Monday, November 15, 2010

The Ethos & Role of the Physician vis-à-vis Society… by Dr David KL Quek

The Ethos & Role of the Physician vis-à-vis Society…
Dr David KL Quek
MMA News, President's Page, November 2010
This month is proving to be a difficult month for me to write my president’s message. There have been many ongoing developments and undercurrents, which continue to rock the equanimity of the profession and society.
Liberalisation Uncertainties from AFAS
Having now visited Sabah, Sarawak and Melaka for the MIDA-MMA Seminars, I now appreciate more the grave disquiet that is now so pervasive especially among our private sector doctors. The issues of the ASEAN Free Trade Agreements (Mutual Recognition Agreements, MRAs), the changing liberalization strategies, and now the 1Care Health Restructuring plans have become ominous signals for an uncertain future.

With the accelerated approach to liberalisation of health services within ASEAN, more challenges are now forthcoming. If our globalisation gurus and bureaucrats have their way, by 2015, our borders would be fully open, and there will be opportunities for doctors from other ASEAN nations to enter freely into the country to practice once they meet the forced modified requirements of our national regulatory bodies. Of course we would also be free to expand beyond our shores. Competition and free flow of services and goods will be the order of the day.
With our growing number of doctors and medical graduates, it is not inconceivable that we would have a severe glut and highly competitive atmosphere, which would threaten the position and livelihood of medical professionals in the country. We have to ask the wisdom of our rapidly growing doctor numbers in this globalised scenario from the perspective of the medical person, and not simply bureaucratic number-crunching. How this liberalisation especially for the private sector will pan out remains to be seen especially with our purported plans to integrate the public-private sector…
The Private Sector Malaise…
Our earlier GP Summit continues to rankle many among those who have participated as to where we are heading, after this exercise. Some of our members have lamented the fact that the GP issues appear to have subsided in interests and enthusiasm.

The primary care coalition is struggling to come up with an adequate and cohesive approach to coming out with a united collective consensus statement or document that is agreeable or consistently acceptable to every disparate group. There remain deep dissensions and emphases of which approach to take. We’re resolving this even as I now write, but sustained commitment is often a hollow if trying experience and I suspect many of us well-intentioned leaders are suffering from some form of lacklustre burnout… Perhaps, it is just me…
But we have let the authorities know that there have been loud rumblings from the ground, and we have been disclosing to the policy makers, some serious points of contention and concern. To be fair, there has been some modification of views and emphases on the part of the MOH and authorities, which now recognize more sympathetically, that some of our grouses and disquiet have merits, while allaying our so-called misconceptions.
The DG of Health has personally written a clarification piece in the October 2010 MMA News, to explain in greater detail the rationale for reform, and what the changes are all about, while at the same time reassuring the GPs that they would not be marginalized—that they would all be incorporated into the larger scheme of things.
But rightfully, DG has re-emphasised that GPs must continually upgrade their knowledge and skills—what is unclear are the minimum requirements or expectation or even the newer regulatory framework that the MOH is alluding to for the near future. Therefore, if anything, the future promises to be more rife with greater and greater oversight and perhaps even more intrusive expectations.
We agree that all of our services in the healthcare must be improved as we move in tandem with modern times and expectations, but knowing our extremely spotty and poor healthcare database or its accuracy or inadequacy, we worry that the true picture might not emerge.
We need more systematic, regular research and ongoing studies on the entire system of health care, the private as well as the public. We need to determine how these can be utilized as reliable focus points and be transparently translated into practical improvements, based on accurate and testable hypotheses and findings.
For example, we need to be able to show that certain sectors have shown inadequate performance outcomes, and failures, but these must be neutrally obtained with the view on how to improve systems. For example, do we have reliable data that some GP clusters or soloists have been poor in maintaining BP goals or diabetic HbA1c levels? Have we data to conclusively identify complication rates which increase hospitalisations or worse, adverse outcome results such as death or amputations, etc?
If so, are they testable and fairly documented? If not, how can we implement incentives or disincentives for such presumed performance outcomes? Do we have an agreed set of parameters, which can be adopted and tracked (preferably via online mechanisms) so that these are easily apparent and cannot be frivolously challenged; or so that supervising authorities are not accused of selective prosecution or discrimination? This is critically important because, people’s livelihoods are going to be affected.
Perhaps, I internalise too much, and feel too much…
Professional Fees Revision, at last?
It is now more than 4 months after the DG of Health and the MOH called a meeting to reconsider a timely revision of the professional fees for medical practitioners in the country, i.e. a revision of the 13th Schedule. Some 160 physicians turned up in this epic assembly at Putrajaya, which clearly showed that doctors are concerned when their bottom lines are at stake. Since then there have been several meetings, sometimes every 2 to 3 weeks.

