Physician Malaise, Dwindling Public Trust, Moral Imperative

By Dr David KL Quek

The most recent Readers’ Digest poll on Malaysia found doctors to be third (behind pilots and teachers) in the line of professions whom they can trust (Nichol David, Dr Jemilah Mahmood (MERCY Malaysia), Lee Chong Wei, and Lat were the top 4 eclectic celebrities that Malaysians chose to trust).[1]

This is perhaps not too surprising but maybe a sign of the times. Just a few years ago, doctors were polled as the most trusted profession, so clearly in the interim the public perception has changed somewhat. Have our doctors done anything to deserve this climb down in public trust? If so, how and what has rankled the public?

To be sure if we do scrutinise the above table, there is little to distinguish the top 3 professions. But it is worthwhile scanning down to see that the paramedic, the surgeon, the dentist, the pharmacist and the nurse are now quite high up the hierarchy of public trust from a list of 40 professions. We are now in a highly competitive climate for public trust and regard, and it will get keener with the times!

This became quite clear, when the MMA and many doctors protested the setting up of 1Malaysia clinics to be manned by paramedics in urban centres in January 2010. While the concept of making healthcare access better for urban poor is laudable, our contention that doctors and not just paramedics man these clinics did not receive the expected attention or response that it should.

Medical assistants—now also renamed as “assistant medical officers” and nurses were up in arms that we were belittling their skills and training, when what we intended was to simply state the facts of inequality and disparity in qualifications, schooling, training and possibly standard of care of the 3 professions.

As medical professionals, we maintain that each of the professions has its own niche, task and role. However, without exception, as is stipulated by the Medical Act, all clinics should be fully supervised and manned by doctors.

Nurses and paramedics are clearly indispensable in their respective roles, and we do not dispute that, nor do we wish to denigrate their responsibilities or capabilities. But ultimately, they are there to assist us and carry out certain tasks, but the final responsibilities must rest with doctors, as full supervisors and hopefully not any less!

Sadly, due to political manoeuverings, our authorities have spun a disingenuous tale that we are elitist and uncaring with the full-throttled support and thrust from the mainstream media and a populist public. Perhaps, such run-ins are the stuff that damages our position, unless we choose to quietly abide by the challenges and events, and let them slip by, without comment or debate…

But I think the medical profession cannot afford to keep quiet and let this erosion of our practice issues continue. It is precisely differences of opinions and approaches like these that the MMA must be willing to challenge and question, and expose the fallacy and/or the unacceptability of these moves. Globally, for various reasons, task-shifting is being manipulated mainly on economic grounds, to undermine the scope and practices of the medical profession, and we have to remain vigilant to stall these measures of convenience.

However, perhaps for a growing number of Malaysians there has been a widening schism of trust pertaining to all things authoritative and maybe elitist to some degree. Alas, doctors have sometimes been labelled as such—that we are too patronising, too paternalistic, oftentimes too self-seeking and too all-knowing, that we give too little precious time and trouble to explain more to our patients, the public at large.

The information asymmetry due to the very wide knowledge gap and esoteric nature of medical jargon and terminology only continues to drive a deepening wedge between the medical profession and the public. Our perceived haughty tone also isolate us from the more curious if lesser informed public. Many now hanker for better understanding but because their educational or belief systems are so varied, these create what appears as an unbridgeable divide that makes communication less amiable and severely limits two-way exchanges.

Unfortunately many doctors and medical graduates are never adequately taught to speak and communicate in simple layman’s language. Perhaps this has to be addressed—doctor-speak and ‘medicalese’ vocabulary creates misunderstanding or confusion, which lessens the doctor-patient encounter.

Most doctors tend to find comfort in their own abstruse medical universe. But this clearly must now change. We have to engage the public as never before, we must make ourselves clear and express ourselves better, if we hope to continue to be as meaningful and as trusted by the public. We must give our patients more time and show a greater empathy. We must not be mere business contractors, too busy and too calculating to care.

Paternalistic attitudes of the past when “doctor knows best” are long gone and passé. We must become attuned to the times—we need to re-engage with our more knowledgeable and more inquisitive patient, so that we meet their rising expectations, their trust that we duly deserve.

However, throughout the rest of the world, most people do continue to find doctors most trustworthy. For example, the MORI poll of the United Kingdom has consistently found doctors to be most trusted (with 92% believing that doctors can be trusted to tell the truth), way ahead of politicians (13%), ministers (16%) and journalists (22%).[2]

Expanded Moral Imperative for the Physician

So, in many ways, the Malaysian doctor is now perceived somewhat differently. We are now caught in the crossfire of growing skeptical if flawed sophistic judgement and inquisition by a larger segment of a more discerning public.

