MyHealthMatters

MANAGING THE RISING COST OF HEALTHCARE Interview by BFM 89.9, Business Radio Station.... By Dr David KL Quek

2012-02-01T20:16:00.002+08:00

MANAGING THE RISINGCOST OF HEALTHCARE

Interview by BFM 89.9,Business Radio Station

By Dr David KL Quek, July 2009

1. What does the averagefamily spend on healthcare per annum in Malaysia?

It is estimated that only about 40% of thecountry’s population or 10.8 million Malaysians, are medically insured. This leaves about 16.2 million peoplewithout health insurance policies. But this is probably not accurate. The UNDP and the UN health accountsdata suggest that only around 11.9 to 14.2 per cent of Malaysians have theirhealthcare cost paid by private prepaid schemes (i.e. insurance or third partypayers). Social Security (i.e. Socso and EPF) contributes another 0.8%, whichleaves the bulk of Malaysians self-paying, out of pocket so to speak.

(Source:Star, 14 March 2009 – “Rising pressure of healthcare cost”)

Healthcare spending is still suboptimum inMalaysia, the government spending just 6.9% of its total expenditure on healthcare services (i.e. 2.2% of the GDP). In 2003, Malaysians spend just USD 374 in total (Purchasing Power Parity)per person per year on healthcare expenditure, with the government contributingUSD 218. However, the last two three years have seen an increase in healthcarespending up to 4.4%, with 2.0% by the government and 2.4% from the privatesector.

We hope we can raise this level to around 7 to 8%,which is what is recommended by WHO. This is all the more important because,there’s been so much development of new technologies, devices and medicineswhich are life-saving and prolonging, that invariably the cost of modernhealthcare, especially specialised care, has escalated. But fueling this is thegrowing demand and expectation from more and more enlightened andknowledge-empowered consumers, our patients.

This compares with USD 1,156 for Singapore, USD 260for Thailand, USD 2,244 for Japan, USD 1,074 for South Korea, USD 2,874 forAustralia, USD 2,389 for the UK and USD 5,711 for the US. As can be seen, although we have pridedourselves as becoming more developed than many other nations around us, we haveyet to emulate those with better and arguably more advanced healthcareservices.

Out-of-pocket spending as a percentage of privateexpenditure on health takes up about 75% of the total costs, with some form ofprivate prepaid plan (e.g. insurance) contributing 11.9 to 14.2% over the yearsfrom 1999 to 2003. Social securityexpenditure as a percentage of general government spending on health hoversaround 0.8% only, mostly from requested withdrawals from the specific allowableaccount within the EPF savings.

We encourage more Malaysians to take up a goodhealth insurance scheme, especially when they are still young, as the premiumsthen will be more manageable and lower. However, the plans should bescrutinized well, so that you fully understand what is covered and what not,and how much is the co-payment or the upper limit of claims.

We have to encourage more of the insurancecompanies to accept more senior citizens for these products, but thoseavailable now can be too expensive for most. Also, we have to work out with ourinsurance companies to reduce exclusion clauses, which undermine the effort ofencouraging more to take up these plans.

Most retirees do not save any money for theirhealthcare when they grow older. This is of course very wrong. If you are apensioner with a retiree benefit then this is probably ok, but do remember thatthis means that you can only utilise the public healthcare services and notprivate ones.

How much to reserve for older age healthcare cost?Perhaps as much as 15 to 20% of all your life savings, because most thesehealth care problems tend to be chronic and catastrophic when one grows older,and then these are the ones that cost the most!

(Source:“The Malaysian Health Care System: A Review” by Dr David KL Quek; WHO NationalHealth Accounts data: http://www.who.int/nha/country/mys/en/)

2. How much does it costfor medication for common ailments (flu, diarrhea) and what are your options –generics vs. preferred and non preferred brands, pharmacies, private hospitaldispensaries (I understand you need a prescription for certain drugs, ofcourse)?

Branded drugs are an ‘innovator products’ which arefirst discovered, tested exhaustively and then marketed after being authorized bydrug control agencies (normally as protected patented products. After someyears (ranging from 10 to 20 years) the patent period expires and generic orcopy products may be produced and sold. These generic drugs is usually intended to be interchangeable with theinnovator product, but may only be marketed after expiry of the patent or otherexclusivity rights. Genericproducts may be marketed either under the approved non proprietary name orunder a brand name. They may bemarketed in dosage, forms and/or strengths different from those of theinnovator products. So they arenot necessarily identical.

Companies who develop new medicines invest 10% to20% of their revenue on R & D. The innovation process may start out with promising compounds, but onlyone out of some 20,000 compounds tested, might make it to the market placeafter exhaustive testing and final approval by drug control authorities. Once the “innovative” medicine has beenapproved, the formulation of the new drug is protected by a “patent” – a grantthat gives the inventor the right for a limited period of time to stop othersfrom making, using or selling the invention without permission.

According to WHO Western Pacific Survey, developingcountries including Malaysia usually spend about 25% to 50% of total public andprivate health expenditures on medicines. This expenditure has increased every year as more people in Malaysia aretaking drugs on a long term basis for chronic diseases.

In Malaysia, the price of medicines can vary widelywithin the same class. Somegeneric drugs may be as low as 60 to 90% less than innovator drugs. Generic drugs are of course lessexpensive because their manufacturers do not have the high R & D investmentcosts of the innovator drug companies. Generic drugs also are not required to repeat costly animal and clinicalresearch on ingredient or dosage already approved for safety and effectiveness.Sometimes, this is where uncertainty as to its efficacy or potency comes in.Are these drugs as good or contain as much active medicine as it purports tohave? Such doubts are more so with smaller companies, and doctors then willhave to use their judgement call to decide on which products to use or not.

(Source:“Generic and Branded Products” by Zarina Noordin, B Pharm, M Pharm, MalaysianPharmaceutical Society Seminar, 28 November 2004)

It is claimed that the price of medicines inMalaysia is much higher than even in developed countries, according to a surveyby local universities. The surveycovering branded drugs and generic medicines at 20 public hospitals, 32 privateretail pharmacies and 20 dispensing doctors found the price of these medicinesto be higher by between 10 and 16 times than the International Reference Price(IRP) under the WHO methodology.

However, this study has not been substantiated orreplicated by another group of researchers. Most doctors doubt the veracity ofthis study because, from our travels around the world, we know for a fact thatmedicines and medical care in this country is one of the cheapest and the mostadvanced in this region and also in the world!

That is why, we are now suddenly known as animportant medical tourism destination—we are probably the fifth in terms ofmedical tourism dollars in the world. Obviously, our standards are good enoughand also that we are very cost-effective and relatively cheap to attract thesemedical tourists.

Doctors in Malaysia sometimes feel that it’s onlyour own rakyat who feel that our standards are low and our fees are too high!But our patients should go out to our neighbouring countries and see forthemselves, the actual cost of private sector healthcare even in ASEAN,excluding Singapore.

But we cannot of course compare with the publicsector which is so heavily subsidised, the government (yes we taxpayers) pays98% of the bill of 12.9 billion ringgit yearly. Only 2% is contributed by thepatients using the public sector! This is revealed by the Health Minister DatoSri Liow recently in an inteview with Malaysiakini.

(Source:“Medicines in M’sia Dearer Than Ever In Developed Countries: Survey” – UCSIWeekly, 27 July 2006)

A recent study by the School of PharmaceuticalSciences at USM indicated that healthcare costs can be reduced substantially ifgeneric drugs are used instead of branded ones. Dr Mohamed Azmi Ahmad Hassali, a senior lecturer at thefaculty, informed that his study showed that the use of generic drugs can helppatients at private hospitals save between 60% and 90% on their medicalbills. However, he said the usageof generic drugs is not promoted in Malaysia, and the lack of awareness amongconsumers is a factor.

In addition, the private healthcare sector ingeneral seems to prefer using branded drugs. This is due to the perception that branded drugs meansensured effectiveness. Accordingto him about 85% of the listed essential drugs in the country have genericsubstitutes. He emphasized thatapproved generic drugs have been tested for their bio-equivalents, and the rateof absorption of these drugs is comparable to that of branded ones.

Even the government is now relying more on genericdrugs to mitigate the effects of rising medical costs. Above all, he said, the healthcaresystem must ensure that “the right drug is given to the right patient at theright dose, at the right time, addressing the right root at the right cost”. (Source: “Generic drugs vs. branded ones”,Star, 14 March 2009)

3. How to negotiate forless when it comes to CT scans, MRIs, other medical tests, healthcare checks,operations – price range for different providers (government vs privatehealthcare providers)?

There really is no comparison with publichealthcare facilities, because all these are massively subsidised. Most testsand medical treatment are paid for by tax ringgit, and certain rules applydepending on which class (first, second or third) you are admitted into.

This is of course very different in the privatesector. Here doctors abide by the MMA Schedule of Fees, which have beenincorporated by the MOH into the Private Healthcare Facilities & ServicesRegulations, 2006.

The charges imposed for any of theseprocedures/tests is based on this Schedule but the public must bear in mindthat this Schedule only serves as a guide, but variations sometimes are allowedbased on either compassion or complexity.

For example, most GP do not charge the allowable professionalfee which ranges from RM 30 to 65, depending on the complexity and time ofconsultation. GPs usually bundle together with medications, during which the amountfor the professional fee is usually pegged at RM10 to 35 only.

When you compare with other professionals, this isindeed a very low rate of fee. Even the consult from your plumber orelectrician would cost you more! Also some newer therapeutic procedures havenot been identified in this schedule however.

What about specialists? Nowadays, most of ourspecialists are well-documented and credentialed, i.e. they are recognised bytheir specialty boards to have had adequate training and experience. However,this is not to say that every specialist will deliver the same identicalproduct of service or excellence of technique or treatment. There will alwaysbe variations, but by and large, most would be close to some form of acceptedstandards of care.

However, it is probably true that experience andindividual skills, may still be something that one acquires with age andpractice among some exceptional doctors. Thus, we hear of some more famousskilled specialists because of their favourable records and results. Thus,sometimes, it is not unreasonable that these doctors may be more expensive to consultor to seek treatment from—best care is akin to having the best services e.g.5-star service as in some hotels, etc.

Having said that, this is only true if thespecialist keeps on updating him/herself with modern advances, training anddevelopment. In some studies in the USA, younger doctors just fresh fromresidency training give the most appropriate and up-to-date treatment! Ofcourse there are exceptional doctors who are only the best with the besttraining and experiences, and who are sort after.

4. How can a patient keepfrom being subjected to needless tests and procedures?

Good communication between the doctor and patientis essential for consent. Patientsshould be given adequate information in a way they can understand to enablethem to make decisions about their medical care. It is a general rule that doctors should examine and treatpatients only with their consent. No consent is valid if obtained under the following conditions:

(i) when there is coercion or threat or force

(ii) when the party giving consent is not aware of the full implications ofconsent.

When the patient is incompetent and cannot give avalid consent, then consent should be obtained from the next-of-kin, who shouldof course be the usual legal authority.

(Source:MMA Code of Medical Ethics)

A 2006 study in the American Journal of PreventiveMedicine found that in 43% of routine checkups of outwardly healthy people,doctors ordered an X-ray, electrocardiogram or urinalysis – tests that are notrecommended for routine prevention under national guidelines.

If your doctor orders an MRI, CT scan or othermedical tests, speak up and ask why this test is necessary, what will be doneafterwards if the results are positive or negative and what the risk factorsare. If the answer is simply“routine screening”, the test may be unnecessary.

If there’s any doubt, every patient should exercisehis or her right to seek another second or even third opinion. There’s also theinternet these days which can offer some background check on some of theconditions or tests that are relevant. Asking your friends and relatives whomay know better can also sometimes help; especially pertaining to the reliabilityand trustworthiness of the doctor or medical center. But these people are alsothe ones who sometimes pressure you into doing too many unnecessary tests—eg.some one had a CT scan of his heart, like the beautiful pictures so much thathe brings all his symptom-free, worried-well friends and family to go have onetoo!

However, the Internet and most of these www sitesare disorganised and cannot be fully trusted or relied upon. Also differentpeople have different problems, presentations and possibly differing responses.Therefore, a doctor is still needed to make some sense as to some medicalcomplaint. Ask more questions and find a doctor that you can relate with thebest to your satisfaction, but also know that consultation is a professionalservice, which should be appreciated, and thus, as patients, you should also doyour bit, and be a good listener, and a good provider of historicalinformation—don’t hide anything which can sometimes compromise the consultationprocess.

TMI: Dissent grows over rumoured healthcare tax under ‘1 Care’ scheme.... By Clara Chooi

2012-02-01T11:15:00.000+08:00

Dissent grows over rumoured healthcare tax under ‘1 Care’ scheme

By Clara Chooi

TMI: February 01, 2012

KUALA LUMPUR, Feb 1 — Public outrage is growing over a proposed “1 Care” scheme to restructure the country’s healthcare system that critics claim would force employees and businesses to contribute 10 per cent of their monthly income to a government-run insurance fund.

Although details of the scheme are still vague and Health Ministry officials have insisted it is still “too early” to sound warning bells, medical practitioners and consumer associations have banded together since last December to kick off the “Tak Nak 1 Care” campaign, hoping to shelve Putrajaya’s plans before they come into force.

Calling themselves the “Citizens’ Healthcare Coalition” (CHC), the group have taken their cause online, using social media tools like Facebook, Twitter, blogs and YouTube to spread information about the scheme and gain wider public support.

Among others, the group have started a “#TakNak1Care” Facebook community page, a Twitter account using the handle @taknak1care and uploaded on YouTube, several video clips urging Malaysians to reject the scheme.

Their efforts appear to be gaining traction among netizens and have even caught the attention of Health deputy director-general (Medical) Datuk Dr Noor Hisham Abdullah, who has been personally involved in lengthy discussions with the group via their Facebook page.

The Malaysian Insider understands that “1 Care” is modelled in its entirety after the United Kingdom’s National Healthcare Service (NHS), a publicly-funded healthcare system, and was mooted in the 10th Malaysia Plan for the Health Ministry’s 2011-2015 strategic plan.

