MyHealthMatters

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.

malaysiakini: TBH 'suicide' finding: Impossible does not happen.... by CT Wong

2011-08-20T17:13:00.000+08:00

TBH 'suicide' finding: Impossible does not happen

CT Wong
Aug 20, 11
11:36am

10 friends can read this story for free

Extracts from Teoh Beng Hock Royal Commission of Enquiry:

Decision on the second term of reference:

[119] "Having considered all the evidence in its entirety, we found that TBH was driven to commit suicide by the aggressive, relentless, oppressive and unscrupulous interrogation to which he was subjected by certain officers of the MACC who were in the ongoing operation by the Selangor MACC on the night of the 15th and into the morning of the 16th."
Forensic psychiatric aspects:

[233] "Tormented by this predicament, TBH experienced a change in his state of mind. And in a matter of hours, this change transformed him from being in the low-risk group for suicide into the high-risk group. The doubts, extreme emotional conflict and the immense feeling of guilt were all intolerable. Finally, precipitating the irreversible crisis that happened to him between 3.30am and 7am on the 16th, was the last straw that broke the camel's back.

Finding no viable strategies to surmount the hurdle of accusations levelled, he found himself unable to escape from the suffocating quagmire in which he was trapped. TBH would have felt trapped and have succumbed to despair. Since the window on the 14th floor was either open or could be easily opened and it was conspicuous and easily accessible near where he was on the sofa outside Nasdzri's room, TBH would have found that the only way for escape from the torment he was undergoing was by jumping out of the window, even though it meant taking his own life...."

Introduction

Self-inflicted death must have meaning and a reason. In Teoh Beng Hock's death, we find neither meaning nor a reason for taking his own life, if we accept the findings of the TBH royal commission of inquiry.

Suicide is rare. It is even rarer for a normal person without abnormal psychology to commit suicide.

It is hard to believe suicide can happen within few hours of experiencing trauma. Hopelessness as an acute warning sign of suicide most often takes time to develop, days or weeks if not months. RCI has confirmed that TBH was "driven to commit suicide" within hours. The impossible does not happen and the improbable only happens very rarely.

This suicide verdict goes very much against common sense and the intuition of many Malaysians. A closer look is hence necessary to critically examine how the RCI arrived at such conclusion and whether the RCI has proved TBH's intention to suicide.

The focus of study here is essentially of the psychological aspects of the section on 'Forensic psychiatric aspects', pages 64 to 72 of the Report of the Royal Commission of Enquiry into the death of Teoh Beng Hock (hereafter called RCI).

Serious flaws in RCI conjecture
RCI evaluated the evidence from forensic pathology and concluded that TBH fell to his death; and from forensic psychiatry that TBH would have jumped to his death. These conclusions are used as reasons to support the suicide verdict that TBH was driven to commit suicide.

However, there are serious flaws observed in RCI's argument. The authenticity of the evidence of intention to suicide used to support the claim is doubtful. Also, the inference from evidence to the conclusion of suicide is invalid and unsound.

The commissioners' method of reconstructing TBH's psychological state prior to death is questionable. The suicide verdict is examined here from the perspective of suicide.

Making attributions minus the proof

One of the two main terms of reference as spelt out in the RCI is "...to enquire into the death of Teoh Beng Hock and the circumstances surrounding and contributing to his death. It does not state clearly whether 'death' means the cause of death (e.g. major injuries, heart attack etc.) or the manner of death (natural causes, accident, homicide or suicide)."

By RCI's verdict of the enquiry, it had taken to itself the responsibility to determine the manner or mode of death.

As for the requirement of the level of proof, RCI stated that their finding would be based on "a balance of probabilities sliding to proof beyond reasonable doubt" (RCI pp.5). This means RCI claims its standard of proof is very high. Also, it says that in order to "understand the probability that TBH took his own life", it is crucial to know TBH's traits of character and his changing states of mind (RCI, pp 64).

It is clear from the above that RCI intended to use the language of probability in the reasoning in the argument. However, the RCI commissioners used the language of certainty when giving the verdict of "driven to commit suicide"; it does not say something like "TBH probably or most probably was driven to commit suicide", but asserted that TBH was "driven to commit suicide".

The commissioners should not use categorical terms of suicide in absolute certainty as the precise mental state of the deceased could not be known.

