Sunday, May 8, 2011

MMA Reflections: Transform or Reform, Change we must! by Dr David KL Quek

MMA Reflections: Transform or Reform, Change we must!

Dr David KL Quek, MMA News, May 2011

“What I'm hoping to accomplish today is for everybody to focus not just on where we differ, but focus on where we agree. And then let's talk about some areas where we disagree and see if we can bridge those gaps. I don't know that those gaps can be bridged.” ~ Barack Obama, President, USA

Never doubt that a small group of concerned citizens can change the world, indeed it's the only thing that has.” ~ Margaret Mead, renowned anthropologist

“Finish each day and be done with it. You have done what you could; some blunders and absurdities have crept in; forget them as soon as you can. Tomorrow is a new day; you shall begin it serenely and with too high a spirit to be encumbered with your old nonsense.” ~ Ralph Waldo Emerson, 19th century American writer

As I now approach the end of my term and look back over the 24 months since I took the helm amidst so much recriminations and angst, I am happy to cautiously state that my term of office has been one of relative success in a number of set goals, which I had alluded to during my inauguration. But of course, I see this with a less than biased eye…

Yet, I am saddened by other developments, which seem to continue to undermine and enfeeble our Association, and diminish our power of unity and strength of purpose. The changes in the Constitution and electoral process have upset a large segment of our members, and our usually sedate apathetic medical practitioners are wondering if this is the way forward, toward more exclusive if already weakened influence…

Recurrent complaints to the ROS pose a severe threat to our continued existence, and tarnish our mission.

There appears to be pockets of disparate troubled truce and factions vying for parochial attention and interests.

There is also fairly widespread if vague disaffection which continues to plaque our association until outbursts of simmering tensions burst and threaten to tear apart the fragile fabric of our uneasy compact.

Shouldn’t we, after half a century of eventful but collective history, be consolidating into a mature and stature evoking society of professionalism, prestige, pride and glory? I wonder…

Engaging & Collaborating with MOH
Let me begin with the positives. I had set out to engage more robustly and closely with the MOH, the Minister, the DG and its officials, and in that, I think we have somewhat succeeded. Not so much in terms of gaining their blanket acceptance of our misgivings or even our points of view (for that we most certainly did not do quite so well!), but more so, in getting their rightful attention that there are alternative opinions and reasons why some of the official policies or practice decisions, need a second or third look.

In May 2009, I had stated that while we sometimes have friction between the MMA and the MOH, we will try hard to mitigate differences in approaches. We cannot always agree with MOH policies and plans unreservedly, but we will continue to share and contribute our ideas and expertise to establish a better healthcare system for Malaysia.”
We certainly had some uneasy moments of disagreements and discords, but I think we stayed our course and continued to maintain that premise of robust engagement. Therefore, in this regard we did have more dialogues, which helped to showcase each other’s stands and viewpoints more clearly. These also underscored our more pointed and divergent differences of opinions, some of which remain seemingly irreconcilable, but still needed to be addressed, resolved even…

We had opposed the paramedic-managed 1Malaysia clinics because of our fear of subtle task-shifting and a possible reduction of standards or quality of medical care for the most indigent and marginalised in the urban areas.  Truth be told, we do understand the need to provide more affordable and accessible care for inner city residents with limited means.

But we thought utilizing our many GP clinics and purchasing their services at negotiable costs, would have been a better and more productive win-win option. But we did manage to open the debate for more supervised care and perhaps arguably stem the more rapid mushrooming of such quality-suspect initiatives…

But we did work well with the MOH when confronting our common enemy in the A/H1N1 influenza pandemic, via timely and collaborative public health outreach at the National and local levels. We also did well in co-organising two hugely successful infectious disease conferences: the first on the A/H1N1 influenza pandemic in 2009, and the other on a wider spectrum of timely updates of resurgent infections such as dengue, leptospirosis, MDTB, influenza, vaccinations in 2010.