It is believed that the five-phase scheme has already entered its third phase, and the full initiative, post engagement with doctors and pharmacists nationwide, is due to be presented to the Cabinet by March.

According to one CHC member, “1 Care” will replace Malaysia’s current two-tier (public and private) healthcare system by integrating both private and government hospitals, in hopes of ensuring more “equitable” healthcare for Malaysians across all socio-economic statuses.

Under the present two-tier system, Malaysians can choose between seeking treatment at private clinics or hospitals and pay out of their own pockets or via health insurance claims, or opt for treatment at government clinics or hospitals and pay only a nominal fee for basic, government-subsidised healthcare.

With “1 Care”, CHC said it would be made compulsory for all wage earners, excluding government servants and pensioners, and businesses to contribute 10 per cent of their monthly incomes to a government-run Social Healthcare Insurance (SHI).

“So those who can pay, will pay, while those exempted from paying, such as the poor and so on, would still qualify for free basic medical benefits offered under the scheme ... Basically, those who can afford it will pay for those who can’t,” the member said, speaking on condition of anonymity.

But, apart from the “fee-before-service” system under “1 Care”, CHC is also griping over the limited healthcare benefits offered under the scheme such as: a patient is assigned to a specific general practitioner (GP); visits are limited to six times per year; visits are limited to one ailment per visit and GPs or primary healthcare providers (PHCPs) are given Key Performance Indicators (KPIs) to meet and would be subjected to penalties.

“Under this system, PHCPs only profit by billing the SHI for their services. Like all insurance, the SHI won’t approve too many claims to minimise cost. PHCPs may be penalised for giving too much service ... or referring too many patients to hospitals or specialists.

“Doctors may have to provide less healthcare to avoid penalty... but you don’t stop paying or pay any less to SHI,” the group claimed in one YouTube video.

The CHC member explained to The Malaysian Insider that “1 Care” budgets a maximum claim of RM360 per patient for each GP from the SHI, which amounts to only six consultations in a year at RM60 each.

“And with the KPI quotas to meet, GPs would try to delay referring too many patients to hospital. Those who need to seek treatment urgently would then have to go to the hospital on their own and pay out of their own pockets,” the member complained.

When attempting to allay fears over “1 Care” recently, Dr Noor Hisham explained that it was merely at “conceptual stage” and that reconstruction of the country’s healthcare system was badly needed.

“Now in the public sector we spend RM16 billion and only recoup two per cent. On the other hand, we wouldn’t want to burden the rakyat so we are currently looking into various options and models.

“At this point of time nothing has been agreed upon. Until everything has been agreed to by the public and such, we need to study the cost analysis. However, there are already lots of assumptions and speculation and bad branding of the system like this TAK NAK.

“I wonder where they pluck the figures from without substantive data to support,” he wrote in one response.

But the CHC claims a new “1 Care Act” is due to be tabled in Parliament imminently, possible as early as the next sitting in March.

The CHC will brief reporters on the issue tomorrow in the build-up to the Selangor/Kuala Lumpur Healthcare Public Forum on February 12. The Malaysian Insider understands the forum will be opened by Selangor Mentri Besar Tan Sri Khalid Ibrahim and attended by Health Ministry officials.

TAK NAK 1CARE! ..... by Eyes Wide Open

2012-01-29T21:19:00.000+08:00

Saturday,January 28, 2012

TAK NAK1CARE!

Eyes Wide Open

http://notsleepinganymore.blogspot.com/2012/01/tak-nak-1care.html

Healthcare"reforms" called 1Care for 1Malaysia are upon us and it's a trulyfrightening prospect.

The BN government has beenselling 1Care in the MSM throughout 2011, describing it it glowing termswithout giving away any details at all. A concerned citizens group called #taknak1care managed to get hold of someinsider information and started a Tak Nak 1Care facebook campaign that'spicking up steam.

The revelations on theirTak Nak 1Care Facebook page worried the authorities enough that the DeputyDirector General of the Ministry of Health, Datuk Dr Hisham Abdullah joined inthe discussions on the page to try and do some damage control. However, he hasso far been unable to answer or categorically refute any of the informationrevealed on the page and has been reduced to repeating the mantra of"nothing has been decided yet, but whatever it is will benefit therakyat".

But interestingly, the DepDG has acknowledged is that Malaysia is currently about halfway through the1Care implementation process. This blogger wonders how you can be halfwayimplementing something that doesn't exist yet?!

As I understand it, 2012is when the implementation is supposed to be stepped up. Already we see variousarticles in the mainstream media about the drawbacks of our current healthcaresystem. This is done so that the rakyat will be conditioned to accept the needfor healthcare reform. The laws authorising the 1Care reforms may even bepassed this year. So we don't have much time to stop this train wreck fromhappening.

I won't be discussing thestructure of 1Care in this article. For that, please “Like” the #taknak1care facebook page.There is a wealth of information about 1Care there, several intelligentdiscussions including long discussions with the Dep DG of MOH himself, and newinformation is posted often. You can also search Youtubefor the Tak Nak 1Care videos.

For now, I would just liketo explore the problems and questions that arise from 1Care"reforms".

Firstly, I believe 1Careis based on some fundamentally flawed assumptions.

Assumption 1:

The Malaysian governmentcannot afford public healthcare anymore.

Although the BN governmentspends significantly less on healthcare (only about 2% of GDP) compared tosimilarly developed countries, Malaysia is internationallyacknowledged for our relatively high level of healthcare. Thislow cost and high effectiveness shows that Malaysia already has aninternationally praised, reasonably efficient healthcare system already inplace now. (This is a very important point to remember as you read the rest ofthis post.)

But despite the low, lowgovernment expenditure, the BN government is saying that it can no longerfinance even the 2% of GDP for healthcare. It plans to force all rakyat to payup to about 10% of their monthly income into a Social Health Insurance (SHI) toshare the cost. This is ridiculous! Isn't the government's healthcareexpenditure funded from taxpayers hard earned money? Why are we being asked topay again?

The BN government shouldfirst solve the problems of leakages, wastages, corruption and runawayoutsourcing costs instead of forcing the rakyat to finance their irresponsibleways.

Instead, we see the BNgovernment spending taxpayers on more "important" projects such asthe:

- RM 1 billion Mega Tower,

- RM 12 billion PKFZfiasco,

- RM 3 billion submarinesthat don't work,

- RM 50 billion MRTproject that only covers a few km, etc.

And let's not forget

- the RM 1 trillion inillicit capital outflow from the country.

If the governmentrecovered even a fraction of all these wasted resources, our country would beable to easily finance even expand our public healthcare system for generationsto come! But as it is, we can see that the BN government has no intention ofhalting its wasteful and corrupt practices. They clearly do not have therakyat's interest as its priorities.

Assumption 2:

The healthcare systemneeds a complete overhaul

Malaysia currently has asomewhat efficient dual system. There seems to be an unwritten rule among therakyat that those who can afford it, go to private healthcare providers. Thosewho can't, go to public providers. The wealthier taxpayers (only 10% of thepopulation) take care of themselves and willingly pay taxes to provide freehealthcare for the poorer 90%.

This dual system hasworked well for decades (and internationally acknowledged, remember) althoughit has some problems. But most of these problems can be traced back togovernment policies and lack of regulation / standards enforcement. These caneasily be solved by conscientious government intervention.

The most urgent healthcareproblems now are runaway profits and irresponsible public financial management.Solving these two problems should be the first step to any reform. However, itwould seem that the govt has little intention to go in that direction. Insteadit wants to implement a SHI to wash its hands of its already low healthcareexpenditure.

But for the sake ofargument, let's assume that the Malaysian healthcare system is really so bad itneeds a complete restructuring. There are many other countries whose modelshave worked very well with little financial burden to the rakyat. But our govtseems to have not explored any other model for the last two decades exceptprivatisation and creating an SHI to pay for it.

Assumption 3:

Privatisation and SHI arethe best reform option

In highly privatisedplaces like America, reforms in the shape of an SHI could be a welcome relief.In a privatised system, healthcare is a product, and pricing strategiesmaximise profits. But healthcare is not normal product – you can choose not tobuy a car, but you cannot choose not to have a heart attack. You can return ablouse for a refund, but you cannot return a surgery. These conditionsguarantee that healthcare providers will forever enjoy a seller's market!

In such a context, SHIpromises affordable universal healthcare in time of need, as long as people putup with a little less spending money every month after the deductions. It's aviable alternative to costly GP visits / prescriptions, long-term care likediabetes, or sudden catastrophic healthcare spending in cases like cancer or accidents.

A well implemented SHIcould also function as a disciplinary tool for healthcare providers. SHIs candemand quality and accountability from healthcare by limiting payments for badhealthcare practices and irresponsible finances. Of course, it has itsdrawbacks, but it's still better than private healthcare being priced out ofmany people's affordability.

But Malaysia does NOT havea completely privatised healthcare system that an SHI initiative could improve.So in order to justify this fundamental policy shift, the BN government is nowCREATING the necessary conditions for it by essentially privatising the entirehealthcare system through 1Care!! It's like banging your head with a hammer sothat you have an excuse to buy Panadol!

Ridiculous!

Of course, now they won'tdare to use the “P” word as the rakyat had put up with so much hardship due topast privatisation policies. The popular euphemism now is “AUTONOMY” whichallows indivdual govt units to decide policies independently without govt interference– like pricing policies, for example.

If that's the case, what'sto stop government healthcare facilities from acting like for-profitorganisations?

Assumption 4:

There will be enough highincome earners to significantly contribute to the SHI.

Using GDP growth and macroeconomic data as an indication of citizens' financial fitness for implementingSHI is flawed. We must take into consideration grassroots conditions such asincome disparity, inflation and cost of living as well. Right now, the incomedisparity is widening, cost of living is skyrocketing and official inflationrates do not reflect the realities on the ground. But looking at macro economicindicators may give the impression that there is a large middle class that canafford a compulsory SHI.

Plus, the government'seconomic indicators are highly suspect. The official poverty level isdetermined as RM800/mth household income. But in Budget 2012, the PMacknowledges that households earning less than RM3000/mth have trouble makingends meet. Official figures show inflation at about 3%, but independent studiesshow that urban inflation is probably at a rate of 10%. This difference isbecause the government measures inflation rate with prices of goods that arenot typical purchases of most Malaysians.

Implementing a univeralSHI based on such vague and confusing financial data could prove disastrous tothe rakyat who are already burdened by high costs of living!

The BN government's rushto implement 1Care based on flawed financial assumptions without a proper studyof the rakyat's situation only demonstrates their insensitivity and misplacedpriorities. Clearly, the rakyat's interest are the furthest from their minds.

Besides the problems theseflawed assumptions create, 1Care throws up several issues of concern as well.

Issue 1:

Double taxation, zeroadditional benefit

The SHI concept itself isridiculous within the Malaysian context. As explained earlier, we areinternationally acknowledged as having achieved a reasonably efficient healthcaresystem at very low expenditure.

With the introduction of1Care, Malaysians will now be paying taxes, AND the SHI, AND their privateinsurance premiums. If the SHI rates were reasonable and the benefits packagegood, many people would probably have no problem with that. The only peopleunhappy would be the private insurers as they will lose business to the SHI.

But as insiders haverevealed, insurance companies are included in the MOH's 1Care Technical WorkingGroups to hammer out the details of 1Care implementation. And since we do nothear any complaints from them even when 1Care implementation is halfwaythrough, we can safely assume that their business has not been threatened.

Insiders also reveal thatall our monthly payments to 1Care's SHI only gets us Primary Healthcare(General Practioners / Clinics). Even then, the rakyat STILL has to share thecost (co-pay) for medicines and medical accessories. And tertiary care(hospital / specialists) is NOT COVERED AT ALL by the SHI. So the rakyat willstill have to pay out of pocket or depend on private insurance, like we do now(no wonder private healthcare insurers' are not complaining - their marketremains undisturbed by 1Care, right)!

How is this supposed to bean improvement over our present system?! Does the BN government really expectthe rakyat to roll over and accept being forced to pay twice for a “reformed”system that burdens them with higher healthcare costs but delivers zero extrabenefit?

Issue 2:

Integrating public/privatehealthcare sectors will drive costs up

Since 1Care integratespublic and private primary care services and standardises their fees, therewill essentially no longer be any "public" GPs. All GPs will be paidprivate rates under 1Care (latest information is RM60 per visit, billed to theSHI). So we can definitely expect primary healthcare costs to suddenly risesignificantly.

1Care GPs are alsorequired to be "jaga pintu" (gatekeepers). No one can see anyspecialist or be admitted into any hospital without a 1Care GP's say-so. Thisleads to the big question – since public GP services and rates have beenrationalised, will public hospital/specialist services also be integrated andtheir charges standardised?

This is very likely tohappen as it would not be “fair” for government specialists to be paid lessthan their private counterparts in this new integrated system. The Dep DG ofMOH himself hinted at this in one of his comments on the #taknak1care page.Specifically he commented that:

"For aspecialist or doctor if I see 10 patients a day or I see 100 patients thesalary is the same. If you are efficient you be given more work. This is thesystem we have now."

Since 78% of hospital bedsin Malaysia belong to the government who also handles 74% of admissions,imagine what would happen when all these government facilities start chargingprivate rates under 1Care. Healthcare costs to shoot through the roof! It wouldalso be reasonable to assume that a large segment of our uninsured populationwould no longer be able to afford the skyrocketing healthcare costs under thisnew 1Care scheme.

What's more, thisdevelopment will have multiplier effects. One of the effects I foresee is inthe insurance sector. Since 1Care's SHI benefits only cover limited GPservices, private insurers will have to raise their premiums and limit theirpayouts to ensure their profitability is not affected by the tsunami of risingcosts in tertiary healthcare.

Clearly, the BNgovernment's 1Care reforms will dump the rakyat in the wayside in pursuit of asystem that values money more than life.

Issue 3:

Social safety netdisappears

Our public healthcaresystem has always been the primary choice for lower income groups. It is theirchance to get good, almost-free healthcare. However, even before 1Care is fullyimplemented, government hospital charges are now no longer “negligible”. Roomsin some government hospitals now cost as much as private hospitals. Other feesmay be much lower than the private sector, but can still run into thousands fora even simple surgical procedure.As it is now, many poor household find it hardto pay for public healthcare - and 1Care hasn't even been fully implementedyet!