Purported intention to suicide unconvincing

When read closely, the RCI para [233] on "conclusion on forensic psychiatric aspects" does not confirm that TBH intended to commit suicide but speculated that TBH must have committed suicide:

"...TBH would have found that the only way for escape from the torment he was undergoing was by jumping out of the window, even though it meant taking his own life." (RCI, pp 72).

However, such speculation is used as the reason to come to the suicide verdict: "...Having considered all the evidence in its entirety, we found that TBH was driven to commit by the aggressive, relentless, oppressive and unscrupulous interrogation to which he was subjected by certain officers of the MACC.." (RCI, pp 37).

Para [233] is of utmost importance in determining whether TBH had the intention to suicide. RCI was unable to confirm the intention to suicide and yet it confirmed suicide had occurred. This is a deep contradiction and the inference is seriously flawed.

RCI is using strange logic intelligible only to itself. It runs something like this: Teoh Beng Hock would have found suicide as the only way out. Therefore, TBH committed suicide. Speculation has then become hard fact. There is little wonder that the public refuses to accept the verdict.

But, why must RCI deliver a suicide verdict? Why not an open verdict? We do not know for what reasons the commissioners felt compelled or were compelled to make a verdict that contradicts its own reasoning. With an unconvincing verdict, the reasoning itself in the RCI needs to be examined critically.

Missing mark in suicide definition

According to De Leo, Burgis, Bertolote, Kerkhof and Bille-Brahe (2006), the World Health Organisation working group had proposed a standard definition for the study of suicide:

"Suicide is an act with a fatal outcome which the deceased, knowing or expressing a fatal outcome had initiated and carried out with the purpose of provoking the changes he desired (WHO/Euro, 1986)".

The key elements of the WHO's definition involve:

1) an awareness that action has fatal outcome,

2) the self-responsibility of the subject both to initiate and to carry out the suicidal behaviour and

3) the intention to bring about wanted changes.

RCI's verdict of "driven to suicide" is not in accordance with WHO's definition of suicidal behaviour. RCI's speculation of TBH's thinking of "...would have found that the only way of escape...jumping out of the window" can only be described as suicidal thoughts rather than an act that was initiated and carried out by TBH himself.

By WHO's definition, one cannot force another to commit suicide without one's intention to commit suicide. One can force another to kill him/herself which is considered as homicidal. In 22 state and three territories of the United States of America, even assisting in suicide is a crime and the charge is murder.

RCI has not proved the crucial elements of suicide: (1) the locus of origin (self-initiated) and (2) the intention (to cause, or not to cause death). Neither has RCI proved that TBH was aware or conscious of the potential of fatal outcome.

The RCI verdict is therefore conceptually illogical.

RCI lacking legitimate psychology data

To establish suicide or suicidal behaviour, from the legal point of point of view, both the physical act (actus reas) and the mental element (mens reas) must be present; the mental element is intentionality i.e. the intention to suicide. It is self-evident that evidence must be produced to support any claims of suicide as the manner of death.

From the psychological point of view, the legitimate data which can or should be used as evidence are derived from experimental methods, observations and introspections.

There are 4 different types of data:

behavioural data;
personal accounts of inner experience;
symbolic data (symbolic creations of the mind such as texts or the language used);and,
material data like the biological data and neuropsychological data

Behaviour is what can be seen or observed from the outside. The data gained and evaluated is called outsider viewpoint without going into the mental state of the subjects studied.

The inner experiences involve the feelings, emotions, beliefs, thoughts, reasons, motives and intentions. The data gained/evaluated is called the insider viewpoint.

These cannot be seen directly from outside and can only be accessible to others through verbal or written reports or inferred from non-verbal behaviour.

Insider viewpoint without evidence

RCI had provided an insider viewpoint of TBH's psychological state of mind without giving any basis of how the data of inner experiences were collected and evaluated. It is more appropriate to say that RCI reconstructed the reality of TBH's psychological state in such a way that the suicide verdict is inescapable. This is a serious flaw of RCI's reasoning.

The relevant passage is found in RCI para [233] page 72 (in italics below) and my comment run as follows:

a) "Tormented by this predicament, TBH experienced a change in his state of mind."

My comments: How did the commissioners know of TBH's torment of predicament and inner experience of psychological changes? What evidence?

b) "And in a matter of hours, this change transformed him from being in the low-risk group for suicide into the high-risk group."

