Sunday, September 12, 2010

MMA News September 2010: What if… Medical Professionals ask the truly important questions? The Dilemma of Leadership…

What if… Medical Professionals ask the truly important questions? The Dilemma of Leadership…
Dr David KL Quek

This month I would like to reminisce on the changing dynamics of medical leadership. In a recent July JAMA commentary, Rand Health director Dr Robert H Brook, discusses some intriguing aspects of “Medical Leadership in an increasingly complex world”.[1]

Medical leadership, he argues must move beyond the usual norm of professional practice issues, which are narrowly defined within the realms of our own immediate interests. While he acknowledges that medical professionals are found in most leadership strata of the political arena, few if any ever reach the pinnacle of being elected national President—in effect to become the quintessential executive policy maker and shaper.

In Malaysia, we did have that envious exception of having had a doctor take on the helm of political leadership of the country. It is debatable if being a doctor influenced the way Dr Mahathir had run the country for 22 years. It is equally contentious if he had left behind a benign or a malevolent legacy!

Many of us still bristle at the thought that Dr M was once heard to have said that we should “flood the country with enough doctors” so that they wouldn’t demand too much in terms of wages and perks! Curiously, in this coming decade, his prescient prediction could become a reality, when MOH plans are afoot to increase the number of doctors in this country to more than 80,000 by 2020, so as to achieve the target of 1:400 doctor-population! As a professional body, the MMA believes that this is too many, too fast, and too soon; perhaps over a 20-year period might be more manageable, but ten?!

Thus, doctors would no longer be a ‘small’ professional group, but one, which could become arguably bloated, redundant, and possibly unemployed or scrambling after some tit-bits or scraps of hand-me-down service!

Our true worries follow 2015, or even 2020. What then with the continuing production of 5,000 new medical graduates or more per year? How long can this go on? Would our standards of medical graduates be acceptable or would the profession self-destruct into a quagmire of second-rated diploma-milled ‘doctor’ that few would accept as trustworthy or good enough professionally or in skills?

Interestingly, we wonder why the lawyers in the country have so carefully shunned such a messy thought experiment, when they jealously guard their turf by scrupulously controlling the production and passing rates of their counterparts!

Perhaps it is not too exaggerated to say, that more often than not, our quiet professionalism (or apathy!) seems to have been parlayed by policy makers into a politically devious cycle of below-the-belt punches instigating public demanded virtue and selfless altruism, while losing sight of what’s realistic or fair-minded.

Sadly too, the few physicians who had embroiled themselves into our Malaysian politics appear to have become more politically expedient rather than to have exerted the more kindly expectations of the soothing caring professional! Perhaps, we expect our ‘comrades-in-arms’ to be more robust in engaging ‘our’ cause with more reason and tempered fairness, as we do our own medical professionals in the bureaucratic policy-making departments of the Health Ministry.

Yes, physicians can and do wield extraordinary influence, or so we believe. But often, not in the most agreeable way that society or the profession accepts as benevolent or agreeable. Worse still, even among doctors there are always those with divergent ideas or expectations: the confused schizoid demands of placard-caring unionist vs. more professional activist stances, vs. advocating even cautious indifference by not rocking the unstable boat amidst the tempestuous calm of government-professional equability.

There appear to be the fragmented and incoherent approaches, which would please some but anger others. But diversity of ideas and demands are perhaps the epitome of ‘intelligent’ single-minded professionals or even the public! Undoubtedly the public is progressively becoming more sensible and knowledgeable. The rakyat is no longer easily satisfied by mere rhetoric or paternalistic dictates. But sadly, as an increasingly emasculated profession, doctors’ voices of concern have become steadily muted…

Therein lies the paradox for the medical profession. Doctors even in Malaysia have been engaged to run huge health ministries and the public sector healthcare service, which literally shape and dictate how healthcare delivery and practices are regulated and implemented. How these public sector physicians envision the entire healthcare sector is important and would in many instances shape the direction and the structure of the health service for the nation.

We can only hope that they can remember their singular profession as they are charged to impact those of the others around them, notwithstanding the touted concept of ‘national’ agenda or ‘national’ interests, or the bigger picture…

Lest it is forgotten, private sector doctors also look after three-fifths of the population as outpatients, annually engaging some 65 million doctor-patient encounters! The MMA does not believe that such innumerable encounters are so deficient as to compromise our rakyat’s health in the long term. As the laws of economics would dictate, people will find their own comfort levels of acceptance for services or goods. We believe doctors are doing a sufficiently cost-effective and acceptable service for most if not all of our patients, for such a system to have endured so long and so well, as proved by our improving health indices!

Our countless patient-doctor connections can serve as powerful opportunities and tools for engagement and sharing of most intimate ideas and thoughts. Doctors therefore, should learn how to harness this possible influence to help shape how health policies are decided and enacted, by advising governments, appropriately. But then again, it is arguable if this influence would be wrought with intelligent feedback, evenhanded bipartisan consensus, or simply timid capitulation, or brushed aside as inconsequential by the powers that be.