Doctor Glut a blooming reality

Justification for ad hoc policy changes or programme shifts must be made more accountable and certainly more systematic, and must include greater and more participative buy-in from more stakeholders. As health professionals we deserve to be at the forefront of such engagement, our voices and viewpoints must be considered and weighed seriously. Our authorities and government must learn to understand this. We must not allow our voices to be muted, to be silenced.

Modern governments must not persist in unilateral top-down dictates but instead engage greater public discourse to find the best, most acceptable way forward. This is indeed the era for people empowerment and right. Otherwise, governments may be forced into flip-flop withdrawal or piecemeal modifications of hastily-made but unpopular decisions. These erratic actions weaken the legitimacy and authority of their power.

This is particularly so, when we are still at odds with the rapidly growing number of medical graduates and the MOH one-sided decision to attain a 1:400 doctor-population ratio by 2020. This meant a projected total number of 85,000 or so doctors coming on-stream by then. We say that this estimated target number of doctors for our country is far too many, too soon!

As if to reinforce the point of feared medical graduate glut, the overcrowded training hospitals have begun to show their bursting seams. Hundreds of new house officers are now vying for adequate attention to mentorship and hands-on training experience; the 2-year programme for rotational disciplines for housemanship certainly does not help.

There are now doubts as to the continued viability of such a 2-year internship programme. There are also concerns of insufficient capacity to train or absorb the resultant medical officers for the mandatory 2 years, worse with some 4 to 5,000 doctors coming on-stream year on year from 2015 onwards! It is now becoming apparent that such slip-shot untested planning has resulted in disrupting civil service order, nearly busting the already bloated civil service payroll costs, and causing an unintended nightmare of uncontainable overcapacity.

New medical graduates: Mismatched quality and competence

In spite of this disproportionate excess of HOs, there have been rising housemen complaints that they have been overworked and stressed out! Recently we have received complaints that some house officers spent some 10-14 hours 6-7 days a week, exhausted daily, and claiming that they have been overworked, by sending anonymous letters to their parents, state assemblymen, MPs, the DG and even the Health and Prime Ministers.

Yet when details of these claims were examined, it had been found that each of these HOs was only looking after some 5-6 patients a day! But they could not cope! Clearly, these doctors were overwhelmed because they have been incongruously bullied into a profession that he or she had underestimated the scope or the task at hand. The Peter Principle is clearly at work here; the poor competence of these graduates sorely tested their limited mettle.

Thus, more young graduates are now regularly referred for psychiatric help, not a few have been deferred or extended their training periods for months or years! This once again proves our premise that many of the younger medical graduates have been poorly prepared for this possibly grueling if rewarding profession!

We have too many local medical colleges with too few experienced clinical teachers, training material or clinical experience. Too many graduates also are returning from poorly monitored foreign medical schools, which have mushroomed to accommodate our burgeoning interest for medical seats, without sufficient attention to academic quality and mental appropriateness of the candidates! Now the chicken has come home to roost, by the droves!

We need more than a moratorium on medical schools! We would soon need to drastically reduce medical seats for our medical schools and beyond. Perhaps house officers must compete in one form or another for jobs and training or even for service. The free-for-all guaranteed job placements of a doctor as a profession, would soon be a thing of the past!

GP Summit 2010
I had said that the MMA under my watch would “shoulder our responsibility to help guide and shape health plans and policies that agrees with our objectives and that of our patients’ and physicians’ interests”.
This we have also done through the first ever GP Summit held in August 2010. Some 200-plus GPs from across the nation, participated to come out with a Primary Care Providers’ Coalition Memorandum, which we hope will be recognized by the MOH as our legitimate consensus statement on how we visualize the aspirations and future of the General Practitioner.
Although in the past we have been quietly, successfully working towards greater physician benefits, these have not always been understood by doctors out there, who perceive that we have been too silent, too slow, too unresponsive, perhaps too submissive. With this GP Summit and memorandum we hope to dispel such a negative perception. But we need to further persuade the MOH that it must learn to listen to our legitimate concerns, and not behave and act as an autocratic overbearing power… Lack of meaningful discourse and buy-in would derail any potential good of any planned reform no matter how small, but worse if huge and all-encompassing!