My comments: Why the immediate grouping into suicidal and not other category? How likely is that within a matter of hours a person becomes suicidal? Having suicidal thoughts is different from suicidal behaviour. What evidence of suicidal behaviour is there with TBH?

c) "The doubts, extreme emotional conflict and the immense feeling of guilt were all intolerable."

My comments: Guilt is an inner emotion and thought. How do the commissioners know? What evidence of TBH's inner feelings was being manifested?

d) "Finally, precipitating the irreversible crisis that happened to him between 3.30am and 7.00 on the 16th, was the last straw that broke the camel's back."

My comments: Metaphor is no substitute for hard evidence. What really happened?

e) "Finding no viable strategies to surmount the hurdle of accusations levelled, he found himself unable to escape from the suffocating quagmire in which he was trapped."

My comments: When and how did the commissioners know that TBH knew of no other viable strategies?

f) "Losing all hope, TBH would have felt trapped and have succumbed to despair."

My comments: When and how did the commissioners know that TBH had lost all hope?

g) "Since the window on the 14th floor was either open or could be easily opened and it was conspicuous..., TBH would have found that the only way for escape from the torment he was undergoing was by jumping out of the window, even though it meant taking his own life."

My comments: How did the commissioners know TBH's intention to suicide?

The above reconstruction sounds more like a survivor's account of a suicide attempt.

Reconstruction and interpretation of suicidal thoughts and behaviour must relate to legitimate data. Without a proper and sound method of data collection and interpretation, we can only infer that the data is manufactured out of imagination.

RCI couldn't have known

RCI had used various terms like "extreme emotional conflict", "guilt...all intolerable", "irreversible crisis", "losing all hope", "succumbed to despair" to give an account TBH's subjective psychological state of mind after the interrogations.

Then, they described TBH's judgement of the extreme situation as "no viable strategies", "unable to escape" and "trapped". The depiction of TBH's immense emotional turmoil and the judgement of "no escape" was framed in such a way as to lead to the inevitable consequence of "jumping out of the window".

The way that extremes in emotion and impairment in judgement are attributed to TBH without any correlation to any specific time, specific location, specific events and specific details raises the serious doubt of its authenticity.

Highly subjective, loaded phraseology

RCI used a large amount of rather emotional, subjective and value-judgement words and phrases to describe TBH's state of mind. For example:

"[219]...Taking his mobile phone away would have meant robbing him of his means to reality and sanity. And the MACC officers did just that. Thus, for the first time in his life, TBH found himself totally and completely isolated from the outside world and thrust into desolation..." (RCI, pp.71)

Are the commissioners suggesting that TBH was losing his sense of reality and sanity just because of a handphone? And suggesting that TBH was going insane?

And how do they know that it was the first time in TBH's life that he felt "totally and completely isolated"? Presumably, they had special access into TBH's autobiographical memories and all the life stories.

The first sentence of the RCI finding using a third-person perspective speaks of "...would have meant...". But by the third sentence, a speculation by RCI had become a fact - "TBH found himself totally....". It is a remarkable feat to blur the reality by switching from one dimension of reality to another.

It is important to analyse this short passage as the whole argument for the suicide verdict is constructed using similar lines of reasoning or reconstruction of mental reality.

Risk factors not causal factors

Risk factors are still risk factors, however high or acute it is. Risk factors are not causal factors unless proven so.

Just because RCI suggests that someone feels trapped and troubled by hopelessness does not mean that the individual would commit suicide. In fact, even most people who have previously harboured suicidal thoughts still do not do so.

All the three psychiatrists who gave expert opinion to the RCI were of the view that TBH belonged to the low-risk group for suicide after reviewing TBH's life history against the risk factors.

The psychiatrists were Dr Badi'ah Yahya, a forensic psychiatrist and Dr Nor Hayati Ali from the Ministry of Health, and Paul Edward Mullen, emeritus professor of forensic psychiatry, Monash University, Australia. Dr Badi'ah and Dr Hayati based their argument on the observation that TBH came from an intact family, had a stable job, and had no history of mental illness, impulsivity or substance abuse.

However, RCI ignored the expert opinions of the low probability of suicide and argued that TBH had undergone dramatic psychological changes from the low-risk group to the high-risk group for suicide when taken in by the MACC on July 15, 2009.

Quite early in their argument, RCI chose to categorise that TBH belonged to a high-risk group for suicide. Instead of choosing to argue out what was the probability of each manner of death (natural, accident, homicide or suicide), RCI ruled out all other scenarios and was fixated on the sole verdict of suicide.