Simply put, while we generally still enjoy our much-vaunted position of trust and respect from the general public, we are getting more than the occasional hiccups from bad press and publicity. Perhaps, this trust has dropped a few notches, but there is by and large hope that doctors can rise above the fray of the mundane mediocrity of Malaysian society!

Furthermore, we are exhorted to become more than what we have been accustomed to do thus far—being far too meek, commonly apathetic, conscientiously practice-oriented, and indeed fully focused only on our parochial medical interests, our bread-and-butter humdrum lives and livelihood…

Perhaps, there is greater expectation that as a whole, our usually higher moral standing should buttress a more consistent level of ethics and good societal practices, most of which have taken tumbles from our previously respected lofty heights. Our debilitating institutions and highly questionable state of affairs have cast a shadow of despondency on a large segment of our more enlightened society.

Although many of us traditional doctors are wary of treading on the wrong side of political correctness, there are increasingly greater demands on the astute doctor to act according to his or her expected standard of intellectual and professional standing, training and moral compass—to do the right thing or at least to come right out and say so.

The public demands that doctors stand up to be counted, to emerge outside of their previously cloistered if self-contained comfort zones. The long gestation within our pupated hibernation phase should cease; doctors must rekindle their sense of commitment and engagement with society.

Doctors are expected to help influence the finer direction of where we hope our Malaysian society should go, although like any other profession, there would be many amongst us, who would be and have been partisan or even ethnocentrically chauvinistic or religiously fanatical! That is why so many amongst us have participated in politics, some more successfully, others less so, some shaping our entire nation, while others simply creating meagre waves of lesser consequence.

But for most of us, we can be less fraternal and still contribute without partisan leanings, which would therefore be less inclined to colour our judgements and perhaps even our professionalism!

That said, it is perhaps time to become more engaged and involved. It behooves our dignity and arguably may enhance our trustworthiness in the eyes of the general public. Doctors must be doing more and must treat everyone with the respect and dignity no matter who they are.[3]

Improving our Caring Ethos

We need to reaffirm our caring ethos, our trained and ingrained approach as our patients’ greatest advocate, no matter the contradictory signals and opposing forces that insist we are out of kilter. Our unwavering stance on the patients’ ultimate welfare should be our primary goal: “Primum Non Nocere”, and that as medical practitioners we are the best professionals to look after their healthcare concerns.

We also need to help expand the dialogue and public knowledge about healthcare issues and costs, and how some reform may be necessary. We need to expound more simply why everyone must play their part, including becoming more willing to contribute either via taxation or by some community insurance. Lack of in-depth information has hampered discussions on this difficult but necessary subject. The MMA and the medical profession must lead the discussion on the issue of affordable and sustainable healthcare financing.

Truth Telling & Ethical Professional Practice

Incredulous and conflicting forensic pronouncements in the Kugan “death in custody” case, as well as that concerning the more recent Teoh Beng Hock fall from the MACC building, have punctured the believability of health officials involved in the truth-seeking exercises and justice—so crucial for trust in our public institutions. Custodial injuries and deaths number into the hundreds or more, and have remained largely unexplained and unaccounted for, again undermining our state institutions, and potentially breaching international law on human rights and detention rules.

We also hear of possibly coerced and altered medical reports from physicians who have been pressured by higher authorities which endanger the independence and reliability of the truth telling process of what the medical examination and reporting is all about. Our forensic integrity has also been shaken, when external experts are increasingly sought to offer more dispassionate and impartial deliberation of the truth.

In this regard, our local experts and medical professionals must re-examine their own conscience and moral anchor to deliver greater believability and accuracy of their duties and findings. Doctors must not become unduly influenced by any external party or forces; they must endeavour to tell the final unimpeachable truth, without fear or favour.³

State vs. Professional Interests must be clearly defined, with the medical professional always taking the position of determining the medical truth and facts, while protecting the rights and position of the patient, the detainee, the prisoner, even the death row inmate. Detention Health, Torture, Injuries, Death & Medical Professional Duties are all well articulated by world-recognised authorities and bodies such as the World Medical Association’s Declarations of Geneva, Tokyo and the Istanbul Protocol, and the United Nations Commission on Human Rights. We encourage our medical colleagues to be fully aware of these onerous responsibilities and roles.

Healthcare Rights Advocacy

Finally, in this day and age, the medical professional is exhorted to be more involved in human rights advocacy. The World Health Organisation (WHO) has quite categorically stated that health is a human right, i.e. every human being should have the right to access to healthcare.