In Budget 2012, the PMacknowledged that households earning less than RM3000/mth have trouble makingends meet and a RM500 one-off cash aid makes a big difference. With roughly 60%of Malaysian households earning below this threshold, how can they be expectedto contribute up to 10% of their income into 1Care's SHI? How will they be ableto afford expensive long-term / tertiary care if there is no longer a publichealthcare system? Where do they go - back to the dukun and sinsei in thevillages?

With the floodgates ofprivatised rates thrown opened, what's to stop our “reformed” 1Care system fromgoing the the free-for-all American way, where any service within thehealthcare industry has the potential to be monetised, subdivided and monetisedagain? Now that the “autonomy” concept seems to be given free reign, governmentowned units can freely make such decisions without interference from thegovernment and the rakyat won't be able to do anything about it.

Conclusion

These and many otherdisturbing issues and concerns are turning up as bit by bit, as the scope andstructure of 1Care are revealed. But so far, the BN government has no answersfor the rakyat.

The information gatheredfrom documents available online indicates that 1Care will create more problemsthan it solves. In fact, the implementation of 1Care's SHI concept willactually destroy our present efficient system, reverse-engineer for us all theproblems of the American privatised healthcare system AND create ALL-NEWproblems because of its very limited coverage. 1Care could be the mostdangerously ridiculous case of putting the cart before the horse thatMalaysians have ever been subjected to by the BN government!

The BN government shouldfix its own fundamental flaws and get its priorites right first beforesubjecting the rakyat to such dubious reforms! The BN government shouldremember that they owe it to the rakyat to provide healthcare and otheressential services, instead of washing their hands in the privatisation basinand kicking back to enjoy less work and more money. We've had enough ofprivatisation policies that forced rakyat to pay through their nose forinefficient monopolies controlling phone services, water, electricity,sewerage, waste disposal, postal service, public transport, and the list goeson... Now the BN government wants to privatise and monetise another essentialservice - healthcare!

The rakyat should not takethis lying down anymore. We must not be held ransom to this "You MoneyOr Your Life" 1Care system. We owe it to ourselves and our children tomake sure 1Care is stopped dead in its tracks!

TAK NAK 1CARE! Join the movement,spread the word.

TMI: Seeking a better healthcare system — by Dr TK Khong

2012-01-19T13:57:00.001+08:00

Seeking a better healthcare system — by Dr TK Khong

January 19, 2012

JAN 19 — Having worked in various parts of the NHS for over 30 years, I know it in virtually every detail. As a health and social concept, the NHS is an unimpeachable undertaking.

However, the NHS in England today is facing severe difficulties caused not merely by demographic changes and medical advances but by the crippling cost of its administration and the inefficiencies of a dominant tax-funded system.

Despite the common belief that it is equitable and efficient, the reality is often the opposite. Although there have been huge increases in health spending over the past two decades, there has been little or no improvement in outcomes across a wide range of specialties, and even a worsening in patient experience in many areas.

The latest reform, with its montage of internal market and private providers, aims to restore some semblance of cost-effectiveness and improved efficiency through delegating the financial decision processes to the medical profession and delivery redesigns targeted at the main causes of ill-health.

The 1Care for 1 Malaysia plan to introduce a nationalised health service in Malaysia partially along the lines of the NHS is a laudable move. Although the per capita income may be rising, the reality is a widening gap between high- and low-income sections of society with poverty on the increase.

Indeed, Datuk Dr Hassan Abdul Rahman, Health director-general, expressed concern that “greater private health sector development would widen the gap of access to healthcare services for the rural population compared to the urban population and between those who can and cannot afford to pay” (The Star, December 3, 2011).

Social Health Insurance (SHI), devised to supplement the amount allocated to healthcare from Government General Revenue, is promoted as an attempt to address income inequalities which are considered as obstacles to accessing healthcare.

However, if as Dr Hassan says, “private investments and the continuous contribution of the private sector are encouraged”, then SHI represents an additional levy on many who are just able to afford their own healthcare but who would under the new regime be financially penalised and who would therefore migrate wholly to the public sector. This in turn will increase the burden on public sector healthcare provisions.

Another key feature of 1Care for 1 Malaysia is that primary care is at the heart of the reform with the GP as its focal point. This transformation is sensible, if only to increase the power of rationing, but co-payment for prescriptions and certain appliances lacks precision over the amount of money that is required from patients. Similarly, there is no clarity over what is within the defined benefits package of hospital care that is free of additional payment.

While commendable in principle, SHI contributions are dependent upon financial ability. Means testing is fraught with difficulties, while the thresholds and variations for additional levy on the rich and healthy have not been defined, nor has the quantification of the “cross-subsidy” been finalised.

Most importantly, it is unclear how much administration of the SHI “organisation” will cost and where the funding for this will come from. Only if the consolidated fund is ring-fenced for healthcare will the public be able to enjoy the full benefit of a properly constructed SHI.

Otherwise, there will be a major adverse impact on the amount of money available for healthcare as management costs will divert significant amounts of funding. Furthermore, there are no indications about commissioning and provision of services. For example, there are no statements on whether the SHI would develop its own provider wing or commission services from external private sector providers, and on the governance of cost and quality issues.

To achieve the success it deserves, 1Care for 1 Malaysia should not be unduly concerned about the ratio of government-to-private spending in healthcare being 55:45 and use it as a starting point for the financial reform of healthcare.

Indeed, the current growth in the private healthcare sector should be recognised as reflective of demand and competition, both of which are natural drivers of quality and restrainers on costs. Instead, the health inequality gap should be dealt with differently cognisant of disease prevalence, and 1Care for 1 Malaysia should focus its attention on detailed analyses and taxonomy of various diseases as causes of morbidity, mortality, emotional distress and economic burden.

The Malaysian government must demonstrate strong stewardship in public health and social care in such areas as care of the vulnerable, the frail and the elderly, those with learning disabilities and the physically handicapped. It should ensure a comprehensive strategy for major killers, such as infectious illnesses and cardiovascular diseases. Health education to promote healthy lifestyles should be a consistent feature in schools and at places of work.

With a safety net in place, Malaysians are then best served in health by reinforcing their financial autonomy and empowerment of individual choice. Rather than follow the path of the NHS and release a money-guzzling genie, the far better approach is for the Malaysian government to craft a robust public health and social care policy that provides for the needs of all Malaysians.

1 Care for 1 Malaysia must not become a wasted opportunity. Its success or failure is critical to the health and welfare of all Malaysians.

* Dr TK Khong, who is a Malaysian GP and a forensic physician in the UK, also serves as a board member of a clinical commissioning group and advises on health and social care policies.

malaysiakini: Gov't not abdicating responsibilities thru 1Care.... by Dr Hasan Abdul Rahman

2011-12-18T13:12:00.000+08:00

Gov't not abdicating responsibilities thru 1Care

Dr Hasan Abdul Rahman
1:58PM Dec 17, 2011

I refer to the article ‘Engage public in changes to health care system’ by G Thomas which is a query on details in ‘With 1Care, the choice will not be there’ by Stephen KW Chow. It is useful to clarify some the processes the government is undertaking in developing the 1Care for 1Malaysia plan.

The Ministry of Health (MOH) is committed to open discussion and sharing of information. In fact, for a number of years now, MOH has been having many sessions to engage key stakeholders whether they are community representatives and parliamentarians, professional bodies including the Federation of Private Medical Practitioners’ Associations Malaysia, and health providers, industry and others, both at national and state level. The MOH has already planned to step up these discussions to another level of engagement next year.

Many stakeholders are also members of technical working groups which are just now working to clarify details of the concept in order to better inform the public and their constituents, as well as ensure that their concerns are addressed. These members who represent agencies are asked to revert to their constituents to get further feedback.

The whole concept of 1Care is to improve the quality and delivery of health services for the rakyat, provide more choice to patients and preserve the strengths in our current health system, which of course for the public sector is founded historically on the NHS.

The NHS has since undergone many reforms to improve service delivery and yet in the 54 years since Independence, our health system has not undergone fundamental changes where necessary. At the same time, the government does not look only at 1 or 2 countries, as no health system is perfect and it is impossible to simply transpose other health systems, as we have our own existing system, values and culture, history, capacity, socio-economic development, policies etc. which also shapes the planning and outcomes.

Therefore, the MOH looks critically at various countries throughout the world, understand the elements and context of their system and evaluates to see what good components may be adapted, given our environment. So it is incorrect to assume that we will apply the NHS, rather look at successful elements within it as with other health systems too.

Within the concept of 1Care, the major role of financing will be strengthened and be managed by a government not-for-profit entity. It should be realised that currently in Malaysia, the public sector manages only a bit more than half (only about 55%) of the financing for health.

About 36% comes from private out-of-pocket spending of individuals, while the balance is paid by private companies, through private health insurance and other private modalities.

So, rather than the government abdicating its responsibilities for health, 1Care is intended to provide the government stronger stewardship and regulatory as well as financing roles. Thus, policies for good health care and concerns raised by the rakyat such as the rising cost of health care services can be addressed more effectively, not just through coercive means such as regulation and enforcement but also employing other means that invite more collaborative efforts in a win-win partnerships between the government, the rakyat, the economy and all health providers. How best to achieve this is currently being studied.

Dr Hasan Abdul Rahman is director general of Health Malaysia, Ministry of Health

Medical Practice under Scrutiny: How much care is too much?

2011-12-18T13:07:00.002+08:00

Medical Practice under Scrutiny:How much care is too much?

By DrDavid KL Quek, FRCP, FNHAM, FAsCC, FACC

NHAM Pulse, 2011 (December): 2-6

“Illness is the night-side of life, amore onerous citizenship. Everyone who is born holds dual citizenship, in thekingdom of the well and in the kingdom of the sick.”

~ Susan Sontag[1]

The Illness Metaphor vs. Medicalisation

SusanSontag’s introspection above encapsulates this very real if unsettlingManichean truism about illness and health in man. This was recently re-quoted in the frontispiece of Siddhartha Mukherjee’s 2010 book ‘The Emperor of all Maladies’ — a Pulitzer Prize-winning book aboutcancers and the heroic battles to conquer if not to deflect cancers’ dismal ifinescapable trajectories and outcomes.[2]

The narrativeon the history and advances of cardiovascular understanding and therapeuticswould probably reflect a similar but perhaps with a more positivehistoriography.* But therehas always been that tendency for physicians from time immemorial toover-extend our professional reach and our self-importance, as we insinuateever deeper into society’s socio-economic web of life. With affairs of theheart, this is even more pronounced!

Sometimes,as physicians we tend to forget that illness is an innate part of man—we willalways become ill at some points in our lives. Yet, most of us subconsciouslyembrace and expect its opposite—health—as a given. Perhaps we have let Medicine’soverarching narrative to reshape our societal psyche into embracing apervasively systematic but false Nemesis.[3]

Eventuallyevery one of us will die, sometimes suddenly, prematurely, but frequentlyenough from a drawn-out chronic ailment, which may be subtly quiescent (‘silentkiller’) or which may visibly stress, depress, debilitate and occasionallydehumanize us. Illness and loss of health in humans and our patients are why wephysicians are here in the first place—patients are our raison d’être.

Healthcareissues now encapsulate some 3 to 17% of mankind’s economic activity, dependingon where you are in the globe.[4],[5] There is that growing conscious demandand push towards ‘good health’ and more accessible health care.[6]Health is regarded as an inherent component of life, and is rightfully demandedas a human right.[7] Asphysicians, we must serve as the natural guardians and advocates to ensurethis, by making every possible effort to improve universal access and coveragefor this increasingly out-of-reach ‘commodity’. At the same time we must remainconscientious that we do not create ‘health’ into an unreachable ideal, whichcan only bilk or disenfranchise the unquenchable demands and expectations ofour willing but poorly informed patients at large.[3]

Yet, as we(as doctors) embark on our furious pace of modern medical practice, we embracesometimes almost blindly all the advances that come our way, not wanting to beleft behind in that unrelenting race to keep up with what are new and trendy,in the name of progress. We readily adopt and utilize whatever technologicaldevices and drugs at our disposal, believing that most of these efforts wouldbenefit or even cure our patients, sometimes at huge costs! But in the sum ofall things, medicine does work—patients do benefit and perhaps arguably livelonger and enjoy better quality of lives.[8]

Why?Because, as doctors we are trained to follow systematic if narrowly prescribedheuristics on how we approach illness, how we deal with it and how we treat it,piecemeal, one at a time. However,increasingly we have been reminded to look at each patient in as holistic amanner as possible—treat the whole patient, not the diagnosis, we say.

But becausemedical information is continually growing and evolving we also need toconstantly keep abreast—hence, the exhortation to lifelong continuing medicaleducation and learning. Knowledge growth also implies periodic shifting of thegoalposts for what are recognized as normal or abnormal, sometimes akin to newwines in old bottles—blood pressure, blood glucose and cholesterol levels arenow lowered for normal acceptable ranges.

This necessarilyimplies treating more patients to achieve lower and lower targets, becausethere have been growing research data that show that perhaps lower isbetter—lesser complications, better prognoses, better outcomes, perhaps longersurvival, even better quality of life. But some detractors have decried suchmeasures as examples of ‘medicalisation’of health, calculated to exploit human vulnerabilities and anxieties.[9]

By lookingat the patient as a whole, multiple risk profiles and factors also imply thatwe treat that patient with more therapies than was customary in the past. Mostoften this approach employs the easiest means—prescribing medications andpills—one on top of the other! This approach remains controversial and is notreadily accepted by all. Lifestyle modification and counseling often takebackseats in our therapeutic armamentarium because these are either too hard ortime-consuming to carry out, too difficult to measure for results, or becausethey are inadequately reimbursed or not at all!