Health professionals have always been seen to serve as the medical profession’s ‘moral compass’ when they are appointed surgeon general (in the US) or Chief Medical Officer (CMO in the UK) or as in the case with Malaysia, when appointed the Director-General of Health and other senior civil servants.

But we do recognise that the CMO or our equivalent DG has important responsibilities too. In the UK, the CMO provides advice to the Secretary of State for Health and other Health Ministers, other Government departments’ Ministers and on occasions to the Prime Minister directly.[2] 
  • The role goes beyond its simple advisory remit. Responsibilities include:
  • Preparing policies and plans and implementing programmes to protect the health of the public
  • Promoting and taking action to improve the health of the population and reduce health inequalities
  • Leading initiatives within the NHS to enhance the quality, safety and standards in clinical services
We believe these roles apply equally to our public health authorities.

However, in the same document, the CMO of the NHS explains his leadership role as follows:
“I do not have a role in the employment or management of NHS doctors. However, my responsibilities include providing national leadership to the medical profession, helping to explain the health policies of the day and listening to the concerns of the profession and their ideas. In this way I can provide, where necessary, a bridge between the medical profession and the government.”

We certainly hope that here too in Malaysia, our senior health officials would also offer a reasonable listening ear to our professional concerns, and serve as a much-needed bridge for the medical profession and the government… Shared leadership implies sharing of concerns and ideas, especially crucial feedback, contrasting viewpoints and counter-arguments to shape and finely-hone policies which hopefully can be implemented with greater precision and less recriminations from public or professional dissatisfaction or disagreement.

In this regard we sincerely thank the Ministry and the Minister for having recently acquiesced to a much needed and definitive dialogue with the MMA, in Putrajaya on 2 September, 2010. Whether anything concrete would come out of this dialogue remains to be seen. But, we must meet more often to share concerns and work closer together toward a common goal for the nation’s healthcare service.

Another tier of regulatory oversight is when doctors are appointed or elected into the Medical Council, where some professional input are expected to be made, on behalf of the profession and the public good. The more academic minded also help train and teach new medical graduates and other healthcare professionals.

But are these all the professional limits of our influence or leadership to make meaningful impact on healthcare as a critical social service?

Conversely, on the other more commercial ‘scientific’ health sector, physician influence and activities serve a different perspective altogether. Scientist-physicians research, invent and innovate therapies or new pharmaceutical modalities, which advance medical care, prolong survival or improve quality of life, but perhaps also increase costs and expense. In the wake of such advancements, they help create public demand for newfangled sometimes cutting-edge therapies or diagnostic procedures, which unfortunately drive healthcare costs upwards in a dizzying spiral of never-ending escalations.

Would 3 months extension of life expectancy for a hitherto terminal cancer be worth say, USD 100,000 as would be needed for a novel therapy? Is aggressive end-of-life futile care a necessary evil to extract perhaps a few extra hours or a few days of prolonged ‘life’?

Can or should experimental therapies such as stem cell or unproven pharmaco-genomic treatments, etc. be offered to every one, any one, or only as research protocols? How does one measure the worth of any life, any life extension no matter how short or long, or the quality? Are doctors as such, fuelling ‘cost and demand’ escalation for healthcare of the future?

Would creating ever more sub-specialised expertise and modalities of treatment mean that there would be that ever-increasing physician demand for greater incentive toward higher professional fees or salaries? Some highly trained and skilled doctors are asking that they be reimbursed more for their expertise, which raises the debate as to how we should gauge professional worth or relative values of one’s talent, skills or training. Is technical skill worth more than say, therapeutic counseling advice? How do we appraise or affix monetary values for skills, for arduous training, etc.? Or, are human values and differing professional skills ‘equal’ in the impartial eyes of society or even the profession?

Should rising reimbursements always be the rightful accompaniment of medical progress and advances? Is the relentless drive toward greater and greater advances in medical care an acceptable paradigm of our health care model?

Is identifying and naming more ‘medical’ conditions, such as impotence as erectile dysfunction, personal self-image disorder as aesthetics, wear-and-tear ageing disorders, etc. collectively and increasingly termed as ‘medicalisation’ of health, always be for the greater good of the public, our hitherto uninformed well but perhaps ‘flawed’ patients?

Is this ‘medical’ model of illness-driven, individual patient care and treatment, sufficient or right for this modern age? Or would the ‘public health’ model be the preferred approach—one that is driven by trying to eliminate root causes to ill health i.e. by preventive measures against communicable diseases, smoking, alcoholism, obesity, drug addiction, etc.

Or would a third model encompassing even wider social strategies such as poverty reduction, wealth redistribution, empowering children, women and the needy, be the better way forward, to enhance health and healthier choices in the community?

Should indeed the medical professional reconsider his or her concept of medical care and the healthcare system by considering all aspects of social determinants that impact health in the community? Or should we stick to our narrow fields of practice, finely tuning our skills in a one-on-one basis, oblivious to the wider scope out there? How do we improve health for the community? Or is this too huge a problem for a puny professional to handle?