The difficulty of course, is to define the quantum and the scope of how much and how comprehensive that right to healthcare should extend. Because, unfettered healthcare is becoming an untenably expensive affair, some form of rationing and queuing will have to be the way forward—with the usual altruistic goal of greatest benefits to the greatest number of people.

This means that we have to collectively find some agreeable way to establish what is considered as reasonable and adequate healthcare at the most affordable means, which can benefit the greatest number of people. The poor must not be marginalized or shortchanged in an ideal world. As doctors we must try and find some equitable equilibrium, while continuing to allow choice and freedom to choose within reasonable boundaries.

In this regard I would like to quote Professor Ian Gilmore (President of the Royal College of Physicians of London who said that:

“As doctors, we are often looking at the single patient in front of us, but as ambassadors for improving healthcare we have roles in the NHS, in healthcare and in wider society to become champions of change to protect the planet from climate change. As private individuals, we may well act ecologically, but may not always have carried our private views into the public arena. It is time we stepped up to the plate.”[4]

In Malaysia, we too have to step up to the plate and walk the extra mile to do more, to show our fellow citizens that we can do more. Perhaps we can help bring about greater and more beneficent reform, measures which would perhaps regain the public’s trust in us once again.

The MMA is fully engaged with the MOH, in trying to find a better way for the Malaysian healthcare system. We believe that the public too has a stake and must also be part of the reform process. However, there are many obstacles and divergent viewpoints, which need to be reconciled and overcome. But, we are confident the best is yet to come, if we all put our minds to it. We need knowledgeable physicians to help us move the momentum towards the final goal, which is unlikely to be static but perhaps dynamically evolving...

“Every now and then go away, have a little relaxation, for when you come back to your work your judgment will be surer. Go some distance away because then the work appears smaller and more of it can be taken in at a glance and a lack of harmony and proportion is more readily seen.” ~ Leonardo Da Vinci

References:

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[1] Readers Digest. Trust Survey 2009 – Malaysia (Accessed at http://www.rdasia.com.my/trustsurvey2009my on 10 April 2010)

[2] Ipsos MORI. Trust in Professions 2009 for The Royal College of Physicians. September 2009, London.

[3] David KL Quek. Malaysiakini: Unbiased treatment for all. http://myhealth-matters.blogspot.com/2010/03/malaysiakini-unbiased-treatment-for-all.html (Accessed at 11 April 2010)

[4] Doctors can no longer ignore climate change, says RCP President, Politics.co.uk. (Accessed at http://www.politics.co.uk/press-releases/doctors-can-no-longer-ignore-climate-change-says-rcp-president-$484799.htm on 08 April 2010)

1Malaysia clinic: is the Health Ministry above the law?

Letter
By RS
From Lim Kit Siang's Blog 

It is distressing to learn from Dr. T. Jayabalan, the health adviser to the Consumers Association of Penang that medical assistants are giving out prescriptions for the wrong medicines or prescribing medicines which they are not allowed to prescribe and they have also been found to have wrongfully diagnosed patients at a study conducted at Kampar, Perak.

And feedback thus far, from the MOH regarding the validity of MCs (Medical Certificates) issued by 1Malaysia Clinics have been unsatisfactory. The explanation issued by the Health Ministry’s Medical Practice Division officer, Dr Noraini Baba, stating that according to an internal MOH circular, MAs are allowed to issue MCs seems to suggest that she either doesn’t know the law or thinks she can actually circumvent a law through a department circular.

But perhaps CAP too should share of the blame for this vague situation. The last time they made so much noise, it resulted in ignorant officers at the Health Ministry rushing to pass an reckless legislation called the Private Healthcare, Facilities and Services Act (PHFSA) which was conjured up in the dark corners of the Health Ministry and stamped with the Official Secrets Act (OSA) effectively excluding the stake holders from taking part in the discussions. The Act is surely unconstitutional.

A doctor today with an Annual Practicing Certificate (APC) is legal under the Medical Act 1971 but becomes illegal if his premise is unregistered under the PHFSA 2006. But a Hospital Assistant (HA) working in a presumably legal PHFSA premise, 1Malaysia Clinic, becomes immediately illegal as he has committed a felony under the Medical Act 1971 since under this Act only registered medical practitioners are allowed to work in medical clinics.

This is the end result of people like SM Idris who give half-baked ideas to our poorly trained civil servants who then create silly laws in a knee-jerk unthinking fashion, which ultimately not only endanger people’s lives but place the government eventually in a legal quandary. Worrying statistics of wrong prescriptions and misdiagnoses seeping out of 1Malaysia Clinics maybe just the tip of a disaster waiting to happen.