Private Health Care Facilities & Services Act & Regulations (PHCFSA-PHCFSR), Fees
We have had several dialogues on the above act and also on revising the fees schedule. However, despite declared urgencies, our efforts have been met with bureaucratic laggardness and internecine infighting (among specialty societies and MMA). Generally there have been too little political will to resolve or to implement these amended regulations, which have already been argued and agreed upon for months, albeit grudgingly… The wheels of bureaucracy and the government actually move ever so slowly.
Thus, these new regulations and laws are here to stay for some time yet. But some of these less palatable regulations have been amended and ameliorated, although not yet reinterpreted in enactments.
Uncertainties in many of these overbearing regulations have consensually been rectified and modified, but not yet enacted. Assurances have also been given that MOH Medical Practice Division will fully and quickly investigate overzealous interpretations by some excited practice division officials…
We urge the Minister and his officials to help us resolve these as expediently and as justly as possible. We remain patient to see if the new fees revision will be announced anytime soon.

Better media rapport
During my term too, I promised to raise our noise level, to be more engaged, so that our standpoints can be better appreciated. In a small way I think we have succeeded. More press and mass media have represented our views and have asked for our input on many health matters, although not always to our expectations. By my own inaccurate count, the MMA has been in the news at least 3 to 5 times a month over the past 2 years, which I believe is a reasonable PR success.
Surprisingly we did get fairly good coverage from Bernama, NST, The Star, Harian Metro, Berita Harian, Sin Chew, China Press, Utusan Malaysia, malaysiakini, The Malaysian Insider.
From my reckoning too, we have received less negative press slants on many issues, when we chose to engage more quickly and aptly with the reporters and editors. Many are now willing to give us space to represent our views without the usual doctor-bashing styles that they are or were wont to, previously!
This improved media relationship is important. I had stated that under my leadership style, the MMA would be more resolute and more vocal. This is not to say that we would be arrogant or unreasonable, but it is important for us as a medical body to articulate our viewpoints and our convictions more clearly and perhaps, more publicly; this I think we did try to do.
I believe that under our current sociopolitical climate of greater participation and expectation, our doctors demand this; doctors continue to urge for a greater voice and say. Therefore, I have not been too fearful of putting our viewpoints across when these are believed to be the best solutions for our healthcare system.
While we have stated that we would cooperate where we share common ground, we have also not been too afraid to disagree where such decisions and regulations impinge upon our practice and our livelihood: the 1Malaysia clinics, the high doctor and medical graduate numbers, housemanship glut and poor teaching-training opportunities, the nebulous 1Care health restructuring plans.
We have no choice but to look after our own professional interests, but we have also made measured responses of workable and practical solutions, which we believe would benefit above all our patients’ interests, without betraying our own.
Where physician professionalism and autonomy are threatened, we have voiced our concerns earnestly so that we remain relevant and consistent with the tenets of global medical professionalism and ethical practices, and as a member signatory to the World Medical Association and the United Nations.
Thus, task-shifting moves associated with the 1Malaysia clinics and forensic human rights abuses have been met with robust calls from the MMA to the authorities to resist and desist from such frowned upon activities and policies. We urge for greater protection of the victim, the patient, and their families, not the errant authorities who might be implicated in wrongdoings!