Risk Factors, Pre-disease & InjudiciousPolypharmacy

BarbaraStarfield et al., a pioneering advocate of primary care medicine has lamented:

“the progressive lowering of thresholds for‘pre-disease’, particularly hypertension, serum cholesterol and blood sugar…(where) risk factors are increasingly considered as equivalent to disease…Encouraged by interests vested in selling more medications for ‘prevention’ andmore medical devices for testing, the pressure for increasing ‘prevention’ inclinical care directed at individuals is inexorable – even though it is notwell supported by evidence in populations of patients…” [10]

Alas, it isprecisely this surge in preventive polypharmacy that has prompted so manypharmaceutical companies to aggressively target the medical community with thecurrent deluge of blockbuster drugs in the hope to explicitly ameliorate theperceived harms of concomitant risk factors/illness, but covertly perhaps for greaterprofits as economic enterprises extraordinaire!

But thephysician’s professional need and mandate to keep current and up-to-date alsoimplies, that we become dependent on various modes of learning experiences andsharing. Clinical and scientific research relentlessly redefines our perceptionand belief systems about illness and health, so much so that we have sometimesdelegated some of these learning encounters to affiliates and peripheralagencies. The danger is that, we might have been kept selectively informed byincomplete snippets of ongoing if premature data by the very same aggressivevendors of such cutting-edge advances and innovations—becoming unwitting agentprovocateurs of their surreptitious influence and propaganda, i.e. we becometoo embroiled in possible conflicts of interest. [11]

Dr James LeFanu warns that “doctors are not justdoing more, but prescribing vastly more – an additional 300 millionprescriptions a year, half as many again compared to just 10 years ago.” Hewent on to question the rationale of this modern shift in medical practice: “the merits of a coronary angioplasty inpromptly relieving crippling chest pains of angina is self-evident, but therationale for the majority of those 300 million extra prescriptions is verydifferent.” He estimates that globally, annual pharmaceutical revenues havedoubled from US$400 billion to US$800 billion (2.6 trillion Ringgit) over thepast 10 years![12]

“This, then, is the Janus face of modernmedicine, the most visible symbol of the power of science to banish disease forthe benefit of all. But the distinction between the relative contributions ofthose technical innovations and the pharmaceutical industry to the spiralingcosts of healthcare reveals, with great clarity, the origins and harmfulconsequences of medicalisation – and what indeed is required to control it.”

~ James LeFanu

Perhaps wehave become too indiscriminate, too undiscerning, and too gullible even. Weappear to have become uncritical on what needs to be critiqued, to becritically analyzed and challenged. We have allowed possibly biased slants ofinformation to imprint, even distort our impressionable minds too easily!

We mustlearn to acknowledge that we might have been somewhat less than judicious indeciding which are truly best for the patients in front of us! Perhaps we havebecome seduced by the glamour and the gloss of the pastiche of moderninnovations—new drugs and devices, new techniques that titillate our sense of‘beauty’ and wonder; and perhaps that patchwork assemblage of molding plausibletheories into meaningful practices.

Perhaps,all these newfound concepts go on to strengthen our physician empowerment associety’s singular shamanic autocrats of medical knowledge. Perhaps, theseconstantly reconstructed patho-physiological models of consistency, of newlydiscovered molecules, gene-based proteomics, of mechanistic pathways, andbiological systems endow upon us that sense of puissance, of control, ofdemigod status.

There canbe no denying that sometimes we may have become enamoured with too much care,in doling out perhaps too many unwarranted tests and therapies, which couldarguably satisfy our egotistical self and enrich us personally, certainly moreso than our patients. We fail to be our patient’s best advocates, whoseinterests should really be our unwritten if expected ethical compass.

Patients’ Interests—First and Foremost

Have wefailed in our duty to place our patients first and foremost, by possibly sacrificingtheir dignity, their interests, thereby undermining their safety and long-termhealth even? Have we fallen victim to our own entangled conflicts of interest,our moral hazard of being less than fully impartial, by unfairly tapping intothe patient-doctor information asymmetry, or physician-industry ties and thelast-gasp hopes and anguish of many of our less than educated or informedpatients?[11]

Yet,perhaps this statement is too harsh as an indictment to our dilemma asspecialist healthcare givers.

Let usreturn to practical considerations as we re-examine our roles as cardiovascularphysicians. Increasingly we have been cast as unwitting but willing diagnosticas well as gate-keeping therapists all rolled into one. Some have even labeledus as unremitting purveyors of ever-newer medical devices: expensive drugs,balloons, stents, pacemakers, etc. Cardiac surgeons have rightfully questionedour objectivity, that we might have unfairly usurped our unique position tosequester all manner of revascularisation therapies, particularly emphasizing PCIto the detrimental exclusion of CABG.

Perhaps the increasingdevelopment and use of appropriateness and organizational care pathways,consensus cardiology-cardiothoracic team approach, of hybrid procedures andglobal budget or diagnostic-related groups (DRGs) remuneration models, canreduce the tendency for individual physician decision-making, which tends tobias the physician toward more costly or self-serving procedures.

Despite the availability ofclinical care pathways and guidelines (CPGs), their variable interpretationalso means differences in emphasis or practice. Many physicians disdain care pathways and CPGs as ‘cookie-cutter’ medicine,and interpret these loosely. They argue that a one-size-fits-all approachcannot apply to differing patient scenarios, best only known to the physicianin charge.

By the verynature of PCI being conceptually ‘simpler’ and less invasive, cardiologistshave cornered the market so to speak, so much so that our patients appear toprefer our services, although the actual long-term results may be inferior tothe initially more disabling bypass surgery.

Mostcardiologists these days appear to have become singularly coronary arterydisease (CAD) experts, but not much more, sadly. Almost every young aspirant incardiology wishes to be that interventionist, that doer who can heal, with thatmagical balloon and stent. It appears that to do more, rather than simplycounsel and advice might be more effective—at least, it seems that way. It hasbeen well described that an injection (even if of sham medicine), surgery orany intervention gives greater effects or is perceived of as being moreefficacious than some simple pill.[13]

So could itbe that we have become too conditioned into believing that all the percutaneousinterventions that we have performed on our patients, are but that ersatzveneer of favourable placebo effects, instead of true outcome-evidencedbenefits? Hence, could this misconception lead to some of us becoming perhaps alittle too reluctant to relinquish control of that patient in need, to someoneelse (e.g. cardiac surgeon, or heart failure expert) more capable, moreadequately, or more appropriately trained than ourselves?

Consider the recent findingsof the extended follow-up OAT cohort that showedthat delayed routine revascularization during the subacute phase, gave nogreater benefit. Long-term clinical events were notreduced after routine PCI in stable patients with a totally occludedinfarct-related artery, if there was no severe inducible ischemia.[14]

It is alsoimportant to note that performing such PCI in the non-ACS setting, for patientswho are symptom-free (silent ischemic heart disease, SIHD) just because of someECG or imaging changes during stress testing would not be associated withsurvival benefits or even lessening of potential CV events. For most scenariosof angiographic stenoses (other than significant LMS and/or proximal LADdisease) the recommendations are Class IIB or even III.[15]

PCI versus medicaltherapy in stable CAD can be summarized as follows:[ 15]

• PCI reduces the incidence of angina

• PCI has not been demonstrated toimprove survival in stable patients[16]

• PCI may increase the short-term risk ofMI[16]^,[17]

• PCI does not lowerthe long-term risk of MI[18]

We should learn to re-examine ourclinical objectivity and soberly address such issues of potential moral hazardfor the ultimate benefit of our patients. Our therapeutic decisions should neitherbe because of our overwhelming paternalistic influence, nor to our subconsciousdesire to profit personally.

TheACCF/AHA/SCAI guidelines also strongly recommend that every PCI program shouldoperate a quality improvement program that routinely: [15]

a) reviewsquality and outcomes of the entire program;

b)reviews results of individual operators;

c)includes risk adjustment;

d)provides peer review of difficult or complicated cases, and

e) performs random casereviews.

Theyrecommend too that every PCI program should participate in a regional ornational PCI registry for the purpose of benchmarking its outcomes againstcurrent national norms. Perhaps this is the sort of benchmarking that everycardiologist and heart centre must adopt, as we embark on our journey to makeour own ACS and PCI Registries more comprehensive and complete.

Medical Screening Dilemmas

The U.S. Preventive ServicesTask Force has in recent reports pose yet more dilemmas in the way of ourclinical practice.[19] The simplerest ECG and the more routinely performed stress ECG of annual medicalcheck-ups, so much a part of cardiology practice, are now considered tooindiscriminately over-utilized.

For the symptom-free person,the benefits of these tests appear to have been inadequately studied. Whateverfew studies available apparently showed no major benefit for the population atlarge. The taskforce warns instead of the potential harms of consequential downstreamtherapies or decision pathways such as more angiography, bleeding complications, radiation exposure, and contrastallergy or nephropathy; more statin use and its possible adverse effects!

This conclusion was somewhatsurprising because the pooled evidence actually says otherwise: “Abnormalities on resting ECG (ST-segment or T-waveabnormalities, left ventricular hypertrophy, bundle branch block, or left-axisdeviation) or exercise ECG (ST segment depression with exercise, chronotropicincompetence, abnormal heart rate recovery, or decreased exercise capacity)were associated with increased risk (pooled hazard ratio estimates, 1.4 to2.1). Evidence on harms was limited, but direct harms seemed minimal (forresting ECG) or small (for exercise ECG). No study estimated harms fromsubsequent testing or interventions, although rates of angiography afterexercise ECG ranged from 0.6% to 2.9%.”

Themain message appears to be quoted from 2 previous studies which state that “a small proportion (<1%) of patients haverevascularization with coronary artery bypass graft surgery or a percutaneouscoronary intervention after screening exercise ECG, despite the risks of theseinterventions and their lack of benefits in asymptomatic persons.” [20]^,[21]

Sowhat are we to do, stop screening of symptom-free patients, and perhaps onlyjudiciously target those who need further evaluation based on complaints andnot necessarily for global risk assessment? The recent accompanying editorialaddresses this conundrum, but did not offer specific solutions, except to urgefor more research.[22]

Shouldwe then not performelectrocardiography at all in asymptomatic adults? Apparently so. Chou andothers of the Task Force argue that because of this persistent lack ofevidence, clinicians should not incorporate screening with resting or exerciseelectrocardiography into their practices except in the context of clinicaltrials! This sadly sounds counterintuitive to most of us physicians andcardiologists!

Themore plausible American Academy of Family Physicians recommends the followingfor the asymptomaticpatient, that:

“Exercisestress testing may provide valuable prognostic information in asymptomatic menolder than 45 years who have risk factors. The higher the number of risk factors,the higher the pretest probability (hyperlipidemia > 6.20 mmol per L,hypertension: systolic > 140 mm Hg or a diastolic >90 mm Hg, smoking,diabetes mellitus, and history of MI or sudden death in a first-degree relativeyounger than 60 years).[23]

“Inasymptomatic patients with diabetes mellitus, there is a higher risk of CAD inthe presence of at least one of the following factors: age >35 years, type 2diabetes >10 years, type 1 diabetes >15 years, microvascular disease e.g.proliferative retinopathy, nephropathy, or autonomic neuropathy. It isrecommended that patients with (these) criteria undergo exercise stress testingbefore embarking on moderate-to high-intensity exercise.”[24]

Currently, theACCF/AHA/SCAI Guidelines recommend that: In patients entering a formal cardiacrehabilitation program after PCI, treadmill exercise testing is reasonable. Butroutine, periodic stress testing of asymptomatic patients after PCI withoutspecific clinical indications should not be performed. For cardiac rehabilitationpurposes however, medically supervised exercise programs should be recommendedto patients after PCI, particularly for moderate- to high-risk patients forwhom supervised exercise training is warranted.[25]

Discussion

Mymalaise with these newer perplexing recommendations or restrictions is notintended to curb or straitjacket medical or cardiovascular practice. But, it isperhaps timely for us to seriously reconsider our own trajectory of clinical practiceand professionalism.

Arewe not somewhat complicit in inventing some new entities of health ailments,i.e. increasingly medicalising health? What are we trying to achieve as we pushthe boundaries and contemplate expanding such concepts as pre-diabetes,pre-hypertension and lower and lower acceptable levels of serum LDL-cholesterol,as we tag along more biological markers such as hs-CRP, hs-TNT, BNP, etc.?Already, many other entities such as serum homocysteine, fibrinogen,lipoprotein (a), PSA (arguably), have fallen by the wayside of bumf rather thanuseful reliable knowledge!

Whoindeed do we serve as we trundle along with exciting if unproven new devices,new paradigms of interventionist procedures, as we become increasingly invasiveeven as we miniaturize our techniques and devices? Does the spirit of medicaladventurism justify medicine’s push for cutting-edge innovation and advances?Does potential future benefits and ends for the many, justify the experimentalrisks as a means for a few and the now?

Whatabout that ‘life sentence’ of medications for life or for as long as deemednecessary? Yes we appear to have many long-term prognostic outcome data thatimplies sustained therapies for the best effect — extending this or thatsurvival by perhaps weeks or months, on a statistical basis.

But,how much of our patients’ lives are we interfering with and for what quantum ofgreater good or longer-term benefits, the possible lost opportunity costs andthe inconvenience, that background intrusion into their lives? It is preciselythis expropriation of health that philosopher Ivan Illich had lamented.[3] Has health become such a scarce even elusive commodity that the common man nowhas to “depend upon the consumption ofAmbrosia”?+

Butperhaps more importantly, we need to reignite our medical professionalism. Wemust become more critical and discerning, as we embrace change and development.We must learn to stand back from and reappraise the increasing use ofindustry-sponsored spectacles of ‘show-and-tell’ ‘live’ demonstration courses. We must re-evaluate the allure toward moreprocedures, devices and interventions than perhaps what might truly benecessary medical care, no matter how promising or how technically beguilingthese appear to be!

Thisincludes even pharmaceutical junkets, which invariably encourage greater use ofnewer, more expensive drugs among physicians. But this is not to say that wehave to revert back into being Luddites, opposing everything that is new andgood. We just have to be more circumspect, judicious, be really objective andevidence-based! We should be imbued with a healthier dose of common-senseskepticism!