If we keep making up unending rules and regulations for the delivery of healthcare in this country, the whole of Sabah and Sarawak will soon be paralyzed as HAs there run many of our rural clinics and even provide anesthesia for many of the rural hospitals there. And anesthesia is no child’s play as even propofol; supposedly a very safe anesthetic can kill as it did the late Michael Jackson. In a country with limited trained medical human resources we have to initially stratify the levels of care that we can offer and much depends on both the quantity and today, the quality of medical professionals we have at hand.

Our rural health clinics are still run by midwives termed “Jururawat Desa“ while our health clinics are run by a combination of staff nurses, medical assistants and doctors. Our hospitals are run by all of these people and specialists. But specialists alone are not good enough if we want to deliver quality care as we need the help of physiotherapists, lab technologists, radiographers, biomedical personnel, critical care nurses, operating room technicians, anesthetic technicians and a whole gamut of other health personnel.

Some of the monster hospitals that this government has built like Sungai Buloh, Ampang and Serdang are today nothing more then glorified nursing homes. Patients rush in thinking they are in for high-tech care, but a quick glimpse of the ICU will show 20 beds with 5 junior nurses trying desperately to man the 20 beds with no respiratory therapists, technicians, doctors or even the critical care specialists or anesthetists around.

A great many of the Malaysian population, especially in urban areas are very dependant on the General Practitioner who are the lynchpins in healthcare both in the UK and Australia . In the UK , GPs are today credited in reducing smoking in the general population, monitoring and preventing strokes and heart attacks from modern day epidemics such as diabetes mellitus and hypertension.

In Mexico , Singapore , the US and in Europe , GPs were in the forefront in stopping the spread of the deadly influenza virus H1N1. GPs there were provided training, test kits and eventually Tamiflu to check the disease. Amazingly, in direct contrast, the MOH in Malaysia decided to bypass the resourceful neighborhood GP and instruct likely infected patients to rush to the Sungai Buloh Hospital with disastrous results where hundreds of patients mulled around at its lobby with staff stretched to their limits. Only after a huge public outcry in the face of mounting unacceptable mortalities did the MOH rescind and supply the generic version of Tamiflu to GPs.

For chaps like Idris, GPs in Malaysia are there only to make money and must therefore be shackled with draconian laws and treated as common criminals if they cross the line. They should be jailed or fined if their premises are unlicensed. In fact one doctor, Basmullah Khan, was needlessly jailed for three months just because his premise license was technically “not approved”. Only a malicious government would close down any health facility where hundreds of patients have been depending upon the expertise of the doctor for treatment and follow-up simply based on a bureaucratic edict.

No country in this world treats its doctors this way except for Malaysia , another Malaysian first I guess.

But what are the repercussions of this sought of enactments on medical practitioners? A GP in Sungai Pelek, who once used to put up a drip for a dehydrated patient suffering from diarrhea due to food poisoning, refers the patient because he doesn’t want to take a risk under the PHFSA. He has even been told to remove the two beds he always keeps for such emergencies at this remote town. A GP in Triang seeing a dengue patient, lethargic, nauseated with a platelet count of 80,000 decides to refer when previously he would have asked the patient to come for a daily course of IV fluids and monitored his clinical features and platelet counts. And a GP out in Gemas refuses to deliver a full-term patient in labour with an almost full cervical opening for fear the baby may be born ‘flat’ and he would have to face the draconian PHFSA. So he decides to be safe and call for the ambulance to Segamat, 20 miles away. The baby is of course born in the ambulance.

And right here in Penang, a GP sees a diabetic patient suffering a coronary, lies him flat and places a couple of GTN tablets under his tongue when previously he himself would have administered crushed aspirin to the patient and given him a bolus of heparin which he always keeps for emergencies of this nature and perhaps some morphine. Of course he could have administered all of this and nothing would have happened if everything went well. But if the patient developed a complication, lo and behold he would be criminally charged and the MOH would tell him to speak to the judge if he wanted a lesser sentence.

The GP doesn’t need this. It’s better to play safe. Is there any wonder why our government hospitals and their outpatient departments are overflowing. This is the type of defensive medicine that placed America into trouble.

The Prime Minister may have meant well in wanting to provide free outpatient care for poor urbanites. And the MOH could have advised him of a multitude of options including opening their own current urban health care clinics, even for 24 hours using their own doctors or outsource the service to GPs for an appropriate price.

Why did the MOH choose to break the law by allowing unregistered medical practitioners to treat patients when surely they know that this is wrong? Were they politically pressured or were they plain ignorant. How would the Ministry defend itself in the event a patient sues for malpractice?