Having said that, our meetings have not been smooth sailing. The various committees and task force for the MOH fees revision for medical practitioners have been mired in contentious parochial interests, with many societies actively demanding that the MMA takes a back seat, even despite the fact that we have been instrumental in initiating, moderating and revising our medical professional fees these past 20 years or so. But history and memories are short, and not often appreciated these days… Perhaps MMA’s role is over, if we believe the main detractors who demand for their greater say and input…
It appears that all our hard work has come to naught (our 5th schedule after some 5 years’ work, were rejected outright due to prejudice and misinformation, more than substance) because others supposedly more intelligent and more studied than us, have allegedly better versions of how to improve the fee schedule.
I would be remiss if I do not argue that most of these new proclamations are noted for their self-interests, and that these discordant if big changes would have resulted in possible public outrage, if fully accepted or implemented, without modification or greater moderation or with a community spirit of give and take.
Each and every college and/or society of medical/surgical specialty/subspecialty are aggressively presenting their cases for the highest ‘most’ appropriate fees for their own perceived weightage and skills. In other words, nearly everyone believed their own specialties are the best, the hardest to learn and practice, the most skilled, the most risky, the most medico-legally costly, and thus deserving of the highest relative value scales. More and more are urging changes in the fee codes and bands, which shift these to the highest level of reimbursement, tolerated by the committee or task force.
Such internecine infighting for our own narrow vested interests, unfortunately, will not augur well for what the authorities will accept or worse for what the public and/or the healthcare buyers or payers will recognize or accept. We simply just cannot afford a free-for-all upward fee revision, which is not based on some form of ethical anchor, of moderation or levelheaded comparisons or relative benchmarking with other professions or other jurisdictions such as those so established in either the USA or Australia.
Of course the free market system is useful for determining changing values and costs, but these should not be dictated by a unilateral presumption on the part of one party alone, i.e. by medical doctors, without due consideration of our social duties, responsibilities and our unwritten compact with our patients and the public on the other side of the equation…
There appears to be a rushed if mad scramble of trying to gain the most for each of the multifarious disciplines, which I fear will undermine the feasibility of real changes and modifications for the fees, which have remained stagnant for the past 10 years or so.
The current schedule now enshrined in the PHCFS regulations is almost entirely based on the MMA 4th schedule of 2002 (which version was initiated since 2000!). Once listed as part of the regulations however, it is extremely difficult to modify, which is why the MMA has been stridently seeking its delinking from the Act and Regulations. We are happy to note that the MOH is rethinking this aspect to enable a fairer system of reimbursement strategies. We do need more frequent and regular revisions of this very dynamic schedule of fees if we are to be fair to the medical practitioner and our changing inflation index.
Still, I wish the MOH, now acting as moderator, all the very best to come up with something more timely, more wholesome and acceptable to the Malaysian public, and certainly not just for a few or even the majority of medical doctors… we are still dependent on our patients, who are our raisons d’être, lest we have forgotten…
Medico-legal Reminders
Recently, I was preparing for a talk for the Medico-Legal Conference, when I found a few catchphrases, which recurred over and over again. One of these is the concept of “truth-telling” and veracity and the physician. It became the most meaningful phrase which exhorts the Physician to an ethical standard far beyond the norm.

“Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.

“In their day-to-day practice, doctors are committed to:
o   integrity
o   compassion
o   altruism
o   continuous improvement
o   excellence
o   working in partnership with members of the wider healthcare team.

“These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society. Each party has a duty to work to strengthen the system of healthcare on which our collective human dignity depends.” (RCP 2005)[1]

Informed consent must be more fully recognized as standard operating procedure and careful documentation and patient family rapport a must, if we were to see a containment of more medicolegal challenges in the foreseeable future. But as more and more of our people are becoming more knowledge savvy, the information gap or asymmetry would drastically decrease, so we cannot afford to remain the aloof paternalistic doctor as before—we have to communicate more and become more caring and empathetic.

Forensic Disquiet
In this regard, our medical professionalism must also extend beyond the usual remit of the clinical medical professional.

Of late, the forensic actions of some of our medical colleagues leave much to be desired. Forensic professionals especially medical experts must exercise due restraint from political or other pressures, which can seriously undermine their roles and responsibilities. It is to be emphasised that as forensic experts, their duty is to the ultimate testable truth and not to be colored by prejudices or other influences (State or police), which determines in many cases, the risk of harm or punishment for the innocent or the guilty.

For the dead, that duty is even higher, when truth-telling must be fearless and impartial so that closure and justice can be obtained by the aggrieved and their loved ones.

It is now recognized that forensic ethics-related problems have remained largely unexamined, but deserved the closest scrutiny. These included testifying with certainty but with uncertain knowledge; the temptations, conscious or unconscious, of harming or helping forensic evaluees; and over-identification with the side that hires. It is crucial that the forensic expert be scrupulously honest and be recognized as one with impeccable integrity.

It is true that few forensic professionals can escape acting as a double agent because he could not combine the traditional goal of beneficence with the simultaneous task of trying to serve the interests of justice. But he or she must adhere to whatever is testable to be true and not be biased. Thus, in many ways, the ethics of forensic science are in chaos.

I’d like to end by quoting the following, on the Code of Chivalry and Ethics of Forensic Science, as food for thought:

“The pledge: To protect the innocent from wrongful conviction, to help convict the guilty. The fulfillment of this two-fold promise requires assurance of professional competence across all disciplines, and enforcement of rigorous ethical standards.” ~ Kathy Reichs[2]
(T)wo broad principles that govern the ethics of forensic work: truth-telling and respect for persons. In regard to truth-telling, I was referring to a two-fold obligation, beginning with the duty of subjective truth-telling or honesty. That is, forensic psychiatrists should testify to what they believe to be true, regardless of whether such testimony favors or disadvantages the parties employing them… Thus, truth-telling must encompass an additional obligation of being objectively truthful. Testimony, whether written or oral—at trial, deposition, or in another venue—should accurately reflect the scientific data on the subject at hand and the consensus of the field. When the testifying expert goes beyond the data or controverts generally accepted professional understandings, that deviation should be made clear… Assuming we circumscribe our role so as to comport with this ethics framework, we can legitimately offer useful information to the courts. Our insights will not, in themselves, resolve legal or moral dilemmas; but they should provide the factual background and interpretive context to allow legal decision-makers to make better choices than they would, left unaided. A modest role, perhaps, but not one to be scorned.” ~ Paul S. Appelbaum[3]

[1] Royal College of Physicians (2005). Doctors in Society: Medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP.
[2] Kathy Reichs in “Camelot? Or Scam a Lot?” in 206 Bones, Pocket Books, New York, 2009
[3] Paul S. Appelbaum, MD in Ethics and Forensic Psychiatry: Translating Principles Into Practice”, J Am Acad Psychiatry Law 2008; 36:195–200

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