Theformer editor of the British Medical Journal, Dr Richard Smith had this to saywhen he reviewed the life and work of Ivan Illich following the latter’s death in2002 from debilitating cancer: “Technology can help, butmodern medicine has gone too far — launching onto a godlike battle to eradicatedeath, pain and sickness. In doing so, it turns people into consumers orobjects, destroying their capacity for health.” [26]

Wemust re-engage with our patients more candidly and transparently, and placethem and their interests first and foremost, after all truth telling is one ofthe universally accepted pillars of ethics and professionalism. We shouldinform more openly and widely (to include risks, especially material riskspeculiar to this or that patient). We should also propose and discuss alternativemodels of therapies and lifestyle modifications, so that we allow patients todecide on their own, which options to choose from and live by. This is perhapsthe modern expectation of patient empowerment and choice.

Alreadythere is declining trust and belief in physicians. We have to reclaim ourtrust. Dr Alice Jacobs, president of the AHA in 2005 stated that: “This issue is the erosion of trust.Lack of trust is a barrier between our intellectual renewal and our ability todeliver this new knowledge… to the bedside of our patients, and to the public.Trust is a vital, unseen, and essential element in diagnosis, treatment, andhealing. So it is fundamental that we understand what it is, why it’s importantin medicine, its recent decline, and what we can all do to rebuild trust in ourprofession.”[27]

“A 2005 U.S. News and World Report cover stated: ‘Who Needs Doctors? Your next doctor may notbe an MD and you may be better off.’ Have we finally come this far, wherethe human touch of the physician can be replaced by healthcare reduced toguidelines, tests, algorithms, procedures, and drugs?”[28]

This isindeed a possible scenario as we move further and further along in thatloosening of the physician-patient bond, that ever-widening chasm ofinformation asymmetry, with Internet or email consultations, video computer-assistedmedical appointments/consultations, telemedicine, etc. But at the end of everypatient-physician encounter, what is still most needed is that caringempathetic relationship, with the physician serving as that trusted healthcaregiver who can provide the best that modern medical care can offer, in thebest interest of the patient, and no one else! Above all, we are called upon toprovide medical care well and prudently, no more and certainly no less.

References:

* historiography — the writing of history based on the critical examination ofsources, the selection of particular details from the authentic materials inthose sources, and the synthesis of those details into a narrative that standsthe test of critical examination (Britannica.com).

+ Ambrosia — the divine potion,which gave the gods unending life.

[1] Susan Sontag. Illness as Metaphor. Doubleday, NewYork, 1978.

[2] Siddhartha Mukherjee. TheEmperor of All Maladies: A Biography of Cancer. Scribner, New York, 2010.

[3] IvanIllich. Medicalnemesis. J EpidemiolCommunity Health 2003;57:919–922. This article is reprinted with permissionfrom Elsevier (Lancet 1974;i:918–21). (http://www.elsevier.com/locate/lancet)

[4] National healthaccounts [online database]. Geneva, World Health Organization, 2010 (http://www.who.int/nha,

accessed 23 June 2010).

[5] World healthstatistics 2010. Geneva, World Health Organization, 2010.

[6] GrossmanM. The demand for health. 30 years later:a very personal retrospective and prospective reflection. J HealthEconomics. 2004; 23:629-636

[7] Leibowitz.A. A. The demand for health and healthconcerns after 30 years. J Health Economics. 2004;23: 663-671

[8] Bunker JP. Medicine matters after all. J Roy CollPhysicians. 1995;29:105-12

[9] R.Moynihan, I Heath, D. Henry. “SellingSickness: The Pharmaceutical Industry and Disease-Mongering”, British MedJ. 2002; 324:886–891.

[10] Starfield B, Hyde J, Gervas, Heath I. ‘The Concept of Prevention: AGood Idea Gone Astray?’ J Epidemiol Community Health2008;62:580–583. [doi:10.1136/jech.2007.071027] Quoted by Chan C.K. in ‘M. K. Rajakumar, Primary Care and Population Health’, in An Uncommon Hero, 2011 (in press), pp308-320.

[11] Duff Wilson. Health Guideline Panels struggle withConflicts of Interest. New York Times, Nov 2, 2011. http://www.nytimes.com/2011/11/03/health/policy/health-guideline-panels-struggle-with-conflicts-of-interest.html?src=un&feedurl=http://json8.nytimes.com/pages/health/policy/index.jsonp&pagewanted=all

[12] James Le Fanu. Beware the 'Janus face’ ofmodern medicine. The Telegraph, 14 Nov 2011. http://www.telegraph.co.uk/health/8883956/Beware-the-Janus-face-of-modern-medicine.html

[13] Kaptchuk TJ, Stason WB, Davis RB, et al. Sham device v inert pill: randomised controlled trial of two placebotreatments. BMJ 2006;332: 391–7.

[14] Judith S. Hochman, MD;Harmony R. Reynolds, MD; Vladimı´r Dzˇavı´k, et al. for the OAT Investigators. Long-Term Effects of Percutaneous Coronary Intervention of the TotallyOccluded Infarct-Related Artery in the Subacute Phase After MyocardialInfarction. Circulation.2011;124:00-00. (Published online Oct 24, 2011)

[15] LevineGN, Bates ER, Blankenship JC, et al. 2011ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report ofthe American College of Cardiology Foundation/American Heart Association TaskForce on Practice Guidelines and the Society for Cardiovascular Angiography andInterventions. J Am Coll Cardiol. 2011;58:e44–122.

[16] BodenWE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI forstable coronary disease (COURAGE). N Engl J Med. 2007;356:1503–16.

[17] HambrechtR, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplastycompared with exercise training in patients with stable coronary arterydisease: a randomized trial. Circulation. 2004; 109:1371– 8.

[18] TrikalinosTA, Alsheikh-Ali AA, Tatsioni A, et al. Percutaneous coronary interventions fornon-acute coronary artery disease: a quantitative 20-year synopsis and anetwork meta-analysis. Lancet. 2009;373:911– 8.

[19] RogerChou, Bhaskar Arora, Tracy Dana, Rongwei Fu, Miranda Walker, and LindaHumphrey. ScreeningAsymptomatic Adults With Resting or Exercise Electrocardiography: A Review ofthe Evidence for the U.S. Preventive Services Task Force.Ann Intern Med. 2011;155:375-385.

[20] AktasMK, Ozduran V, Pothier CE, Lang R, Lauer MS. Global risk scores and exercise testing for predicting all-causemortality in a preventive medicine program. JAMA. 2004;292:1462-8. [PMID:15383517]

[21] CournotM, Taraszkiewicz D, Galinier M, Chamontin B, Boccalon H, Hanaire-Broutin H, etal. Is exercise testing useful to improvethe prediction of coronary events in asymptomatic subjects? Eur JCardiovasc Prev Rehabil. 2006;13:37-44. [PMID: 16449862]

[22] Michael S.Lauer. What Now With ScreeningElectrocardiography? Ann Intern Med. 2011;155:395-397.

[23] Bruce RA,DeRouen TA, Hossack KF. Pilot study examining the motivational effects ofmaximal exercise testing to modify risk factors and health habits. Cardiology.1980;66:111–9.

[24] Diabetesmellitus and exercise. American Diabetes Association. Diabetes Care.1997;20:1908–12.

[25] LevineGN, Bates ER, Blankenship JC, et al. 2011ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College ofCardiology Foundation/American Heart Association Task Force on PracticeGuidelines and the Society for Cardiovascular Angiography and Interventions. JAm Coll Cardiol. 2011;58:e44–122.

[26] Smith R. Limits to medicine. Medical Nemesis: theexpropriation of health. J Epidemiol Community Health 2003;57:928.

[27] AliceK. Jacobs. Rebuildingan Enduring Trust in Medicine: A Global Mandate. (PresidentialAddress American Heart Association ScientificSessions 2004). Circulation. 2005;111:3494-3498.

[28] Brian Olshansky. Placebo and Nocebo in Cardiovascular Health:Implications for Healthcare, Research, and the Doctor-Patient Relationship.J. Am. Coll. Cardiol. 2007;49;415-421.

With 1 Care, the choice will not be there.... by Dr Steven KW Chow

2011-12-14T01:42:00.002+08:00

With 1 Care, the choice will not be there

Dr Steven KW Chow
2:42PM Dec 13, 2011

The 1 Care health system transformation plan for Malaysia is now in the process of being sold to the public.

To our knowledge, the development of the blueprint is being fast-tracked and that the detailed plan to implement 1 Care will be ready as early as 2012.

Technical working groups are already hard at work on this. As the term technical working group implies, it is the technical details are being worked out - not the decision for plan for a new health system. Thus, we are way past the “still in planning process” (The Star, May 13, 2011).

We must address certain issues that are raised before implementation.

We are told that the new health system will be in the substance and form of the NHS of the UK. We strongly urge for a critical rethinking of this for the following reasons:

1. Existing Primary Care Provides Better Accessibility and Choice

The primary care model of the NHS has many failings. The picture from the NHS shows that it is not the proven mechanism to facilitate appropriate access to higher level of care. In the UK, this system requires patients to make appointments with the GP, even for acute conditions. As a result, the A&E Departments of hospitals are jammed with patients and waiting lists for cold cases to see the doctor or undergo surgery is long.

On the other hand, Malaysia has a better healthcare system. We had good KPIs reported in the latest National Health Accounts Report. Our health system has been praised in many international reviews and articles published in journals.

In Malaysia, government health facilities have a good system of referral and provide the safety net for the poor. Those who can afford to pay out-of-pocket consult private doctors. This is a good balance of those seeking private and public healthcare.

What the government really needs to do is protect those using private care from exorbitant charges and being over serviced. This can be handled by strict enforcement of the relevant provisions in the existing Private Healthcare Facilities and Services Act1998/Regulations 2006.

There is choice with the present system. With 1-Care this choice will not be there. The patient and public pay upfront in the form of insurance or taxes. If they do not want the doctors or the service that is allocated, they will have to pay again for what they choose.

2. 1 Care will cost more

Worldwide it is recognised that a system based on general taxation is the most efficient and equitable.

Experiences from many countries have shown that the rise of healthcare cost is higher when other forms of healthcare financing are introduced.

Instead of finding another method of financing, including social health insurance, to improve efficiency through provision of greater choice and better control on cost of health care delivery, the MOH should look internally on wastage and efficiency and improve the government system to be better than the private sector as shown by experiences in Singapore and Hong Kong where the public prefers the public system.

The 2002 Report of the Study on “ Healthcare Reform Initiatives in Malaysia” by three Health Ministry-appointed consultants led by Donald S Shepard have clearly diagnosed the important issues of healthcare delivery in Malaysia and proposed solutions.

Cost-wise, the consultants “calculated that in the year 2000, the average ambulatory consultation (public facility) outside of a specialised hospital (including average prescriptions and laboratory services associated with that visit) costs RM91, while the average inpatients stay cost RM1,091 (or RM286 per day).

In contrast, the fee for an amublatory visit, RM1, has not increased in years and covers only one percent of the economic cost of an average visit”. This does not include the economic cost of long waiting time and time off work.

We know that the average cost for a GP outpatient consultation including prescriptions would only be between RM30 to RM50. Waiting time is shorter. Thus it is clearly cheaper and more efficent to just outsource this ambulatory outpatients to the existing robust GP system thereby releasing the public system to concentrate on secondary and tertiary care. The recovery economic cost of a shorter waiting time will also benefit the patient and the community.

3. Transformation versus Evolution

The overall recommendation of this extensive study based on the diagnosis of our healthcare system was for the country to proceed with “limited reform”.

This reform “should improve the management of the public healthcare services so that they can provide better working conditions for their staff,fill critical vacancies,enhance responsiveness to population’s needs and wants, and maintain an equitable basis for financing healthcare services”.

4. Improving stakeholders' feedback for 1-Care Consultation

The cost and implications of 1-Care affects all. Judging from the concerns expressed by many doctors and the public in the media, it is clear that those so called stakeholders that are invited for discussion are:

1. Either not real representative of the profession
2. Or the stakeholders are not providing feedback
3. Or the stakeholders are some favoured few

It will be good governance to inform the public who the stakeholders are (in name and organisation) to ensure that they are truly representative and to include more public representation like patient groups, consumers, employer representatives and more NGOs.

5. Corporatisation of Public Hospitals.

The 1 Care systems requires corporatisation of public hospitals - the establishment of administratively autonomous hospitals through devolution of authority from federal control, a variant of corporatisation ala IJN. This will be in line with the seamless integration of private and public healthcare facilities.

This is clearly not possible as private facilities are profit-driven as compare to public facilities which is socially-driven. Furthermore this is contradictory to that reassurance given by the health minister in 1998 that the government will not corporatise public hospitals.

At the end of the day one would create a huge profit-driven monster that will be impossible to control as the regulator (i.e. the government) will also be an operator of the industry via its GLCs.

DR STEVEN KW CHOW is president of the Federation of Private Medical Practitioners’ Associations Malaysia.

Medical Education nears Saturation in Australia.... MJA Insight

2011-11-21T10:32:00.001+08:00

Medical education nears saturation

- Sophie McNamara

MJA Insight, 21 Nov 2011

MEDICALschools are struggling to provide adequate clinical learning experiences tostudents, due to increasing numbers of students and changing medical practices.

Thenumber of Australian medical students has increased by 65% since 2004, fromabout 9000 students in 2004 to 15 000 students in 2010. The number of medicalgraduates is predicted to increase by 120% from 2004 to 2012, according to theAustralian Medical Students’ Association (AMSA). (1)

In aletter published in the latest MJA, academics involved in medicaleducation at James Cook University, Townsville, and Bond University on the GoldCoast described the challenge of providing high-quality clinical opportunitiesfor their students. (2)

For full article go to eMJA

http://www.mjainsight.com.au/view?post=Medical+education+nears+saturation&post_id=7261&cat=news-and-research&utm_medium=ET_email&utm_content=drquek@gmail.com&utm_campaign=November-20-2011_b2c_20111121_newsletter&utm_source=b2c_20111121_newsletter&utm_term

The Standards of Medical Education in Malaysia and Its Acceptability

2011-11-16T23:54:00.001+08:00

The Standards of Medical Education inMalaysia and Its Acceptability

Dr. David KL Quek,

MBBS, MRCP, FRCP, FAMM,FCCP, FASCC, FAPSC, FNHAM, FACC, FAFPM (Hon.)