RCI then used the hypothesised emotional state to justify suicide was the only way out for TBH.

No warning signs of suicide

RCI adopted the approach of insider viewpoint in arguing for the suicide verdict. RCI first classified TBH belonging to high-risk group for suicide and then provided purported details of TBH's inner emotions and thoughts before he purportedly took the decision to 'jump'.

From their approach, we would have expected that RCI had managed to gather evidence of signs of TBH of wanting to commit suicide. Strangely, no such evidence was produced.

According to the American Association of Suicidology, a person in acute risk for suicidal behaviour most often will show the following warning signs:

"Threatening to hurt or kill himself or herself, or talking of wanting to hurt or kill him/herself; and/or
Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or
Talking or writing about death, dying or suicide, when these actions are out of the ordinary."

RCI had not provided any credible and convincing evidence that TBH had suicidal thoughts or suicidal behaviour. It is at best mere speculation and at worst the manufacture of inner experience of a supposedly insider viewpoint.

RCI had failed immensely to establish TBH's intention to suicide.

TBH stable and supported

Van Orden et al. (2010) proposed that the most dangerous form of suicidal desire is caused by the simultaneous presence of two factors - the thwarted belongingness (I am alone) and perceived burdensomeness (I am a burden) - and the hopelessness of these situations.

Also, the individual must acquire the capacity to engage in suicidal behaviour.

It is most unlikely that TBH would have felt hopeless when he was only detained less than 24 hours and there were ample opportunities for him to be reconnected to the outside world.

There is no reason for TBH to entertain the thought that his family, friends and colleagues in the outside world had abandoned him.

Subsequent events following news of TBH's death saw an outpouring of support - including many friends, colleagues and ex-colleagues - for the family. It is clear from this that TBH had a sound social network of support to cope with any traumatic events.

Thus, the attribution of despair and hopelessness by RCI onto TBH is falsely created.

No suicide for physical, mental wreck

Para [229] stated that "By the time the fourth or final stage of the interrogation was over, TBH would have been almost a mental and physical wreck. When Ashraf fetched him a glass of water [demanded impolitely by TBH], TBH was said to have sat up very slowly."

It is clear that in such a tortured weakened state, TBH would not have sufficient strength to commit suicide. When he could hardly move, he could not be expected to jump out of the window. This RCI conclusion now of TBH's physical near collapse is self-contradictory to its melodramatic reconstruction of a fevered, despairing mind planning an energetic act of self-annihilation.

It is more probable that TBH would want to get out of the dreaded MACC building the moment he had the chance and the energy.

Conclusion

The RCI's suicide verdict is questionable as the reasoning in its argument is deeply flawed. Mere speculation of TBH's psychological state prior to death had become hard facts.

The authenticity of the evidence of intention to suicide used to support the claim is doubtful.

The inference from such evidence to the conclusion of suicide is invalid and unsound.

RCI based its reasoning on reconstructed suicidal thought. It is not inevitable that suicidal thoughts would lead to suicide. Also, it has not provided any evidence of suicidal behaviour or warning signs of suicide. The seriously weakened mental and physical state TBH as described by the commissioners shows that suicide is implausible.

RCI should have delivered an open verdict as it is a matter of intellectual honesty and integrity to respect facts and evidence.

Death would only have meaning when the truth is revealed and justice is done.

CT WONG is a practicing engineer of over 30 years, who also takes great interest in exploring non-technological matters of psychology and philosophy.

Medical Graduates from Russia - When gov't scholarships are mismanaged... by Weasley

2011-08-19T11:59:00.000+08:00

Medical Graduates from Russia

When gov't scholarships are mismanaged

by Weasley | May 26, 09 4:24pm

I am a medical student from Russia as well. Best part is, I or rather we, did not choose to come here. We are all scholars sent here by either JPA or MARA.

If you were to Google "Moscow Medical Academy" it is ranked by UNESCO as the second best medical university in the world.. Do not be fooled by this because I was one who was fooled as well. Only after I landed in Moscow did I know that the "2nd best in the world" is specifically granted to the Russian medium of this medical school.

We, Malaysians, are doing the English medium and I must say it's an utter shame that the government actually spent millions of tax payers money to send us all here to study medicine. The teaching facilities or methods of the English medium here is way below par, way below that of a third world country even. Some classrooms here even resemble the ones we have in our 'kampungs' in rural areas such as those in Sabah and Sarawak (thank you so much for sending us here all the way to Moscow to experience this!).