It is an irony in itself that the MOH goes around closing clinics run by registered medical practitioners while they themselves use unregistered medical practitioners to run clinics in urban areas where there are an abundance of doctors. Is the Ministry of Health above the law?

The GP Conundrum—Whither the Future?

The GP Conundrum—Whither the Future?

Dr David KL Quek, MMA News, February 2010

“A doctor must work eighteen hours a day and seven days a week.  If you cannot console yourself to this, get out of the profession.”  ~ Martin H. Fischer

“A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.”  ~ Harvey Cushing

“To me the ideal doctor would be a man endowed with profound knowledge of life and of the soul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by his mere presence”.  ~  Henri Amiel

“Despite all our toil and progress, the art of medicine still falls somewhere between trout casting and spook writing.”  ~ Ben Hecht, Miracle of the Fifteen Murderers

Of late the general practitioner (GP) has become a marked and endangered species, or so it seems.

The private medical practitioner, for so long the backbone of the primary healthcare structure for Malaysia appears to be teetering on the brink of corrosive extinction, if not emasculation. The GP’s role has become increasingly deprecated, marginalized and severely delimited, even competed against directly and indirectly by government-backed 1Malaysia clinics, run by medical assistants and nurses.

This is especially poignant when we know that whenever someone falls ill and/or needs medical care, some 62% of our nation’s population would seek direct treatment from GPs for the initial health concerns (3^rd National Health & Morbidity Survey, 2006).

GPs remain the very affordable, conveniently-sited and perhaps the most efficiently accessible approach for primary healthcare for most urban as well as for suburban citizens.

Yes, it is true that many of these encounters are reimbursed from out-of-pocket (OOP) mechanisms, which seem to bug health economists these days. But, the cost of such one-to-one care, then and now is still very reasonable and affordable, and often does not escalate as high or as frequently as inflation!

In more rural or remote locations, many patients often find hard-earned means to seek treatment from caring family-based GPs who are often the preferred healthcare provider, rather than to avail themselves to public healthcare clinics where wait times and changing personnel provide a less than continuous system of care. Many have complained of disjointed, impersonal care, which appears to be inherent in our present public healthcare system of rotating transient medical officers or assistants, who come and go…

Thus, despite lingering perceptions by certain authorities that the care provided by GPs are piecemeal and sometimes fractured and deficient, many people when asked would declare that in most cases, the care provided by GPs are what had made our Malaysian citizens as healthy as they have been these many decades following Merdeka!

More than the usual coughs and colds, cuts and scratches, fevers and diarrhoeas, chronic ailments (such as hypertension, diabetes, asthma, arthritis, etc) are also given sufficiently good care by many GPs who provide comprehensive medical services to entire families and their children’s families too. Sometimes, different GPs acquire different reputations for being that singular ‘specialist’ for unremitting fevers, for hypertension, for asthma, and so on.

When I was young, Dr Alice Low from Johor Bahru saved me many times over from my debilitating asthmatic attacks, and generously provided sampled inhalers when my family could ill afford to buy them on such a regular basis. Despite my nearly monthly attacks, I was thankfully, never ill enough to have been hospitalized due to her dedicated care, nearly a half-century ago. I finally outgrew my wheezy tendency in my mid-teens, perhaps a legacy of her care and therapy. Thank you Dr Low!

 

Dr Alice Low (84yrs, left standing), at Dr Martin's 95th birthday, seated. Photo Courtesy Dr Wong Yin Onn, JB

My late father, who passed away at 80 years last year, had severe hypertension from young. He received ‘special care’ from Dr Ho Ung Chek along Jalan Terus, JB, for nearly 20 years. When Dad finally died, he did not have LVH, but the scourge of microvascular effects led to some mild Parkinsonism. He did not have the privilege of better, more efficacious drugs then. But I am convinced he did get the best that medicine and good doctoring could provide then, under those trying circumstances, at affordable and cost-effective prices.

Dr Ho used to work very long hours, from 9 in the morning to nearly 9 at night, six days a week. I did not remember a time when he took leave. When I accompanied my Dad sometimes on Saturday afternoons, Dr Ho was always there for his throngs of patients who would patiently queue for hours to access his ‘special’ touch, his singular ‘knowing’ therapeutic expertise! He spoke little, but had a kindly, approachable façade and calm nature that belies his true quiet authoritative professionalism. In some ways doctors such as these have helped nurture my enduring interest in medicine.