Collaboration with fellow professionals groups e.g. PCPC
I have also alluded to the fact that currently, the MMA represents a diminishing number of doctors in the country, some one-third or so. This number will increasingly become smaller, as more graduates join the ranks of the public service, where many if not most are not ready to embrace membership of the MMA. Unless and until this policy of voluntary membership change, we will see a continuing dilution of our representation.
Perhaps it is time to review this state of affairs, getting numbers via recruitment efforts are sporadic and can never keep up with the growing numbers of doctors. We have to see how other foreign medical associations recruit their members or consider modifying our membership rules. We must remember that greater membership means greater representation and therefore implies greater clout when meeting or bargaining with or confronting public officials and the MOH.
Sadly, MMA does not and will not have the exclusive right to usurp the attention, the involvement or the representation of every medical practitioner. There have been smaller societies, even new ones, which represent more vested interests of some of our doctors. Unfortunately these will not see the greater importance or need of the MMA, and will vie with us for attention and coveted policy conversations with the authorities. These are not always mutually exclusive, and we will have to learn to accommodate them. Because, humans will always choose diverse associations to cater to their disparate needs and interests. These are as legitimate and as influential as their leaders would have them be.
I believe that we should not exclude doctors even if they choose to be more active elsewhere. We should work towards more inclusive and collaborative positions of cooperation and consistency of objectives. Some of these medical societies have very dynamic if narrower interest bases, which represent the urgings and intentions of some factions of doctors, but their ability or courage to deliver on certain issues, make them relevant.
Whether we like it or not, some societies’ strength and special expertise may even exceed our own MMA’s collective vision, action or inaction. I believe we must not shun them as competitors, but employ their strengths to enhance our capacity to present a more united front for our shared dialogue, lobbying and pressure roles.
We must harness their strengths and successes. We should attempt to work together with them, to further the greater goals for the medical profession and the physician. I attempted this by co-founding the primary care providers’ coalition (PCPC) when we organized the successful GP Summit. This is one model of cooperation that we can further explore to enhance our worth and our value for our members and the profession.

Relationships with Pharmacists, MPS, MSQH, AFPM
Although we have connected with the Malaysian Pharmaceutical Society (several dialogues and a joint Symposium), there have been slow moves to fully cooperate with each other due to the hardening of our differing positions on professional tasks and duties, with suspicions and cross-purposed accusations mucking up the atmosphere for better collaboration.
We too have had a stormy confrontation with the MSQH (Malaysian Society for Quality in Health), where the officials through their MOH connections, have been clamouring for a medical clinic accreditation programme (MCAP), and which we have been trying to find alternatives so as not to encumber our GPs. Although voluntary, we have worries that such accreditation will become a subtle way of assessing GP appropriateness for reimbursement or pay for performance incentives, in the possible near future.
We are exploring with Academy of Family Physicians, to see if there are parallel programmes, which can be more affordable and perhaps even more comprehensive and preferred. We urge our partners in this endeavour not to charge exorbitant fees for such QIP, educational or credentialing programmes. If we can widen our buy-in platform, we would all collectively benefit in a win-win scenario!
If we show greater leadership, then I believe others would also agree to be part of our show and strength of purpose. If on the other hand, other similar societies are more dynamic and innovative, then we should not be too proud to acknowledge their strengths and leadership—we must work towards a win-win partnership to attain our greater common goals.
We must share a more inclusive attitude with all who wish to join us in enhancing our medical professionalism and practice. We must refrain from excluding membership participation just because of perceived or preconceived differences. This will instead turn away many who would have joined our forces to move in tandem within the MMA. We lose membership gain and possibly too we lose our legitimate representation based on strength of numbers.
Therefore, we must work harder to show that we can still attract our younger physicians to join us. We must show that we are still relevant, that we still have a greater purpose of policies and influence, within which our new members can take greater pride of place.

Caring Ethos
As I began my year as president, I called on doctors to remember and return to our Caring Ethos. I reiterate that we must regularly remind ourselves that ours is the only one that demands a caring value system. We must be mindful of our tradition, our Hippocratic oath.
As humans with our inborn foibles, we will slip from our conscientiousness. Sometimes, we will even regress into our baser instincts. We might sometimes let our better judgement succumb to the demands and lure of lucre, of money, of personal and/or professional arrogance, which beclouds our inner voice, our true vocation.
Sometimes, we are just too immersed in the tedium of our work and more work that we forget to reflect on this. We forget our professionalism, our ethical moorings and our gradually eroding if still circumscribed worldview. We then slither into conduct unbecoming, which may or may not be challenged or reported, but which we know is wrong or less than right. We must therefore strive to reduce this possibility to the null experience as possible. It is hard, but it is possible, and we must conscientiously strive toward this demanded role, our healing art and science.

