Sunday Star: MMA: Send the young ones to rural areas... By CHRISTINA TAN

MMA: Send the young ones to rural areas

By CHRISTINA TAN
chris@thestar.com.my

Sunday Star: January 16, 2011

PETALING JAYA: The Health Ministry should make it compulsory for younger specialists to serve in remote areas to reduce the country’s dependency on foreign specialists, said the Malaysian Medical Association (MMA).

Its president Dr David Quek said contract specialists and medical officers have been serving in remote areas in Malaysia for many years.

He said to overcome the shortage at district hospitals, locally trained doctors should ideally be deployed there. “But many young specialists do not want to leave the towns and cities, thus creating a problem.”

He said it was time to work out a more structured programme, under which the junior but qualified specialists or advanced trainee specialists could take turns to provide services at district hospitals.
“Perhaps we can work out a rotational posting of a few months to two years,” he said.

Dr Quek was responding to a recent statement by Health Minister Datuk Seri Liow Tiong Lai that the Government was hiring qualified foreign specialists on a contractual basis to provide improved access to medical services in district hospitals and help reduce congestion in general hospitals.

The ministry would work directly with the governments of Egypt, India, Pakistan and Sri Lanka to bring quality specialists in six disciplines – internal medicine, paediatric, surgery, obstetrics and gynaecology, orthopaedic and anaesthesia.

Dr Quek said it was a genuine concern that some of these foreign doctors might lack commitment or medical professionalism.

“Foreign doctors working in a different environment from their own country may have cultural differences, which sometimes cause patient-doctor miscommunication and misunderstanding,” he said.

Dr Quek said although there were perks in place for young doctors to serve in remote areas, the Government should also give them the guarantee to return to urban choice hospitals for post-graduate training as well as better hardship allowances and tax breaks.

He added that working in district hospitals could provide good experience for young specialists and help reduce the need for patients to be always referred to the tertiary hospitals.

“We urge all young doctors to consider their career paths and serve the public dutifully.”

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The Full Email Interview with The Star Reporter:

1) If it is compulsory for all specialists with the government to serve at the rural areas, does is that mean that the shortage of such experts at rural areas can be overcome and the government do no have to import foreign specialists to be placed at rural areas?

At this point in time, the govt and the MOH only makes it compulsory to serve the govt for 2 years after the 2-year housemanship training--a total of 4years.

At the current time, once completed the housemanship training, the newly minted Medical Officers (MOs) can be deployed anywhere in the country on the basis of need, which is why many of these more junior doctors are posted to more remote and rural areas, or smaller district hospitals.

But, many of these facilities remain understaffed by MOs, that is why Medical Assistants (also called assistant medical officers, but not really trained doctors) have been utilised for these functions. Ideally all such posts should be filled by trained doctors, with the MAs helping to look after more mundane and manual aspects of medical care under supervision.

When it comes to specialists, unfortunately these are really not usually posted to these remoter or rural areas, because there is shortage even in the urban tertiary specialist hospitals. So for a long time, few if any are sent anywhere to the district hospitals. Usually senior medical officers/registrars or trainee specialists are sent to perform some simpler surgeries in some of these district hospitals, so that fewer need to be referred to the city hospitals.

For example when I was in my earlier MO days in JB, I was posted on weekly rotation basis to Kluang District hospital to look after some Obstetric and Gynecology clinics and surgeries, where I had the opportunity to perform Caesarian sections, more complex deliveries, and some other surgeries like miscarriages, etc. after my consultant in JB Hospital certified that I was capable of performing these safely. Of course we do have to make important judgement calls to refer more difficult and complex cases to Hospital JB. this is always based on the patient safety factor, if we feel incompetent or outside our purview of skill or training, then we should refer upwards for more specialised care, i.e. to tertiary city hospitals.

These days however, the expectations are higher from the public, and most of these are performed by qualified specialists where possible, rether than just registrars, but there is a clear need for distributing more specialised care to the district levels to ease the congestion in tertiary city hospitals.

Most of the district hospitals have been upgraded recently and can certainly perform more complex medical or surgical procedures, if there are enough manpower to do this. Hence the need to import some of these specialists from abroad to fill this need. But this is a stop-gap measure and not the optimum approach.

Perhaps it is time to work out a more structured programme where junior but qualified specialists or advanced trainee specialists can take turns to consistently provide such services at these district hospitals--as this will count as very valuable hands-on experience or even skills development for advancement in their careers or for promotion prospects of these doctors.

 

2) Are the government hospitals in the cities and the bigger towns have more than enough specialists?

Unfortunately even these are often insufficient because of the huge demand for such specialised care. We do suffer from a shortage of specialists in many disciplines still, including special surgeries e.g. neurosurgery, cardiothoracic surgery, some special orthopedic surgery,  paediatric surgery, cancer specialists, anaesthetists, etc.

Many of these are actually available in most of the city private hospitals, which create this sad dichotomy of private vs. public access to such special care. Sometimes many very highly skilled specialists are rehired on an ad hoc basis to help out the public hospital shortages, neurosurgeons are often the ones who have contributed.

We must find better incentives and remuneration packages to help retain such specialists in the public sector, and perhaps also ensure that good senior specialists are not retired too early--55 is too young for many. Although the perks offered by the MOH is much much better these days, they still lag behind what can be reimbursed in the private sector--sometimes it is the internal bureaucratic bickering and unpleasant working conditions which cause many senior doctors to leave.

 

3) You also mentioned that young specialists are reluctant to serve in rural areas. Why? Because of family commitment or other reasons?

In general, most young specialists or for that matter, most doctors prefer urban living. For many they are reluctant to leave for more difficult postings in the remote or rural areas, sometimes because of the posting being too far from their loved ones and families, but this is now no longer a sufficient excuse.