Immediate Past President,Malaysian Medical Association (MMA)

(Lecture presented at the Medico-Legal Society of Malaysia Conference, Royale Chulan Hotel, Kuala Lumpur, on 16 November 2011)

Glut of MedicalGraduates—Too Many, Too Soon…

The past 5 to 10 years have been a watershed period for medical educationin the country. During this time, Malaysia has embarked on an ambitious ifmisguided (in my opinion) approach to rapidly attaining ‘self-sufficiency’ inhealth care providers for the nation’s perceived needs and demands. Fordoctors, it was finally announced that there is now a directed plan by thegovernment to try and achieve a doctor-population ratio of 1:400 from thecurrent (2010) 1:903.

To achieve this, some 34 medical schools have been now licensed by theMinistry of Higher Education (MOHE), with almost 50 medical programmes (theseinclude public medical schools teaming up with other foreign or local medicalschools to form for-profit private joint medical programmes). The objective isto generate the requisite medical graduates to quickly fill in the projectedand computed vacancies for the various public sector health facilities. The ultimategoal is to become a country with the so-called ‘recognised’ developed status doctor-populationratio of under 1:400. And we aim to do this in a short span of under 10years—by 2020!

By comparison, the United Kingdom has some 32 medical schools for apopulation of 63 million, producing some 7,500 medical graduates per year. Itis good to remember that the UK has had a long hallowed tradition of excellentmedical services and education for centuries, with an extensive cohort ofready-made clinical teachers, professors and academicians. We are just about 45years since we began our first medical programme at the University of Malaya, in1965.

In UK, the annual output of medical graduates is around7,500 and they are trained in 140 hospitals; in Australia 3,400 graduates aretrained in 60 hospitals; in Hong Kong, 350 graduates in 13 hospitals; and inSingapore 150 graduates in 4 hospitals. In Malaysia, 2008, there were 2,274 graduates undergoing training in 38hospitals and, since then, the number has increased tremendously, so much sothat the Ministry of Health has had to increase the number of accreditedhospitals for housemanship training, barely scraping by with sometimes just asingle clinical specialist for each discipline, at more remote districthospitals.

And the truth is that we really don’t have a happy history of strongmedical educational expertise and consistency of academicians; most of oursenior and experienced medical specialists and professionals are in the privatesector, or they would have migrated overseas. (It is estimated that as many as40-50% of Singapore’s health service personnel are manned by Malaysian medicalgraduates!)

A few dedicated senior doctors are in our medical schools, but most aredriven and run by relatively ‘young’ post-graduates or even specialist intraining, whose ability to impart and inculcate ethical healthcare values andinspiration for compassionate care may be untutored, wanting or uninspired.

(I would at this juncture like to apologise to our younger colleagues outthere, that this is not a disparaging remark to belittle their efforts atmedical education or their skills—age and seniority are not requisites formedical excellence, for sure. Indeed when we are young, hungry, and foolisheven, we tend to have the best and most aggressive approach to learning andhopefully teaching special skills—“see one, do one, teach one”.[1]I began as a lecturer at the age of 29 years, and I fully recognise that we canall be good dedicated teachers, when we choose to become one—yet there is nodenying that experience and seniority helps create a sense of stability andperhaps more importantly, ethical balance and professional equipoise,particularly in the field of medical education and the hugely important responsibilityand privilege of training medical professionals!)

Yet by 2020, we are targeted to produce some 5000 medical graduates everyyear for our projected population of 35 million, excluding those others whomight be returning from foreign medical colleges. This is by any measure ahumongous number of new medical graduates, which any middle-income country canill afford to sustain or worse to develop a sensible program at accommodatingthe requisite progressive training of young interns or even to provide a qualityhealth service!

Table2.4.: Number of AnnualPracticing Certificates Issued

According to State and Sector, 2007 to 2009.

STATE	2007		2008		2009
STATE	Public Sector	Private Sector	Public Sector	Private Sector	Public Sector	Private Sector
KUALA LUMPUR	2,239	1,762	2,590	1,881	2,797	1,952
LABUAN	18	16	12	17	12	17
PUTRAJAYA	254	9	257	10	294	10
JOHOR	612	981	752	1,041	933	1,072
KEDAH	446	458	484	483	580	482
KELANTAN	637	209	784	207	926	218
MELAKA	306	378	322	363	374	406
NEGERI SEMBILAN	354	341	401	401	532	372
PAHANG	340	355	440	378	489	385
PULAU PINANG	514	874	559	938	683	960
PERAK	662	803	759	835	924	854
PERLIS	95	28	120	28	139	38
SELANGOR	1,198	2,337	1,393	2,508	1,692	2,624
TERENGGANU	260	166	266	182	335	193
SABAH	462	342	592	358	696	379
SARAWAK	471	357	543	378	605	382
TOTAL	8,868	9,416	10,274	10,008	12,011	10,344
GRAND TOTAL	18,284		20,282		22,355

Malaysian Medical Council—Annual Report 2009

By 2011, we suddenly realized that we had taken on more than we couldchew, literally! And this is not simply because of the huge financial burden ofreimbursing these young doctors; almost double that number from just a fewshort years before! Since 2008, there was an unprecedented hike of publicsector doctors jumping from 12,000 to almost 21,000 by early 2011, which appearto totally overwhelm the capacity of the public sector facilities to cater tothis sudden influx of so many medical graduates. This glut has placed at severerisk the quality, the consistency and the efficiency of apprenticing theseyoung trainee doctors![2]

This unforeseen supply glut (together with the recent introduction of the2-year foundational housemanship period) has created a bottleneck of poorlyanticipated training or residency programmes.[3]We have now a reversal of the ratio of public vs. private sector doctors, bymore than 2:1 (~21,000 vs. 10,500)!

Houseman training hospital wards are now awash with white coats ofmedical interns (some as many as 50-60 per shift, per department!), scamperingabout with somewhat aimless, under-instructed and under-prepared purposes.Harassed and hassled medical officers, registrars and specialists now havegreat difficulty remembering even the names of their charges and most cannotguarantee the adequacy of the proctor-apprentice contact time relationship.[4]

What’s the Beef on Medical Education?

Atthe risk of sounding self-important and elitist, I would venture to state thatthe medical graduate is expected to be different from that of other professions,including our counterpoint nemesis—the lawyers! Medical education has by longtradition been exceptionally controlled and regulated.

Ourethical and professional boundaries are jealously guarded and inculcatedbecause of our singular privilege of exercising our ‘bedside’ manners i.e. havingexpected and unimpeded access to our patient’s medical histories of symptoms,their innermost thoughts, secrets and also that special license to bodily contactand intrusions i.e. the medical physical examination, and the mentalexamination.[5]

Thistraditional ritual is more than simple routine. It is now considered as anintegral exercise, which can reinforce and enhance the physician-patientencounter and relationship, even if there is that constant unequal tension ofantipodal opposites—that paternalistic giving vs. the pliant receiving and thesurrendering of one’s innermost self to some extent. However, this dynamic isnow changing, with greater patient empowerment these days.[6]

Thisdiscrepancy of the doctor-patient relationship and asymmetric privilege carriesimmense responsibilities, self-control and conscientious self-abnegation on thepart of the physician, the doctor. This concept has to be incessantlyinculcated so that the physician’s hitherto uninitiated ‘blank slate’ mindsetbecomes habituated toward embracing this professional ethos. Of course weexpect that the acquired medical professionalism and skill must be of a certain‘standard’, be Hippocratically-modeled and be universally acceptable!

Thus,it is not surprising that we expect stringent and well-defined clinical pathwaysand regulatory mechanisms which are directed toward ensuring patient safety,reducing medical errors, safeguarding against potential physician abuse, whileat the same time also addressing or ameliorating medico-legal concerns.

Studentsunder training are rarely allowed to practice independently on their own,unless rigorously supervised. Thus, medical students have very limited hands-onexperience, while in medical school—they are expected to have closer and greater‘hand-holding’ guardianship and proctorship. Hence, medical schools must adhereto the mandate for adequate and comprehensive clinical material as well asproficient teachers! So we need good teaching hospitals, clinics, wide range ofdisease or illness spread, with wide spectrum patients, as well as goodexperienced and dedicated teachers and professors!

Allmedical graduates are expected to further hone their experience and skills ininternship and residency (medical officer) programmes following graduation,before they can be fully registered as medical practitioners and certified topractice autonomously. Depending on the discipline or specialty that one wishesto pursue, the duration of residency or apprenticeship programme varies. Eventhen for some highly specialized disciplines, post-specialist experience (andongoing further training) is critical to ensure the highest standards of skillsrequired to function as acknowledged experts. It is a travesty of goodapprenticeship; if the new intern is left on his or her own device to muddlethrough what is probably the most critical formative period of the doctor’scareer.

Itis no longer acceptable that sporadic exposure to some esoteric or mundaneailment will do for the young learning doctor, most training hospitals andinstitutions are now insisting on greater structure and more hands-on supervisedapproaches.[7]

Ourunique professional learning-teaching structure dictates that the fresh medicalgraduates would need more in-depth practical training and closer supervision.Clearly this is crucial because in many instances we are dealing with extremelynarrow tolerable margins of errors and possible life and death encounters.While no doctor is infallible, medical mistakes and lapses are not readily acceptableoptions, and the consequences are too dire for society or the patients and/ortheir families to bear.

Eachand every medical graduate must therefore, experience that arduous if rigorousand preferably well-structured apprenticeship-internship programme, and bepersonally certified as safe and competent by a host of supervising seniors, toensure that the final product is as sound and safe for our Malaysian rakyat, orfor that matter, for any other patient anywhere around the world!

However,it is also increasingly clear that haphazard and poorly planned approaches toinstituting change and innovation can lead to severe disruptions of service andtraining within health systems, as recently experienced by the United Kingdom’shurried implementation of the so-called ‘ModernisingMedical Careers’ initiative.[8]

In 2002, there was an attempt to transform postgraduate medicaleducation and training in the United Kingdom. This ill-fated initiative called “ModernisingMedical Careers” plunged the entire system of training application andimplementation of junior doctors into complete disarray, with many good andqualified trainees failing to get job interviews. This heavily criticizeddebacle lasted some years until the Tooke Report in 2008 highlighted andrecommended some 47 rectifications to offset the weaknesses of this scheme.[9] Thus, transformation ofhealth care structure, training and systems need gradual progressiveinitiatives rather than revolutionary frissons of disruptive madness, even ifwell-intentioned!

Let’s return to the question of medical education for our nation’s needs.

Foreignand Local Medical Schools Malaise

Iam sure that most of us are aware that we have nearly as many Malaysianstudents studying abroad as at home for a medical degree. That many youngMalaysians and their parents hanker for such a tertiary education in medicine islegendary—year in year out, we have vociferous complaints of inadequate medicalseats for so many of our aspiring young students. Many aspirants unfortunatelydo not fully comprehend what it really means to want to become a doctor. Manytoo would find the cheapest, perhaps the easiest way in which to achieve thisresult, that they become vulnerable to the untested promises of so many medicalprogrammes, which are now available to them!

Whatirks us is that there have been mounting complaints that some of these veryquestionable foreign medical schools have educational programmes that have beenformed purely as business concerns. These medical programmes have blossomed oflate, to cater for the lucrative foreign medical students from third worldcountries, or as luck would have it, even from middle-income nations such asMalaysia. Worse, the end product i.e. the foreign medical graduates appear tobe of dubious quality with grossly inadequate clinical training and verydivergent foreign experiences.

Wehave Russian, Indonesian or Ukrainian universities offering medical programmesstrictly for foreigners in the English language just for the sake of it, whenmany if not most of the teaching staff have problems even speaking, much lessmastering the English language. Medical graduates are expected to leave upongraduation and not practice in the host country! So, one wonders as to thecommitment and trustworthy responsibilities and duties of such medical schools!

Whetherthe standards, communication skills and didactic quality of these dubiousmedical schools are as good as expected, is therefore difficult to determine;although on paper, the programmes appear to meet the minimum standards of mostmedicals schools around the world. Diploma paper mills are often moreattractive on the surface and self-claims, than its true worth in depth andpractice!

Sofor parents and students wishing to invest in such medical programmes, pleaseseriously reconsider the options, it’s not just the medical degree from ‘any’university, but ‘the’ prestige and quality of the medical university or collegethat truly matters!

Theseconcerns also apply equally to some of the local private medical schools, whichhave sprouted up recently. Our own mushrooming newer local medical schools andprogrammes unfortunately also appear to suffer such predicaments.

Thereinlies the difficulty for quality assessment of these programmes, and theMalaysian Medical Council faces an unenviable dilemma of having to balance ahard-nosed strict sanctions approach to deny or to approve such standards basedon a minimum of requirements, and then possibly sacrificing some qualityparameters, or earn the wrath of parents, medical school agents andpolitically-linked investors/detractors.

The MMC’s fiduciary responsibility has been questioned. Asan elected MMC member, I stand chastened that collectively, we could not be as forthcomingand as forthright as we possibly should as we balance society’s need vs. occasionallyirrational public demand. I am saddened about the arbitrary loosening of the standardsof acceptability and quality of so many of these medical schools and theirprogrammes. Many among the more critical of our own medical profession havequestioned the tacit and toothless complicity of the MMC, as the perceivedstandards of our medical schools and that of our medical graduates continue to decline.(I have personally been attacked as trying to undermine the medical seats andeducation for bumiputeras, which is farthest from the truth, ever.)

Theformation of these newer medical schools are more often than not, politicallymotivated—election promises by the government as pork barrel quid pro quo. It has become an accepted norm that everystate should have at least one medical school.

Thepublic wants this, so the government complies, notwithstanding the fact thatthe requisite standard ground rules cannot be applied and that fulfillment of time-honoredquality cannot be assured. This leads to the ‘compliant’ lowering or‘adjustment’ of the minimum standards for establishing these schools. Thepressure is to have as many medical student numbers and intakes as possible tocater to the demand rather than to worry about the quality of the medicalgraduate, or the capacity to deliver in terms of teaching staff and thenecessary appropriate standards of excellence.