Practice Issues—Regaining our ‘Magic’
In the daily grind of routine, that heady pursuit of monetary gains, that overpowering ‘busy-ness’, we can forget our healing art.
We distractedly dissipate our empathy, our special relationship with our patients. We lose that subtle touch of healing, that singular ‘intimacy’ with which we have been entrusted.
We let those “mystical chords of healing” slip away from us. We fail to harness and weave that innate physician attribute, that ‘magic’, which is by itself so powerfully therapeutic. Given with empathy, this special relationship may sometimes even supersede the need for medicines, intervention and the like…
Perhaps, it’s the overpowering commercialism so steeped in today’s medical practice, which has helped extinguish this sense of therapeutic healing. We are no longer admired as benign benevolent healers, but increasingly seen as purveyors of a commodity to be purchased, avoided even if possible!

Transforming MMA, What if?

I am also glad to note that the last 2 years have been blessed with relatively subdued disagreements and misunderstandings. But I am also emboldened to have noticed that perhaps more exist under the surface of calm than meets the eye…

What if MMA transforms itself into a different model of Leadership, without ethnic, cabalistic or opportunistic, even historical baggage?

What is MMA’s Relevance to today’s Physicians, to our rakyat?
The question of MMA’s relevance to today’s Malaysian doctors has been raised time and again. With our membership growing so slowly or stagnating even, it appears that our representation is quickly but surely contracting.
Our 9,000 members now pale in comparison to the more than 31,000 registered doctors nationwide! Thus MMA represents less than one-third of all our doctors, and the percentage is likely to decrease with each passing year. Arguably, the MMA still remains the largest association representing doctors in this country, but with diminishing strength!
We are not alone in this. Many medical associations, which require annual fee contributions, suffer from such a fate of erratic membership numbers. The American Medical Association also recorded a sharp 5.3% drop in membership in 2010, down from 228,000 to under 216,000. Thus, AMA represents just some 20% of all American physicians (1,144,282). Interestingly, some 21.9% of AMA’s members are medical students although they form just 8% of the U.S. population of physicians including medical students.
Many have argued that the MMA is no longer relevant. Others have insinuated that MMA no longer carries the commitment or the clout of representing doctors’ interests. Has the MMA been protecting our vaunted professionalism? Have we been defending our more than straitjacketed practice issues?
Sadly, we must admit that there have been moments when we appear to have been floundering. We appear to be doing just that, once again! We’ve been so engrossed with our own parochial infighting, internecine politicking that we appeared to have lost our bearings. We appear to have forgotten our purpose of serving our members. We’re seen to have been silent when certain of our medical professional interests had been encroached upon. I dare say, that is the general perception, but not altogether misplaced…
For one, I do not believe and cannot accept that the MMA is a fraternal club just for pandering to some insular interests. It is not an old boys’ club. It has to be more than that.
Perhaps, this is the time to rein in our baser instincts, tame our selfish inward-looking fixation, and finally get down to the brass tacks of leading and working for the doctors, and ultimately benefiting our patients. We have precious little time to work on so many pressing problems and issues.
The MMA must seize our role and stamp our relevance!
We must learn how to harness and use our ‘power’ as the premier national representative body to help shape and influence national health issues, policies and direction. We have to encourage our younger leaders to come forwards and engage themselves with greater passion and enthusiasm. But as more mature members, we must set the pace and the example; not the other way round and certainly not by creating circumstances which undermine our beloved association!
Above all, we must move beyond our petty obsessions, important while these may appear to our limited frames of mind. We can better channel our energies toward greater, more purposeful activities, which enhance our medical profession and our practice conditions.
We must show our non-member doctors that we are still a force to be reckoned with; that we are indeed espousing their interests and welfare. We must enlighten them that they have a duty to join us so that we may have a bigger say and mandate when we pursue dialogues and representation with the authorities that be.
We must show that the MMA is the best hope for meaningful input and voice of the medical profession. We should actively work towards and gain more membership numbers. We must not shortchange ourselves by trying to dis-empower members because of perceived slights, prejudices, or even ethnic racist considerations. We must not drive them even more into their comfort zone of apathy and resignation!
We must be credible dialogue partners with other stakeholders of the health care industry, including the Ministry of Health. Thus, we must learn to identify important national-level issues, gain more in-depth interests and knowledge so that we can play a more meaningful role to help modify or revolutionize policies, which ultimately require change for the better. Above all, we must strive to remain relevant and engaged.