I salute Drs Low, Ho and all others who I believe continue to live on in the thousands of GPs around the country—plying their dedicated quiet practice, looking after so many patients, so many families, that can only leave behind lasting legacies of health, confident connection and friendship…

But times and medical practice have changed somewhat. It is difficult to quantify how much and how this has impacted upon the GP, the medical practitioner, who engages in direct patient care.

There’s greater depth and breadth of old and new medical disciplines, which necessitate constant updating and continuing professional development (CPD). Knowledge and even basic concepts continue to evolve and shift into more plausible, more evidence-based certainty, although these stand correctible with newer findings and research.

Furthermore, the physician is called upon to withstand the onslaught of rehashed mumbo-jumbo and complementary alternative therapies, which continue to mindlessly but alluringly erode into the impassive cold sanctum of scientific medical practice.

The doctor has to steel himself/herself from such quackery, which is seductively simpler to adopt and to share folie-a-deux ideation with our increasingly credulous patients (and even some doctors themselves!). Many are generally becoming more gullible than scientifically rigorous! How can we differentiate truths from pseudoscientific gobbledygook, and avoid the lure of lucre from overwhelming our humdrum practices?

The question arises whether the ordinary doctor can maintain his level of competence and knowledge base so as not to endanger his ward—the patients. Worldwide, the medical practitioner is called upon to maintain his expertise and standard of care, his core competency through rigorous and standardized continuing educational programmes. Most are voluntary, but increasingly, many regulatory authorities are beginning to impose mandatory proof of keeping up with currency of medical knowledge.

Unfortunately however, there has been a general passivity about many of our GPs, our doctors here in Malaysia. It is estimated that as few as only 10-15 percent of our doctors routinely attend CPD programmes. The majority simply sit on their past educational base, and continue regardless without venturing into newer advances in a systematic way.

This will have to change. Doctors have to be more proactive in learning and maintaining their skills and knowledge, if they are to do justice to their profession, no matter their conviction that ‘all’ of medicine had been learnt in his/her tenure as a medical student! So how do we encourage or even mandate such a change, a requirement, to ensure that modern medicine is now as scientific and as evidence-based as can be?

GPs must look within themselves to re-engineer their modus operandi, their ways of medical practice even. GPs have to emerge from their cocooned complacency that simply serving quietly and earnestly behind long hours of general practice will suffice. It is not.

More is now expected, it is no longer simply more of the same, with an unending gravy train of endless patient queues. Fee-for-service models may also need a re-tweaking, as more and more primary care services are moving toward a capitation/gate-keeping and pay-for-performance model.

Will the solo practitioner be extinct? Can he/she cope with the rising expectations and keener competition to be better, more efficient, more diverse yet more encompassing?

Or would larger group practices with greater diverse interests and greater pooling of resources and capacities be the trend for the future?

There is louder and louder talk of locale-base patient-registered medical practices which will be regionally reimbursed through a single payer system. Will the GP be prepared, and if so, how can this be made better or improved upon? There is also talk of co-payment possibilities to reduce abuse and over-use of amenities or medications, even separation of pharmacy-dispensing roles…

Would the GP be ready to act as responsible financial-controller and gate-keeper, with that onerous duty on who to continue to treat and who to refer forward to tertiary specialist care, on a timely yet medically-defensible way?

Would he or she be ready to look after returned patients, who have been referred back for chronic care management and rehabilitation, after acute tertiary therapies, including major surgeries?

Will our GPs be up to the mark of being the primary care-led physician who can help keep the cost of health care as low as possible?

Would the GP be trusted to ensure that the societal interests be the primary concern, while maintaining a high performance standard, which enhances measureable and auditable healthcare targets?

Will he or she be ready to be rewarded for performance rather than rely on the lure of pure profits, alone? Are the GP’s skills sufficient at this juncture to cater to these potential and impending challenges?

Therefore, as can be predicted, there will be tremendous emerging transformations, which would continue to shatter the equanimity of more and more GPs—creating in its wake more uncertainties and piqued disappointment.

There is thus, the growing spectre of more regulations, possible accreditation plans for both professional/practice and clinic standards, and possible recertification/revalidation moves which only add to the litany of more bad and cumbersome news.

Then too, there’ve been moves to introduce family medicine specialists (FMS) or family physicians as another tier of ‘specialist’ primary care doctor, who supposedly would be better equipped to enhance modern day primary care practice…

I know that many GPs are quite distressed by all these developments. Many have complained loudly and are understandably angry because they feel so hopeless as events continue to unravel around them with such paces that seem to leave them behind. Some complain that they seem to have been neglected and left out of the loop, whenever discussions on their future take place.