A Recent Example: Recently a local private medical schoolhas been set up with just one professor of surgery, and 2 associate professorsof orthopaedic surgery and obstetrics. Others recruited were young traineelecturers on a lecturer-training scheme as part of the school’s postgraduateprogramme. Yet, the ‘standard’ paper work detailing the syllabi and the courseprogramme appear intact and adequate. There are also ‘sufficient’ teacher tostudent ratios, based on arbitrary naming and recruitment of ‘teachers andinstructors’ whose qualifications and experience are undisclosed. Can justabout anyone become a medical school teacher or professor, these days?!

Sotheoretically, this program passed muster and was duly awarded the license bythe MOHE, as well as the temporary recognition to begin the medicalundergraduate programme, by the MQA and MMC. There are just paper plans ofwhere these students would be placed for clinical teaching and in which hospitals,which as many of us know, are already under siege from the surfeit of medicalgraduates already present! There are no plans to build a dedicated teachinghospital; and even if there was, this attempt would be fraught withdifficulties of staff and personnel shortage as well! The brutal truth is thatsuch a piecemeal slipshod medical school starting off this way can at best bedescribed as incredible—perhaps only possible in this nation!

Indeedthis has been the trend over the past few years of recruiting medical teachersin as nonchalant a manner as possible. Isn’t this a travesty of our expectedmedical excellence when it comes to medical teaching? Isn't this a shame thatit is now acceptable that anyone will do when it comes to being considered as medicalschool teachers—what happened to the concept that only the best and the mostacademic doctors are recruited as teachers and professors? How would thefinished product of medical graduates be, if and when the teachers teachingthem, are as mediocre or as uninspiring as the basis of their lacklustrerecruitment has been?

Non-clinicalteachers (many not registrable as doctors in this country to practice) areimported from our neighbouring nations to fill the quota of our chronicallyshort teaching staff. Young professors are elevated, as are instructorspromoted, without adequate quality assurance standards, to simply provide theminimum teacher-student ratio. Sometimes these are contracted on part-time adhoc basis, and tasked with scheduled but unregulated point-of-contact teachinghours, which short-sell the impact of the teaching quality. Patient simulatorsand simulated clinical teaching are more the norm than real lifestudent-patient contact.

Thus,we hear of anonymous complaints of disparate and substandard teaching andlearning experiences. Many students are left on their own to muddle along, inwhat are increasingly known as “self-learning” modes and even that toutedcatchphrase of “instilling of self-responsibility and maturity”! Except that manyof our young charges are not quite mature or ready enough for such unsupervisedlearning! But perhaps, I wrongly underestimate them, in which case, I humblyapologise…

Butsadly, unless the student is exposed to better medical schools and teaching,they would not have known any better. My own niece, who was enrolled in onelocal private medical school for one semester before transferring to theNational University of Singapore, faced a huge educational and cultural shock!The quality of teaching and programmes are worlds apart, but luckily she iscoping well because clearly NUS did their homework when assessing whichexceptional student to accept into their very high standard medical school!

Butalas, do our medical students have any recourse to complain? I fear not,because there is simply no mechanism to do so; neither is there, anystraightforward comparison of quality and standards—ignorance is bliss, so itseems. Thus, caveat emptor is the buzzword!

Whereassome of our neighboring universities are pushing their standards higher andhigher, while chasing the globalised expectations of excellence and prestige,we in Malaysia appears to be doing the opposite—just provide the seats becausethere is great demand, produce the numbers, and let the quality deliver itself,as if economics alone would suffice to temper the emboldened but invisible handof the free market for profits!

Conversely,and out of sync with many developed nations around the globe, our students areclamouring for more and more medical seats. The lure of becoming a doctorappears an unquenchable one for many a young Malaysian chasing that vocationaldream to become a professional, with a supposedly assured job post-graduation.The oft-painted picture that the doctor would not starve and would almostalways be assured of having a decent, somewhat respected, even luxuriousquality of life, remains the colour-blinded vision and dream of many anaspiring student! Sadly for many, the reality is quite the opposite. In thenear future, this could become a nightmare!

So, Can we do better?

It is clear now that with the ever-increasing numbers of medicalgraduates coming on-stream, there is an urgent and compelling need tosystematically address their training-internship programmes, so that there is sufficientwork and experience which can be imparted, shared or taught. There has to bemore structure and planning, and less ad hoc piecemeal slotting into whatevervacancies there are to be had.

Teachers, proctors and supervisors have to be identified andtheir job descriptions clearly spelt out so that proper logbooks, minimum professionaltasks and learning skills can be properly taught, documented and approved. Theobjective must be to ensure that at the end of each posting to a discipline,the house officer would be certified as competent in some minimum core skillsand also be safe as an independent medical practitioner, ready to embark on toanother level of his or her career.

The MMA has been urging the training hospitals to ensure thatthere is a better-defined career path for each house officer or trainee. Aftergoing through the mandatory rotations, there should be mechanisms to allow thetrainee to embark on a planned rather than a haphazard chancy careerdevelopment pathway. It is unfair to simply slot these freshly brewed medicalofficers into every available vacant discipline just to fill them, although ofcourse some compulsory distribution to rural or remote postings would stillhave to be worked into the system as part of their national service.

But simply jostling these young medical officers into vacant andunpopular service areas without much supervision is also highly irregular, evenirresponsible, although this may be inevitable, for some. For those brightertrainees with clearer goals and determination, i.e. those who aspire forspecialist training, they can be encouraged to take and quickly passpreliminary specialist examinations, so that they may be placed on fast tracktoward specialty training opportunities. Of course those who volunteer or whohave been earmarked for remoter postings should be given priority to choices ofspecialty or advanced career paths, upon stipulated return.

Unfortunately our available seats for post-graduate specialisttraining are quite severely in short supply. Annually our major university andhospital trainee posts number less than 800, which means that increasingly, thegreater majority of medical officers completing their internship, would be leftby the wayside of unfocussed and directionless service. But what do we do withthese exponentially growing numbers, which will be the majority of theseunplaced or misplaced junior medical officers?

Already enough young trainees have been querying if there areindeed sufficient places for them to train or to work towards some form ofspecialist training—many fear rightly that there would not be enough places,and that competition for the rare postgraduate programmes, severe.

We must recognize that such unprecedented numbers of medicalgraduates place a severe strain on the available system for such postgraduatemedical training. We simply would not be able to cope and a time will surelycome when, medical officers would have to compete even for simple service jobs.There may be no guaranteed placements with either internship programmes or anyother programme!

The time may come when fresh graduates might have to apply andwait for vacancies, and they may also be selected based on other criteria suchas graduates from more prestigious medical schools, those with better grades orhonours, those with better testimonials from teachers/professors, or worse,those with political strings and cables!

Already, recently, the Health Ministry and Public ServicesCommission have asked the MMC to seriously reconsider the necessity forcompulsory service for our medical officers, principally because of the hugenumber of interns completing their service.

In June this year, house officers are no longer employed aspermanent service civil servants, but instead as contract workers. Thus, theirforward service as automatic medical officers would no longer be guaranteed. InOctober this year, the ongoing glut of house officers has led to the MOHtowards embarking on a mandatory rotational shift basis of work and training—nolonger will overtime be paid, but a fixed shift allowance! These are the signsof our system bursting at the seams!

Why is shift rotation unacceptable in our current service oftraining house officers?[10] Because, asof now, there is no mechanism of ensuring that the quality of supervision andteaching can be consistent, especially for those who have been earmarked fornocturnal shifts. Such ‘graveyard’ shifts are notorious for lack of seniordoctors reliably being available for attending to the many patients presenting inthe night or early hours. There is also fear of lack of continuity of care bothfor the patient and the intern, the latter’s learning skills may be curtailedby disjointed passing over of cases and patients to temporary shift-empoweredtrainees—transitional responsibilities are known to lead to greater misseddiagnoses, mishaps and errors.

Despite such serious concerns, which have been raised by manysenior physicians, the MOH has seen fit to push forward this major shift inpractice! For many of us doctors, we are appalled that this has come to pass.Such changes are not for the betterment of the houseman training programmes,but simply to stop gap and whittle down the yawning financial andadministrative bungles, which have resulted from such an explosive medicalgraduate glut!

If there had been more planning, this could have been avoided. Wecould have transformed more controlled numbers of medical graduates into morecompetent doctors by ensuring that we have in place systematic training modulesfor general or family practice, emergency medicine, administration and healthmanagement, public health, etc. But we must get these administrative steps inplace before these unwieldy numbers overwhelm us totally!

Thus, there must be an urgent moratorium not just on the numberof medical schools, or programmes, but also the number of medical studentintake or graduates. The rampant production of medical graduates must bedrastically checked to ensure that only the best and most well equipped can beallowed to continue. No medical school should be allowed to arbitrarilyincrease its intake or output, and neither must there be 2 or 3 batches of intake,which makes a mockery of good or even adequately high quality medicaleducation, both for undergraduate and postgraduate programmes.

Recently, a senior medical specialist and prolific healthcommentator, Dr. L. Pagalavan[11]^,[12]has proposed the following, and this is worth re-emphasising:

Tactics that control the numberof fresh graduates entering the local workforce

• Continuous reevaluation of future requirement forhealth workers.

• Controlling the number of Malaysians being admittedand graduating from medical schools. This can be achieved through:

◦ Creation of a body to oversee the quality ofmedical education, the functions of which may be similar to the Council onMedical Education in the United States.

◦ Introduction of standards to improve the quality ofmedical education, e.g. requiring a basic university degree before acceptanceinto a professional degree program (as in some parts of the world),establishing minimum expectations in a medical curriculum, and a minimum numberof full-time medical faculty.Following the Flexner Report whichadvocated these changes (and more) in similar circumstances to the present inMalaysia, a large proportion of medical schools in the United States merged orclosed, and the average physician quality improved significantly.

◦ A standardized examination for all newly graduatedmedical practitioners entering the workforce.

◦ Review of requirements for admission andgraduation.

◦ Review of school recruitment practices.

• Manage student and parent expectations.

All of these points, I have already alluded to in my abovediscussion. The ball is strictly at the feet of the Ministries of Health andHigher Education.

What do we want or wish for? Just the numbers game, or should weensure more importantly, the product i.e. quality medical doctors, andultimately, the safety of our populace? There must be a better alignment andcohesion of purpose and vision, and not just reliance on whimsical bureaucraticor political expediency!

Who would you rather have at the end of the day to look afteryou when you are ill, when you are older and who would you perhaps entrust thehealthcare of your children, your loved ones? Just a barely competentinadequately trained doctor, or the slightly stressed, overworked butexperienced and highly skilled one?

Conclusion

Thestandards of our medical education are falling. This is an unacceptable trend,which should not be allowed to continue. If we do not take drastic remedialsteps and actions to stall this slide, we might see a deteriorating climate ofhealthcare services in the country, with possible lowering of our medicalprofessionalism and our clinical expertise as a whole. We might be reduced tothe standards of some of the third world countries’ health services, whereexcellence is a rarity than a norm.

Wecould see a decline in our competitiveness, our competence and a deterioratingbelief in ourselves, as a developed nation—perhaps to be bogged down once againin a quicksand trap of mediocrity and ‘tidak apa’ lackadaisical mindset. Wemight soon be having so many poor quality doctors and medical graduates who maybe unemployed, even unemployable, and not trusted to be good enough to be ourhealthcare providers!

Potentially,there could be greater chances of endangering of patient safety and lives, formedical mishaps and errors, and greater risks for medico-legal challenges.Finally, the quality of our health service could deteriorate so much that our routineservices would be called into question, with possibly the skeptical questioningof the integrity and foundations of our health service. Instead of trust in ourhealth service, we could see the reversed medical tourism of more and more ofour own citizens to other neighbouring countries with perceived higherstandards of care and excellence of service!

Disclosure:

Iam the immediate past president of the Malaysian Medical Association, and havebeen arguing against the glut of medical schools and graduates in the country.I am also a 3-term elected member of the Malaysian Medical Council (since2004—2013), where despite our independent stance as individual autonomousmembers, we have to abide by collective decision-making and policydeterminations, as well as to respect certain Official Secrets Act mandates.

Ihave taught undergraduate medical students at the Universiti KebangsaanMalaysia (National University of Malaysia) from 1985-1991. Since then, I havebeen actively involved in post-graduate teaching in cardiovascular medicine aswell as in medical professionalism and medical ethics.

References:

[1] Patricia J. Numann. See One, Do One, Teach One. J Fam Practice online. Contemporary Surgery (Editorial). http://www.jfponline.com/Pages.asp?AID=293 (Accessed 2 November 2011)

[2] Loh Foon Fong. Houseman Glut: Too many new doctors and too few hospitals to train them, in The Star, Saturday, 27 November 2010, pgs 1, 4.

[3] MMA Press Statement on the Extension of Housemanship to 2 years. August 4, 2009.

[4] Richard Lim and Loh Foon Fong. Cleaning house. The Star, 12 December 2010.

[5]Abraham Verghese, Erika Brady, Cari Costanzo Kapur, andRalph I. Horwitz. The Bedside Evaluation: Ritualand Reason. AnnIntern Med. 2011;155:550-553.

[6] Jerome Groopman. How Doctors Think. Mariner Books, Houghton Mufflin Company, NewYork, 2008.

[7]Tan TC,Tan KT, Tee JCS. An End to “See One, Do One and Teach One” Residency TrainingProgramme – Impact of the Training, Education, Surgical Accreditation andAssessment (TESA) Programme on Medical Care and Patients’ Safety. Ann Acad Med Singapore2007;36:756-9. www.annals.edu.sg/PDF/36VolNo9Sep2007/V36N9p756.pdf (accessed 28November 2010)

[8]Departmentof Health. Unfinished Business – Proposals for the Reform of the SeniorHouse Officer Grade. London: Department of Health, 2002.

[9]Departmentof Health. Implementing the Tooke Report: Department of Health Update.London, DS, November 2008

[10]Malaysian Medical Council’s stand onissues raised by the YDP at the MMC meeting on 12/04/11.