Closing Remarks
I believe we can and we must be bold enough to change, transform or reform, whatever! We must learn to believe in the art of the impossible…
Oprah Winfrey in urging for better and best performance said, and I quote:
My philosophy is that not only are you responsible for your life, but doing the best at this moment puts you in the best place for the next moment.”
Each and every one of us has that little something that we do, that we must carry on in our mundane labors. But we must do the best that we can, and with dignity.
As medical professionals we can do no less. Indeed, we are called upon to do even more. Let’s make our profession even more luminous as we enter into the new century. Allow me to re-quote yet another segment of Barack Obama’s inaugural message:
“The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea, passed on from generation to generation.” How aptly these words reflect the profession of medicine!
Let us practice the noble art of medicine as has been enjoined upon us from time immemorial!
Let’s engage more meaningfully and help shape the kind of medical practice that we would all be proud of.
Similarly, Ralph Waldo Emerson, renowned literary author had said that "What lies behind us and what lies before us are small matters compared to what lies within us.”
Franklin Delano Roosevelt, US President has been quoted as having said this counterintuitive statement: "The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little."
This is especially so, in this era of newfangled, tech-driven and costly medical care. As doctors striving to be constantly current and the best, we tend to lose sight of the bigger picture, as we narrowly focus more and more on the few and the fewer patients, who can afford our care, our expertise, while excluding the rest, who could not... Perhaps it is time to reconsider, reflect, and remind ourselves of our greater purpose and responsibility…
Let’s find ways to ensure that healthcare is not simply an unreachable luxury only for the privileged few, but one that every Malaysian citizen can access without barriers.
Let’s work to find common solutions, which will benefit all, but especially those in need, i.e. our less-well-of or uninsured patients.
Let’s work towards a common system where healthcare is not splintered and dichotomized among those who can afford and those who cannot.
There is much that needs to be done, and more that should be considered and thought about.
Let us doctors and the MMA concern ourselves with more and more of our actual medical professional issues, instead of being bogged down in enervating trivialities of administrative lapses or personal differences, perceived slights or piqued egos.
Let’s rise above parochial interests and work towards achieving our collective objectives.
Recent challenges and setbacks for the medical profession should not cause too much despair and despondency for doctors. Our own controversial administrative crises should not dampen our spirit of resilience and strength.
We do have challenges, which seem to impinge upon us with the unexpected regularity that sometimes overwhelm our sense of calm. Martin Luther King, Jr. had said:The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.”
Finally, I’d like to leave you all with this cryptic Chinese saying by 6th century BCE philosopher, Lao Tzu: Do you have the patience to wait till your mud settles and the water is clear? Can you remain unmoving till the right action arises by itself?
I wish to thank you all for the singular and memorable privilege and honour of having served you as the MMA president, these past 2 years and more!
I know there is more that I could have done. There would always be more that needs to be done. But circumstances and my human frailty clearly limit my capacity, and I apologise for not doing or achieving more.
For all those, whom I have inadvertently upset, hurt or offended, in the heady pursuit of my undertakings; I extend my sincerest and heartfelt apologies.
God Bless you all!
And may MMA live long and prosper!

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