For your information, this so-called Moscow Medical Academy does not even have a campus to begin with. Classes are scattered all over Moscow.

We students are forced to travel everyday via Metro, or by foot, or bus to attend classes. Also, there are times when we would have travelled so far to attend classes, and upon arrival at school, only to be told that classed are cancelled.

The Malaysian government could have spent the money more wisely to educate us in Malaysia, Singapore or India. We get paid almost USD700 per month, which I believe is a huge amount of taxpayers money. However, I doubt we will bring back much knowledge to be able to help the patients back home.

While there are some of us who save and spend the money wisely due to the high cost of living here, there are a huge majority of private and sponsored students who come here just to enjoy. Frequent parties, weekend getaways, world tours, and shopping sprees are common among students here.

The lifestyle of many Malaysians change tremendously once they came here. They behave even worse than the "Mat Sallehs" here.. Malaysian girls here, for instance, would walk around ever so skimpily leaving nothing to the imagination (even during winter!).

Whatever happened to the Malaysian culture? Many here have even lost their virginity at the tender age of 18 or 19 simply because a guy or girl can walk in ever so easily into the rooms of the opposite sex.

Many Malaysian medical students behave as though they have no self dignity. However, they portray the best behaviour once they land in Malaysia as though they are the best Malaysian angels. Sadly, we all know their true colours when they are here in Moscow. Hypocrites!

These Malaysians are surely to be huge dissapointments to their families as well to the nation. Exams and studies are the least priority for the many who are here. I wonder why did some people choose to study medicine in the very first place.

Let me also give u an insight of the education system here. You want to know why the majority of Russian grads are so incompetent and useless?

Well, first and foremost, we can get away with cheating ever so easily during exams. You may ask how.

Many students here aren't bothered about being honest for themselves. Many just merely do the bare minimum of studying and copied their friend's answers or directly from the books during the exams. These students fail to realise that they are only cheating themselves. The one who helps with the cheating is also going to lose out in the end once he/she is out of medic school and into the work world.

Another method which works really well for the girls is simply to shed some crocodile tears during exams and instantly the lecturer would grant her a mere pass. How is this fair to students like me who slog day and night, mugging and studying extremely hard with the simple intention of
graduating as a competent doctor?

After all, these cheaters would be graduating with a MD certificate and would turn out to be the bad apples in the healthcare system in Malaysia. Thus, leading senior doctors to generalise and say that all Russian grads are incompetent. Does anyone have any idea how frustrating this is?

Many students who sit for exams earlier would simply snap a photo of the different sets of questions and answers to be distributed to the rest of the students who have yet to sit for their exams.

How is this helping anyone? Can you even call this an exam? Does it fit the definition of an exam? So, can you imagine what kind of doctors we're producing here? A bunch of cheaters, liars, and irresponsible future doctors!

No wonder countries like the UK refuse to accept Russian medical grads for their postgraduate courses. Simply because we have never even sat for a proper exam per say throughout our six years of study here.

Look at the UK universities/colleges. Do they even allow any student of theirs to bring in PDAs, camera handphones, bags, and books into the exam venue? Do they allow any exam candidate to communicate with another candidate once the question paper has been distributed? Do students know the exact questions and answers prior to the exams? Hell no! These only happen in Russia.

So, wake up people.

To those of you who are planning to send your offsprings to Russia for a medical degree, please, I'm begging you, think again. You're not only going to lose your money, but also perhaps the good name and dignity of your family.

This is merely an opinion of mine and not directed to insult, degrade or humiliate anyone. I believe there is nothing wrong in sharing my opinion.

DISCLAIMER (DQ):

I'm not at all sure of the authenticity of this letter writer to the malaysiakini online, in 2009 ad just forwarded to me recently. (?)

However, it is a good eye-opner for those who would wish to go to unorthodox medial schools.

For the hundreds if not thousands of medical graduates out there from Russia, perhaps you can dispute this experience.

I personally know of quite a few graduates who are making very good progress when back here for medical internship. I know that it is an especially long slog having to re-study quite a lot to cope and keep up... But please speak up so that the authorities and the med school agents can listen!

Singapore MOH: Booster Shot For Healthcare...

