge outside of their previously cloistered if self-contained comfort zones. The long gestation within our pupated hibernation phase should cease; doctors must rekindle their sense of commitment and engagement with society.
Doctors are expected to help influence the finer direction of where we hope our Malaysian society should go, although like any other profession, there would be many amongst us, who would be and have been partisan or even ethnocentrically chauvinistic or religiously fanatical! That is why so many amongst us have participated in politics, some more successfully, others less so, some shaping our entire nation, while others simply creating meagre waves of lesser consequence.
But for most of us, we can be less fraternal and still contribute without partisan leanings, which would therefore be less inclined to colour our judgements and perhaps even our professionalism!
That said, it is perhaps time to become more engaged and involved. It behooves our dignity and arguably may enhance our trustworthiness in the eyes of the general public. Doctors must be doing more and must treat everyone with the respect and dignity no matter who they are.[3]
Improving our Caring Ethos
We need to reaffirm our caring ethos, our trained and ingrained approach as our patients’ greatest advocate, no matter the contradictory signals and opposing forces that insist we are out of kilter. Our unwavering stance on the patients’ ultimate welfare should be our primary goal: “Primum Non Nocere”, and that as medical practitioners we are the best professionals to look after their healthcare concerns.
We also need to help expand the dialogue and public knowledge about healthcare issues and costs, and how some reform may be necessary. We need to expound more simply why everyone must play their part, including becoming more willing to contribute either via taxation or by some community insurance. Lack of in-depth information has hampered discussions on this difficult but necessary subject. The MMA and the medical profession must lead the discussion on the issue of affordable and sustainable healthcare financing.
Truth Telling & Ethical Professional Practice
Incredulous and conflicting forensic pronouncements in the Kugan “death in custody” case, as well as that concerning the more recent Teoh Beng Hock fall from the MACC building, have punctured the believability of health officials involved in the truth-seeking exercises and justice—so crucial for trust in our public institutions. Custodial injuries and deaths number into the hundreds or more, and have remained largely unexplained and unaccounted for, again undermining our state institutions, and potentially breaching international law on human rights and detention rules.
We also hear of possibly coerced and altered medical reports from physicians who have been pressured by higher authorities which endanger the independence and reliability of the truth telling process of what the medical examination and reporting is all about. Our forensic integrity has also been shaken, when external experts are increasingly sought to offer more dispassionate and impartial deliberation of the truth.
In this regard, our local experts and medical professionals must re-examine their own conscience and moral anchor to deliver greater believability and accuracy of their duties and findings. Doctors must not become unduly influenced by any external party or forces; they must endeavour to tell the final unimpeachable truth, without fear or favour.3
State vs. Professional Interests must be clearly defined, with the medical professional always taking the position of determining the medical truth and facts, while protecting the rights and position of the patient, the detainee, the prisoner, even the death row inmate. Detention Health, Torture, Injuries, Death & Medical Professional Duties are all well articulated by world-recognised authorities and bodies such as the World Medical Association’s Declarations of Geneva, Tokyo and the Istanbul Protocol, and the United Nations Commission on Human Rights. We encourage our medical colleagues to be fully aware of these onerous responsibilities and roles.
Healthcare Rights Advocacy
Finally, in this day and age, the medical professional is exhorted to be more involved in human rights advocacy. The World Health Organisation (WHO) has quite categorically stated that health is a human right, i.e. every human being should have the right to access to healthcare.
The difficulty of course, is to define the quantum and the scope of how much and how comprehensive that right to healthcare should extend. Because, unfettered healthcare is becoming an untenably expensive affair, some form of rationing and queuing will have to be the way forward—with the usual altruistic goal of greatest benefits to the greatest number of people.
This means that we have to collectively find some agreeable way to establish what is considered as reasonable and adequate healthcare at the most affordable means, which can benefit the greatest number of people. The poor must not be marginalized or shortchanged in an ideal world. As doctors we must try and find some equitable equilibrium, while continuing to allow choice and freedom to choose within reasonable boundaries.
In this regard I would like to quote Professor Ian Gilmore (President of the Royal College of Physicians of London who said that:
“As doctors, we are often looking at the single patient in front of us, but as ambassadors for improving healthcare we have roles in the NHS, in healthcare and in wider society to become champions of change to protect the planet from climate change. As private individuals, we may well act ecologically, but may not always have carried our private views into the public arena. It is time we stepped up to the plate.”[4]
In Malaysia, we too have to step up to the plate and walk the extra mile to do more, to show our fellow citizens that we can do more. Perhaps we can help bring about greater and more beneficent reform, measures which would perhaps regain the public’s trust in us once again.
The MMA is fully engaged with the MOH, in trying to find a better way for the Malaysian healthcare system. We believe that the public too has a stake and must also be part of the reform process. However, there are many obstacles and divergent viewpoints, which need to be reconciled and overcome. But, we are confident the best is yet to come, if we all put our minds to it. We need knowledgeable physicians to help us move the momentum towards the final goal, which is unlikely to be static but perhaps dynamically evolving...
“Every now and then go away, have a little relaxation, for when you come back to your work your judgment will be surer. Go some distance away because then the work appears smaller and more of it can be taken in at a glance and a lack of harmony and proportion is more readily seen.” ~ Leonardo Da Vinci

[1] Readers Digest. Trust Survey 2009 – Malaysia (Accessed at on 10 April 2010)
[2] Ipsos MORI. Trust in Professions 2009 for The Royal College of Physicians. September 2009, London.
[3] David KL Quek. Malaysiakini: Unbiased treatment for all. (Accessed at 11 April 2010)
[4] Doctors can no longer ignore climate change, says RCP President, (Accessed at$484799.htm on 08 April 2010)

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