Yet GPs are supposed to have been represented. They have various groups, which purport to be acting on their behalf, with the MMA being the largest body representing them. Yet, these do not appear to be enough. Whenever any call is made for GPs to come forward to be heard, only a select handful turns up to be counted.

In January 2010, in the wake of the contentious 1Malayia clinic launching, a dialogue with the Health Minister saw just some 13 GPs out of 25 MMA members, who could find the time and effort to make a presence, and let their voices be heard.

This perceived apathy and lack of forceful passion is deafeningly disturbing, and gives the impression to the authorities that GPs are malleable and thus perhaps can be led without too much pressure. Thus, events continue to unfold, and the dice appears to have been cast…

But the brutal honest truth is that GPs appear to be floundering, like fish out of water. The tide of good ole times seems to have ebbed. We appear not to have a cohesive or comprehensive General Practice policy, which is devised by GPs themselves, when this should really be the optimum practice.

As president, I have been publicly censured for opposing the popular 1Malaysia clinics, and told in no uncertain terms that I should simply lead, and that the GPs would follow. Even another medical group leader suggested that since some proposed changes are good for the profession, such upgrading efforts should be pushed and led, not necessarily with input by the GPs on the ground! Lead, not by consensus or feedback all the time, I’ve been told… Let a few disgruntled ones make some noises, but as leader, just do the ‘right’ thing by what MOH or some of us, feel is right…

But I choose to listen to the background noises, because many GPs did email or sms text me their rising discomfort level, their rightful concerns, their livelihood realities, their professional right. Yes, we do need more doctors to speak out and be counted. Now we should do even more!

It is with this in mind that the MMA has through its PPS, initiated a Primary Care Group which is striving to champion the policies of the GP. The Academy of Family Physicians, and some interested GP interest groups are also involved.

We are planning a GP Summit where we hope all the issues, which pertain to the GP and its future challenges and scenarios can be discussed, debated and finally arrived at, in a comprehensive policy document which will enhance and protect the interests and ultimate practice conditions of all GPs.

We need as many of you as possible to support this initiative. Do come forwards to make this a great success with all your input, to help shape our collective future! This is in your hands!

For those in the public sector, it is also incumbent on most of you to consider seriously that your future would also depend on the many policy changes, which are coming on-stream very soon. You too must come forward to join us in the campaign to ensure that our voices about our future be heard.

For once in a long while, please come forwards and make your own future! Doctors of Malaysia, it is time to unite and be counted, lest we be accused of engineering our own demise through neglect and apathy…

1Malaysia Clinics: President's Response, 27 Nov 2009

My latest response to Dato' Dr Thuraiappah and Dr Xavier (27 Nov 2009)

Dear Dato Thurai and Xavier,

I'm sorry if I sounded quite brusque the last time. Personally I concur with both of you and many others who feel that the GPs need to boost their capacity to be more full fledged and perhaps arguably more complete and competent primary care physicians, and that the only way forwards is to ensure that everyone undergoes CPD lifelong.

However, the reality of the ground is that most GPs are totally averse to more regulations and prescriptions of more rules which dictate what each should do to benefit from supposedly wider disbursement of primary care services.

Last night we just had a National Health Policy committee meeting, and we heard from 2 GPs, Dr Tan and Dr Krishnamurthy who were vocalising their unease with any more restrictions on their services and their livelihood.

They represent some GPs on the ground who feel that the OPD services of MOH is far worse than their anecdotal cases they have looked after. Conversely the MOH feels that our GP services thus far is also below bar. we have to find the truth in between, finding the strengths of each rather than just the weaknesses.

It is in this context that I think the MMA have to present a collective front of consensus. There are just too many disagreements right now and we all have to work towards a more persuasive atmosphere of voluntary CPD including the AFPM QIP which I have actually encouraged for some time.

But if we at all individually begin to suggest that stringent and restrictive requirements for GP involvement in the MOH distribution of its primary care patients, then we can lead to impasse and a lot of GP unhappiness, even outright revolt. So I welcome all discussions on this, but please let's have internal dialogue and try and find a way forward--some compromise will be needed on a win-win basis.

Cheers and best wishes!

Can I encourage you both to join our MyHealth Matters-MMA 2009-2011 facebook chat site?I would also include your emails for further discussions by others.

1Malaysia Clinics and AFPM: Dato Dr DM Thuraiappah's Comments

Dato Dr DM Thuraiappah's Comments 27 Nov 2009

Dear Dr David Quek,

I have read with interest the many replies to Dr Xavier’s mail with interest. I feel there has been some misunderstanding of Dr Xavier’s letter.