2011-08-19T11:21:00.001+08:00

Press Releases

Booster Shot For Healthcare

Singapore MOH 15 Aug 2011

The Ministry of Health (MOH) will be introducing a series of initiatives to make healthcare more affordable for Singaporeans. This is part of the Ministry’s on-going effort to review and evolve our healthcare system to better serve the needs of Singaporeans. These changes will be implemented by the first quarter of 2012.

The key changes are as follows:

i) We will enhance subsidies to make medications more affordable by offering greater financial assistance on selected high-cost drugs to middle – low income patients.

ii) Private outpatient primary care will be made more affordable and accessible for middle-low income patients, thus enabling these Singaporeans to better manage their chronic diseases early, remain healthy and active and avoid unnecessary complications.

iii) The annual withdrawal limit for Medisave use for outpatient care will be raised so that patients can tap on more Medisave to pay for their bills.
iv) Medifund will also be expanded to include non-residential Intermediate and Long Term Care (ILTC) services, so that elderly Singaporeans can recover and age gracefully in the community.

a) Making care more affordable by increasing subsidies for high cost standard drugs

MOH will increase the drug subsidy for selected high-cost standard drugs for eligible patients, required for chronic disease management from the current 50% to 75%. The same eligibility framework as the PCPS will apply i.e. patients with per capita monthly household income of $1,500 or less, economically inactive households, and patients with residential Annual Value of $13,000 or less.

These drug subsidies are applicable to eligible patients seeking care in the Restructured Hospitals, National Centres, as well as at the Polyclinics. They will have to show their healthcare benefits card to qualify for the subsidies.

b) Expansion of the Medication Assistance Fund

In addition, MOH will enhance subsidies under the Medication Assistance Fund (MAF). This fund was set up in 2010, to help patients pay for expensive drugs used for specific medical conditions. The MAF currently covers selected expensive medication, including certain cancer drugs.

However, some patients, especially those with less common diseases or complex conditions, may not respond well to the standard drugs. To financially assist these patients, the MAF will be expanded to cover other non-standard drugs if they are assessed to be clinically necessary and appropriate for the treatment of the patients’ conditions. The hospitals will put in place a framework to assess patients’ need for the drug on a case-by-case basis.

The level of subsidy provided under MAF will also increase from the current 50% to 75% for needy Singaporeans.

c) Expansion of the Primary Care Partnership Scheme for private GP and dental care

The qualifying income for the Primary Care Partnership Scheme (PCPS) will be raised from the current $800 to $1,500 per capita monthly household income. At the same time, the age criteria for eligibility will be lowered from the current 65 years old to 40 years old.

There will be two benefit tiers under the expanded scheme (Table 1). With this change, 710,000 Singaporeans can receive subsidised care at participating PCPS GP clinics to better manage their chronic conditions. Successful PCPS applicants will receive a healthcare benefits card to identify them as PCPS members to the participating clinics.

There are currently more than 31,000 PCPS members, and 405 participating GP clinics and 170 participating dental clinics.

Table 1

The new changes will be implemented from early 2012. Existing PCPS members can continue to benefit from the scheme until their card expires. Those who qualify under the current PCPS criteria and wish to apply for the scheme now can do so. Application forms are available at the CDCs and Community Centres.

d) Raising the Medisave withdrawal limits for outpatient expenses under the new Medisave 400

To help Singaporeans better manage chronic diseases like diabetes, high blood pressure, lipid disorder and stroke in the outpatient setting, the Medisave withdrawal limit allowable for such outpatient treatments will be raised from $300 to $400 per Medisave account, per year. The scheme will be renamed Medisave400.

Medisave400 can also be tapped on for preventive mammogram screening and selected vaccinations. About 112,000 chronic disease patients will stand to benefit from the scheme.

e) Expanding healthcare financial assistance to needy Singaporeans through Medifund

The Government will further enhance Medifund to include non-residential ILTC services such as day rehabilitation, home medical and home nursing. With this, needy Singaporeans will be able to opt for non-residential care, thus helping them recover and age in the community in the company of family and friends. This is expected to benefit about 1000 more Singaporeans, a 10% to 20% increase in the number of Medifund recipients in the ILTC sector .

These schemes will be introduced from early 2012. Members of the public who are interested to find out more can visit the MOH website at http://www.moh.gov.sg.

For detailed Factsheet

malaysiakini: 1Care health reforms: Can one size fit all?... by Keruah Usit

2011-08-18T15:06:00.002+08:00

1Care health reforms: Can one size fit all?