[11] Pagalavan Letchumanan. For Future Doctors:Physician Workforce Planning in Malaysia: Better Coordination Needed,July 27, 2011. http://pagalavan.com/2011/07/27/for-future-doctors-physician-workforce-planning-in-malaysia-bettercoordination-needed/(accessed 08 Nov 2011)

[12] Flexner A. Medical education in theUnited States and Canada: a report to the Carnegie Foundation for theAdvancement of Teaching. New York: Carnegie Foundation for theAdvancement of Teaching, 1910.

malaysiakini: 'Storm is coming' for our medical profession ....... by Keruah Usit

2011-11-15T16:36:00.001+08:00

'Storm is coming' for our medical profession

Keruah Usit
11:51AM Nov 15, 2011

There has been a recent rash of angry letters and articles in the press, detailing the incompetence and lackadaisical attitude of many of the new generation of junior doctors, known as interns or house officers.

Most writers are contemptuous about the majority of the 7,000 new doctors entering the ranks of the medical profession every year.

Some letters, on the other hand, are written by house officers or their families, complaining of long working hours and harsh treatment by specialists.

It is obvious that feelings are running high. Traditionally, most Malaysian doctors do not write in much to the press. Doctors rank among the most conservative citizens in the country.

Even when the profession was faced with the torture of 106 prisoners of conscience in Operation Lalang in 1987, most doctors remained silent.

But in recent months, like other urban, educated and Internet-savvy Malaysians, many doctors have been changing tack.

Senior doctors took a concerted stand in July against the tear gas and water cannon used in a police assault on Bersih 2.0 protesters sheltering in the grounds of Tung Shin Hospital.

Following the arbitrary arrest and imprisonment of Dr Michael Jeyakumar Devaraj (left), one of the Emergency Ordinance Six (EO6), a large group ofPerak doctorsworking in public hospitals looked squarely into the camera, and called for Dr Jeyakumar to be freed.

The Malaysian Medical Association (MMA), the professional body representing over half of all registered doctors, also criticised the detention without trial.

This mutiny by middle-class Malaysians augmented the efforts of Parti Sosialis Malaysia (PSM), PAS, PKR and DAP, as well as civil society groups like Suaram, Aliran, the Bar Council and religious groups, in pressing the Home Ministry to release the detainees.

Vocal debate over ‘substandard’ interns

Some concerned doctors are now warning of future disaster in our health care, caused by substandard new interns.

“The storm is coming... Commercialisation of medical education will soon affect all of us. The glut of doctors is getting worse and many of them are being under-trained,” wrote Dr Pagalavan Letchumanan, a consultant rheumatologist and prolific blogger on crucial issues in health care.

Prominent doctors argue that profit-seeking degree factories in Russia, Ukraine, Romania, Egypt and Indonesia, as well as local medical schools with low teaching standards and inadequate lecturers, have condemned thousands of house officers to a hollow career they are not qualified for, and ill equipped to cope with.

The number of medical schools in Malaysia is 35, a staggering number for a population of 28 million. This is twice the corresponding ratio for the United Kingdom, with 33 medical schools for a population of some 62 million.

Of these 35 local institutions, 18 in the public and private sectors have already passed out house officers. Another 17 medical colleges will produce graduates between 2012 and 2017. Understaffing in local institutions is endemic.

The government claims the new doctors are needed to improve the ratio of doctors to patients from the current 1:1000 to 1:400, a level typical of developed nations, by 2020.

The Health Ministry has reneged on last December’s promise of a moratorium on new medical courses.

Several senior government doctors, requesting anonymity, blame political patronage by ministry officials, in this lucrative business of producing doctors, for the huge excess of house officers.

Greed, they claim, has been the prime mover behind the proliferation of officially recognised, but substandard, medical degrees from deficient medical schools, both inside and outside the country.

But many of these same senior doctors in the public service fail to report the poor performance of some of their new interns to the Malaysian Medical Council (MMC), the licensing body.

Some supervisors dread the paperwork involved in blocking the inept doctors from being registered. Others are simply reluctant to rock the boat.

These established doctors clearly lack the mettle of more vocal colleagues, like the current MMA president, Dr Mary Cardosa, who spoke up for Tung Shin patients, and for Dr Jeyakumar.

‘Pampered and reluctant’

Several specialists tasked with training the new doctors say many of these interns are pampered, reluctant members of the profession, cosseted by unrealistic, well-to-do parents.

Firsthand accounts by these specialists indicate the average quality of interns has plummeted, even though there has been a surge in quantity.

One surgeon said he received a telephone call late one night from the angry father of an intern. The father complained bitterly that the surgeon had ticked off his daughter for a mistake, earlier that day.

The surgeon asked to postpone the conversation until the next morning, explaining he was on his way to the operating theatre, but the father kept up his barrage of verbal abuse.

A specialist in Sabah recounted an episode of a house officer going absent without leave for several days. When challenged, the young doctor claimed he had been admitted to a private hospital for a “heart attack”. A check with the private hospital confirmed it had never heard of him.

“Some house officers just don’t know the basics,” one exasperated consultant told Malaysiakini. “I was trying to teach two house officers, both of whom had been working for a year.

“I was soon reduced to asking the most basic questions. Even then, they couldn’t tell me the normal range for the heart rate. One guessed ‘60 to 80'.

“Even Wikipedia has the correct answer. They couldn’t tell me what a normal blood pressure was either.”

Another specialist added, “Some of these house officers did not make the grade to enter reputable universities for a good reason. Their parents shouldn’t have forced them to become doctors, they’re simply not interested.”

There are, undeniably, a number of bright, dedicated potential doctors in the ranks of the new house officers. But the lack of motivation among many of the interns is plain to see.

One government specialist tried an age-old trick to elicit some empathy for a patient who had been treated badly by an obdurate house officer, by asking him: “How would you feel if this were your own mother, lying here in this bed?”

The specialist was taken aback by the young doctor’s reply.

“My mother wouldn’t be in this bed. She’d be in Singapore if she fell sick.”

KERUAH USIT is a human rights activist - ‘anak Sarawak, bangsa Malaysia’. This weekly column is an effort to provide a voice for marginalised Malaysians. Keruah Usit can be contacted at keruah_usit@yahoo.com

Comments in Malaysiakini:

dkay Blame parents too....parents want their children to be doctors by hook or crook....thus the demand for substandard unis and interns.Vast majority of interns don't know,dont bother to know and dont want to know "what mdeical care and practise" is all about.When they are questioned,they brag about their uncles,relations etc who are practising doctors....with subtle body reactions;;;they give u the impression " hey you are just an ordinary consultant in govt...dont talk so much"....Hmmm...thus consultants dont say much.....they are force to pass them as interns(everyone knows why)......thus the quality......GOD help us when we get old......
	Onyourtoes I know most house officers especially from medical schools of certain countries are totally hopeless. When asked, they do not know the normal body temperature, normal sugar level and normal blood pressure. I am not exaggerating. But then I also want to ask who are the patients of specialist doctors in government hospitals? Try to get a appointment, they are usually not available. Are they only treating the Tansri and Datuk seri and the vvips?
	ksn There are two professions that no govt. should NEVER mess with- doctors and second teachers. Here include the U teaching staff as well. You mess with them, you mess with the country's future. We have a fair idea of the FACELESS LISTLESS TEACHERS (LKY's words) exceptions granted, of our teaching profession, judged from the standards of the products. For these two professions, aptitude, devotion, care and inclination should be the criteria, the only criteria: not race, not numbers and not NEP. They are like our vital organs to the nation: the heart and the lungs.
	ONE HAND COVER THE SKY This is all the faults of our present govt. They prefer quantity rather than quality ! Churning out substandard graduates who know nothing of what they are studying. The future will be worse if they insist to change the teaching of science and maths subject from english to bahasa malaysia.
	Jimmy Ng Finally, the cat is out of the bag ! The rumours that we have been hearing about all this while have finally been confirmed to be true ! This is what happens when we have ill-qualified people running the govt suffering from the obssession with churning out incompetent numbers instead of focussing on quality !! Worse yet, in the noble field of medicine & health care , where one's life and health is probably at stake !!
	DontPlayGod This is what happens when the NEP comes into play. NGO's and pressure groups like PERKASA, and a host of other fanatic groups will keep up the pressure to maintain the NEP. I am afraid things will get worse and disaster will strike our medical profession. Thanks to this quota business where even below average students are pushed into medical courses, and for which they may not even be interested in. We all have this 22-year PM to thank for. Malaysia to be a developed nation by 2020? I can only say we may be like Greece, Iceland, and now Italy, maybe even before 2020. Our Asia tigers like S. Korea, Taiwan, Hongkong, Thailand, and Singapore will be so far ahead of us in development that we will be like Somali and Zimbabwe by then, if not sooner. Even Indonesia will soon surpass us, and we will be sending our maids and labourers to Indonesia and other places.
	Sankar @ Chandran a/l K.C. Pillay One woman complained that her daughter was rejected by a prestigious local private uni. The daughter did not get to do dentistry even though the woman said she was prepared to pay the fees for the entire course upfront. According to her, the uni. refused. Now the daughter is pursuing a dentistry course in India. This woman thinks her money can buy her a seat in a prestigious uni. Good unis need good students; not some half-past six candidates. I have renewed respect and confidence in the kind of medical graduates that this uni is producing. Local private unis must endeavour to maintain their prestige and reputation.
	Pemerhati There has been a drop in quality not only in the medical field but many other areas. For this the country has to thank the constitutional Malay of Indian ancestry, Mahathir. He tried to prove to the native Malays that he was one of them by promoting racist policies that favoured them. During his 22 year premiership he destroyed, amongst other things, the excellent education system by making even the most incompetent Malays into teachers, lecturers, professors, engineers, lawyers, doctors, civil servants, etc. There were many able and brilliant Malays amongst this group but Mahathir preferred and promoted the apple polishers who mostly came from the incompetent group. Not surprisingly these incompetent people implemented the idiotic policies that have caused the catastrophic drop in standards not only in the medical field but in the whole public service. The racist policies have provided a few hundred thousand jobs to incompetent Malays to the detriment of about 15 million Malays.
	Anonymous_4031 Four years ago, my mother-in-lawhad traumatic experience when UM Hospital changed her stent. A simple procedure almost cost her life. After being hospitalised for several days, she was finally discharged and taken to San Fransico hospital for treatment. It is now 4 years, stent change is easily done; and she could go home the same day!But, not UM Hospital!Hospital authorities can check the record of the patient, Madam Ting Mee Nguk four years ago. Do we have really qualified doctors? Qualified lawyers, qualified engineers, qualified architects, qualified dentists? Lettting loose unqualified professionals will harm the consumers.Does the Government really care for the welfare of the people?Malaysia has no place for , self-serving , uncaring leaders. Do not try to serve yourself first and ignore the welfare of the common people who flock to hospitals and clinics for treatment.Do not lower standards so that you become popular.Be honest. Have integrity.Dot sell your soul to the devil.
	ksn In this situation which needs to be corrected immediately, it is essential that the good and bad interns should be identified, separated. This assessment must be done by an independent panel of eminent doctors, the good ones to progress and bad ones penalized as long as it takes until they are assessed by the same panel to be competent to treat. We had housemen working weeks at a stretch without any break and they never complained. How come suddenly the housemen are complaining about hard work and long hours, Tough learning? Then they are in the wrong profession. Is the easy going philosophy of the civil service and automatic rewards spreading to the medical profession as well without earning it? Do we need so many housemen and so many medical colleges? Is there not a need to control them at the initial stages if it is not too late already? Can we hope that our people will not end up as the experimental pigs in the hands of the housemen who will become doctors? Standards please.
	Anonymous_4031 How could you "re-mark " , with the intention of addimg marks! The lady lecturer spoke to Star which ran a whoel page on this episode. By "diluting " the quality of students, you are condoning the lowering of stadards. Strangely, the Minister was re-appointed by the PM, who has also appointed non-elected MPs as Ministers.This is a serious flaw in the PM himself. For political expediency, the PM chose unwinnable candidates as Ministers.No-go in honest selection .) Graduates must be qualified to become doctors. While we are judging foreign medical Universities, at local level, we must ensure that our standard is not diluted so as to show the world that we could produce many "doctors" . There is no pride in such production in the mill. For housemanship, if trainees cannot put in honest work, then extend t he period of internship.Do not let loose sub-standard doctors, please. Tun Abdul Razak lamented that UK did not recognise MU medical degrees.
	Anonymous_4031 Stop this quota business. Be honest and truthful about the quality ofmedical graduates produced. There is no pride in churning out a high percentage of doctors, who are of sub-standard. Better to have quality doctors than half-past doctros!Note care4fully, that if we allow sub-standard doctors to be let loose to the sick population, you are condoning the deaths of patients. Univesities and Ministers should bear vicarious responsibility for causing the deaths of patients.Resign as Ministers and Deans of medical faculty and VCs! You want to score political points at the expense of lives of patients.The public must condemn thiks attitude.( As an aside, I remember one law lecturer-cum-examiner as chided for failing many law students.In her protest to the Higher Education Minister,she failed to get a reply on time; and she resigned in December. The Minister replied the following year and, horror of horrors, he said that it was alright to "re-mark " the papers. Rubbish. I wrote to Star.
	Anonymous_4031 All professional courses must have a higher passing bench-mark than that of non-professionanal courses.Recently Newspaper reports indicated that sub-standard housemen have been going the rounds in wards.The Health Ministry in particular and the Government in general should look at this serious short-coming and act at once. Do not wait for lives to be lost before they act.They must be proactive and not reactionary especially where lives of patients are concerned.I would like to suggest ideas to ensure that good doctors are produced. Firstly,we must set at least 40 marks as the passing mark. Those students who fail to attain this bench-mark should not pass.Universities must not try to show a high percentage of passes by lowering the passing mark.They must be ethical. If they cannot be honest, they should not be in t he University. Besides this strict passing mark system, Higher Education Min ister must not try to put pressure on Universities to allow a quota of graduate.
	pity him !!!!! Blame the federal goverment UMNO for the situation in our beloved country. Despicable, naming Malaysia an education hub.