Firstly the concept of ‘One Malaysia Clinics’ was the Prime Minister’s proposal that twenty odd clinics be opened to be manned by HA’s or equivalent to manage simple outpatient illnesses with standard prescriptions by a visiting medical officer and these clinics are to be located in heavily populated areas in Malaysia with budget of about RM200,000.00 and to be opened by January, 2010. This is indeed a tall order and whether this will be realised is questionable.  This idea is good for patients who currently use the public primary care system.    

Secondly, the proposal by the MOH to enable general practitioners to care for chronic diseases in order to reduce the workload of Kelinik Kesihhatan and public hospital outpatient departments was the point which Dr Xavier was making. For this to happen, to be fair to all concerned, although it will be good for the general practitioner there are several prerequisites to be in place. 

1. There has to be a referral system in place from the general practitioner to the consultant and returned to the care of the general practitioner. In order for this process to happen, the consultant has to be confident that such care can be continued in the general practitioner set-up. Here, various definitions have to be clear and precise.
2. That the patients will have to be able to receive the same investigations, procedures and prescriptions from the general practitioner as they receive from the public sector. How the mechanism for payment for such services rendered will take place will only take effect when the national health financing mechanism is in place or any other mode of payments is established.
3. Currently there is concern whether the investigations, procedures or prescriptions can be uniform among all general practitioners. The concern has arisen that some clinics may lack some essential items to carry out acceptable methods of care.
4. The nature of general practice is family care but some clinics may not have some essential equipment and do not practice a variety of services such as pre-employment medical examinations, wellness services, counselling services,  surgical or gynaecological care or procedures. The common chronic diseases which need to be looked at are hypertension, coronary artery disease, metabolic syndrome, screening for cervical cancer, asthma ad mental health.  
5. It is therefore in our interest that these disparities must be discussed among ourselves and we must endeavour to provide the expectations of the public sector so that we can be united by auditing our selves by our own profession.
6. CME may not be sufficient because of its opportunistic in nature. One must look at structured CPD be in place so that doctors can learn skills to equip them in accessible, continuous and comprehensive family oriented care.  
7. The Director General of Health has repeatedly announced at various meetings that general practitioners should be trained to a level of primary care physician, and I think there is a message in his frequent announcements that it may be a requirement in the future.

I hope that Dr Xavier’s mail be taken in the spirit it was written.

Yours truly,

D. M. Thuraiappah, Council Chairman, AFPM        

1Malaysia Clinics: Letter from Dr Gnanasegaran Xavier, Family Physician Penang

This letter was cc'd to me on 21 Nov 2009

Dear Dato Dr.Teh, (Penang State Director of Health)

Thank you very much for your prompt reply. I think we should do a pilot project amongst GP Clinics interested to become 1 Malaysia Clinics. To become 1 Malaysia Clinics maybe we can request the doctors to at least have a diploma in Family Medicine organized by the Academy of Family Physicians. If the pilot project is a failure we can always discontinue it. But if it is a success I think many people would gain and it would be a win win situation.

For the management of chronic cases these clinics could be used. I had asked about the cost incurred by KKM in managing chronic cases like Diabetes Mellitus during the Nadi Conference. If cost incurred by KKM and the private clinics are going to be similar than we can always use these clinics to manage the chronic cases. This would definitely reduce the work load at the Klinik Kesihatan. I have attached here a Diabetic case. With Amputation of toes and another management of Diabetes Mellitus with gross protein urea.

I also had dissccused with Dato Dr.Christhoper Lee about H1N1 Management by GP Clinics and being reimbursed by KKM. Would management of H1N1 be better if there is combined effort?

At the moment I feel the General Practitioners are neglected and we should bring them into the main stream. KKM can definitely monitor these Clinics and make sure they meet the required standard. I think if we put all our heads together we can have an excellent GP force in the country.

 Mr.Palani ,Dr.Hooi and I are already preparing for the 13^th Teaching Course for GP’s from 23th September 2010 to 26^th September 2010. Attached also is the previous feedback for the 12^th Teaching Course. This course was motivated by our late Dr.M.K Raj Kumar and it is now going to its 13^th year.

I help out the Tzu Chi Dialysis centre at Bagan Ajam (voluntary) and I notice most of the people undergoing Dialysis there are due to end stage renal failure from Diabetes Mellitus. If we can prevent an amputation of a single toe and prevent one Diabetes Mellitus patient from becoming End Stage Renal failure than I believe we have achieved something very great.

1 Malaysia Clinics should not be a political issue but should be a KKM issue.

Regards,

Dr. Gnanasegaran Xavier

MBBS FAFP FRACGP CIME AM