The President of the Royal College of Physicians of London, Dr Richard Thompson in the September 2010 Bulletin, wrote recently that medical leadership must indeed be made a part of our profession: “We must be the catalyst once more in improving care and spreading more kindness… so as to offer the same standard of care we would expect for ourselves and our families. There are too many stories of thoughtless and unkind care from friends and relatives in the media. Physicians can and should be leaders in every part of their trusts.”

In a RCP 2008 document Understanding Doctors: Harnessing Professionalism[3] the question of fragmented and incoherent medical leadership was discussed:

“If the leadership of the profession is fragmented, then the profession may have a problem in terms of wasted opportunities to impart its collective wisdom. Equally, society as a whole has a corresponding problem if a lack of transparency about professional leadership, or a lack of agreement within the profession, makes it difficult for politicians, policy-makers, patients and the public to engage in dialogue with the medical profession as a whole.

“As we shall see, doctors are keen to make their voices heard on a wide range of issues. There is clearly scope to develop the leadership of the profession so that they are better able to do so.”

Sadly, when a straw poll carried out by the King’s Fund on 406 doctors and 376 non-doctors, leadership of the profession was found to be severely wanting: “86 per cent considered the leadership of the medical profession in the past 10 years to be ‘poor’ or worse than poor.”

In arguing that medical leadership means harnessing greater and wider professionalism, more of us doctor-leaders must become more proactive. Below I paraphrase the conclusions of this insightful document.[4]

First, the medical profession must collectively seek to understand the dynamics of future healthcare demands, medical education, students and graduates. We must explicitly place modern medical professional core values at the heart of our collective behaviour in order to buttress the inculcation of these values in our younger colleagues. We must also work with others to develop clearer roles for the doctor working in an increasingly multidisciplinary clinical environment. 

Second, the profession at all levels must work towards developing new relationships with government, patients and the local community. We must take responsibility for establishing a more constructive and influential relationship with the authorities and the government. We must continually learn how best to meet patients preference for a less paternalistic and more facilitative relationship with their doctors. And we must find ways to engage with the community served by the health care system where doctors work. We must help build more realistic and informed understanding of services and resources, and work towards constructive engagement to improve future restructured systems. 

Third, the profession, particularly leaders of national institutions, must take a hard look at how our profession might adopt greater flexibility in work patterns across all medical roles and responsibilities. We must ensure more effective and widespread implementation and adoption of continuing professional development and possibly revalidation of our skills and practice. Ultimately, as medical leaders, we must make our collective voice stronger in public debates about issues of health and health care.

From a more personal and individual perspective, the doctor is always to be reminded that his duties and responsibilities remain as robust and as expected. Medical leadership must therefore, take on this solitary aspect too, particularly with regards the last statement of duties, i.e. ensuring that we are personally accountable for our professional practice and that we must always be prepared to justify our decisions and actions vis-à-vis our patients and the public at large.

The General Medical Council’s Good Medical Practice[5] sets out the duties of a doctor as follows:

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:
  • Make the care of your patient your first concern
  • Protect and promote the health of patients and the public
  • Provide a good standard of practice and care
    • Keep your professional knowledge and skills up to date
    • Recognise and work within the limits of your competence
    • Work with colleagues in the ways that best serve patients' interests
  • Treat patients as individuals and respect their dignity
    • Treat patients politely and considerately
    • Respect patients' right to confidentiality
  • Work in partnership with patients
    • Listen to patients and respond to their concerns and preferences
    • Give patients the information they want or need in a way they can understand
    • Respect patients' right to reach decisions with you about their treatment and care
    • Support patients in caring for themselves to improve and maintain their health 
  • Be honest and open and act with integrity
    • Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
    • Never discriminate unfairly against patients or colleagues
    • Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

Medical leadership indeed is much needed in today’s healthcare scenario, more so in systems undergoing change and restructuring. As concerned medical professionals, we must all rise up to the challenge and engage as robustly and as intelligently as we can. Anything short would be a travesty of our moral position as an enlightened professional.

What if every one of us dare to take on this challenge, and urge the authorities to work with us, listen to us more as we do so too, and arrive at measures collectively, which present the best possible win-win approaches for all, especially for our patients and our rakyat, to improve and restructure the health system so as to achieve the best that can be for all Malaysians; what if?

[1] Robert H Brook. Medical leadership in an increasingly complex world. JAMA 2010; 304(4):465-6.
[2] Department of Health. ‘The role of the Chief Medical Officer (CMO)’. Department of Health website, last modified 10 Jun 2010. Available at: DH_4103960 (accessed on 10 September 2010).
[3] Ros Levenson, Steve Dewar, Susan Shepherd. Royal College of Physicians, London. Understanding Doctors: Harnessing Professionalism. Chapter on “Leading the profession”. King’s Fund, London 2008, pg 38-45.
[4] Ibid. Chapter on “Conclusion”. King’s Fund, London 2008, pg 50-52.
[5] General Medical Council (2006). Good Medical Practice. Duties of a doctor. (Accessed 10 September 2010)

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