Keruah Usit
Aug 18, 11
11:36am

10 friends can read this story for free

After the delivery of his second child in Limbang, Sarawak, five years ago, proud father Ketua Baru, a farmer from a rural Penan community, was told to wait before he took his baby daughter Robina home.

He says the medical assistant at the counter at Limbang Hospital insisted that Ketua had to first pay the hospital bill. The sum was small - around RM10.

Ketua (left) asked for the bill to be waived. He is a subsistence farmer, with a negligible cash income, and every ringgit was precious to him.

Ketua said the medical assistant insisted there could be no exemption, although a Health Ministry circular stipulates free treatment for Sarawakian families earning under RM700 a month.

"The medical assistant said, 'If you cannot afford to bring up your children, why do you make babies?'

"I answered him: 'Where do you think I would get a salary of hundreds or thousands (of ringgit) from?' He told me 'you Penan people are always lying.'

"In his mind, Penan people are really like animals. He walked into his office after that, otherwise I would have said angry words to him, I might even have spat at him," Ketua said.

Ketua is now a volunteer citizen journalist for Malaysiakini. His income remains the same, but thanks to training courses and a basic, AA battery-operated camera supported by Malaysiakini, he is now adept at making videos and conducting interviews.

He has become aware of the importance of taking note of the names of bureaucrats behaving in an uncouth manner. Ketua is creating his own record of the experiences of the Penan, a community facing encroachment by loggers, and trying to come to terms with modernity.

Ketua is also aware that local and international media are showing growing concern for the social and economic deprivation common among Sarawakian natives. .

Attempts to reach the state health director by telephone and email, to seek comments on Ketua's experience, were unsuccessful.

1Care 'nebulous and unclear'

Rural healthcare faces new challenges. 1Care is the latest manifestation of healthcare funding introduced by the government.

Under this reformed system, both private and public sectors will be funded by a national health insurance scheme, managed by government appointees and drawn from contributions from employers and wage-earners.

Briefings on 1Care have gone on throughout the nation. The briefings have been long on expositions on principles, and short of detail. It remains unclear where the funding will come from, who will manage the insurance fund, how healthcare will be rationed and which groups will be exempted, if any.

No minister has spoken on the legitimate concerns of Malaysian citizens with low incomes or without adequate documentation. Suhakam has noted large numbers of Penan citizens without MyKad.

The lack of these essential documents has affected all ethnic groups in the country, particularly among rural minority groups in Sarawak and Sabah. Promises and deadlines issued by the Registration Department to provide MyKad to these disenfranchised citizens have come and gone.

The proposal for a national insurance scheme picked up speed under the recently retired director-general of Health, Dr Ismail Merican.

However, he was unable to provide concrete reassurance for undocumented Malaysians, or for the poorest segments of society, that they would receive free treatment under a new healthcare financing system.

No declared policy of equitable healthcare

Concerned doctors say Ismail told them that the MyKad issue had to be resolved by the Registration Department, not by the Health Ministry.

Dr David Quek, immediate past president of the Malaysian Medical Association (MMA), has on several occasions, called for concrete details and frank consultations with the public, over the proposed health funding reforms.

"We (in the MMA) lament the fact that up until now, Malaysia still does not have a declared policy of equitable healthcare for all... ideally healthcare should be freely accessible for all, regardless of ability to pay, and should be based entirely on the basis of need.

"Slogans such as 1Care remain nebulous and unclear, and are not convincing enough to encourage acceptance by our citizens, and certainly in the current form, not by the medical profession," Quek wrote last February.

Despite Quek's warning, no public dialogue on proposed 1Care reforms has ensued, and details have remained jealously guarded by the government.

Doctors and citizen groups, Quek asserted, are anxious that leakages, "already legend with many government and government-linked entities", would waste more money and shrink even the meagre benefits present under the current system.

Other healthcare professionals have expressed similar concernsthat the agency overseeing the healthcare fund would have enormous opportunities for largesse and corruption.

Yet most of the debate over the proposed healthcare funding reforms, held by civil society groping in the dark, continues to centre on the issue of choice.

Urban Malaysians are concerned over their liberty to consult any family doctor. Many are worried general practitioners will be designated for them, in imitation of Britain's National Health Service.

Others are also worried that they may be deprived of more expensive investigations or treatments, under a rationed 1Care scheme.

But in Limbang, as in many other poorer parts of Malaysia, most members of the public have never enjoyed the luxury of choice.

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 atkeruah_usit@yahoo.com