The MMA feels that younger doctors must do their part to contribute their share of national social duty to participate in all healthcare areas of need. Of course we will fight very hard of these postings to be offered with greater guarantees of timely return (6 months, 1 to 2 years maximum) to postings of their choice, with no lost of seniority or promotion prospects, if anything, these should be extra points in favour of preferential treatment by the MOH. But, all doctors must be prepared to serve anywhere in such needed services, (which can be computerised for fairer distribution allocation), but with strict career plan structures attached, with perks, hardship allowances, additional points for promotion/special training preference, etc.

 

4) Why it is important for the young doctors/specialists to serve in rural areas? What kind of experience that they can gain when serving in rural areas? How it will benefit them?

In many instances, the more rural/remote areas provide a greater number and variety of possible hands-on experiences for the younger doctors. In large city hospitals with many doctors all vying for training and experience, this can be sometimes short and inadequate. Also, in smaller hospitals, it is possible for younger doctors under training or in the earlier part of their specialist career, to be given more time and opportunity to learn by reading more, accessing the internet more consistently and honing their skills, and clinical acumen.

The more experience one gets as a doctor the better one becomes, especailly when these are well-studied and carefully though about. The more procedures or surgeries that one perform well, the better the skills too. Perhaps, the MOH can come up with greater structured programmes which can enhance such experiences and training. Periodic oversight and supervision is of course very important to enable these younger specialists or trainees to interact and learn from their senior mentors.

 

5) In you opinion, specialists should serve at least for how many year in the rural areas.

For many, this is a loaded question, but for the purposes of national service and duty,perhaps we can work out a rotational postings of perhaps a few months to perhaps 1-2 years maximum. We know that some specialists have actually opted to remain in these areas, after accepting such posts. So not every one finds such deployment too objectionable as to wish to leave as soon as possible.

My China Press interview is below:

 

Malaysia has been having contract doctors working in the country for many years now. Some are specialists while other are medical officers who have served in remote unpopular sectors. The contract is usually for 2 to 5 years, renewable, depending on the quality and assessment of the service provided by individual foreign doctors.

 

In the past many were of mediocre standards and most were not renewed, unless they provide critical services in very remote sites such as in interiors of Sabah and Sarawak.

 Currently in MOH upgraded hospitals there appears to be shortage of specialists designated to provide some secndary care. So this is the rationale for the contract doctors specialists. Ideally our own trained doctors should be deployed to these hospital, but may younger specialists do not want to leave the major towns and cities, which create such a problem.

 Perhaps the MOH need to be more forceful in this implementation so that these specialists can play their public duty and responsibilities. Nowadays the perks and incentives for young specialists are quite good, although not nearly as good as in the private sector, but the private sector is getting saturated too!

 

Working in thes district hospitals can provide good experience training for younger specialists too and help reduce the need for patients to be always referred to the largest tertiary hospitals for more difficult operations, so the MMA supports this.

This is genuine concern that some of these foreign doctors may lack commitment or medical professionalism. Having foreign doctors working in a different environment from their own country may have cultural differences which sometimes cause patient-doctor miscommunication and misunderstanding.

 

MMA is most concerned with quality issues and patient safety and there must be better mechanisms to check and evaluate the service quality of such contracted specialists. We do not want our rakyat to suffer from poor quality service of medical or surgical care, which can cause harm or even unnecessary complications or death.

If local specialists are willing to work in these areas of need, we are convinced that their career goals and paths will be much enhanced. Service in more remote or hardship areas are always as looked upon as a qualitfying point for faster promotion and perhaps better incentives. Persuading our local doctors to serve anywhere in Malaysia is a challenge.

In the near future, with so many medical graduates coming into service, there will likely be a glut of medical officers who would have to fight very hard for limited training posts for specialist training. By then we are more likely to produce more locally trained specialists if the training structure and programs are enhanced now. The MOH should look into this aspect of more structured careers paths for all medical officers, so that the doctor an know how his final goal and position can be, rather than muddle along, as simply extra pairs of working hands!

We are not sure which disciplines are truly lacking, but the distribution of doctors in the country can be made even better with greater planning and also greater determrination so that doctors cannot simply say no, when they are posted to less attractive areas. Our perks are already in place, but guarantees to return to urban choice hospitals for postgraduate training would help, as are better incentive hardship allowances and tax breaks.

 The MMA urges all younger doctors to seriously consider their career paths and serve dutifully for the rakyat as well as work very hard to gain as much experience and skills as possible to become excellent doctors specialists and also become competent professionals to serve the country and rakyat.

Dr David Quek
President, MMA

malaysiakini: Good doctors are good communicators... by Dr S

Good doctors are good communicators

Dr S
malaysiakini, Sep 14, 10
4:52pm

 

I am writing to 'AM" in response to his/her letter Taiping Hospital snuffed out my father's life. 

Firstly my condolences to you and your family on the loss of your father. I have taken some hours to write this reply to hopefully make you feel a little better by shedding some light on the reasons behind some of the actions by the doctors who treated your father. I would also like to shed some light on possibly what could have been improved on and hopefully relieve some of the negative sentiment towards Malaysian hospitals and doctors despite me not being affiliated to any of them.

My name is Dr S, a Malaysian, and I graduated and currently work in the UK for the National Health Service. I will pitch my letter for everyone including non-medics and try not to use very technical terms or to simplify any that I use. From the story you have related, and my experience working in General Medicine, Old Age Medicine, the Emergency Department, and other critical departments, I gather that your father suffered (in simple words) a large heart attack, and as a result had rapidly progressive heart failure.

Such an occurrence in a 94-year-old is almost always not remedial no matter what is done, especially if the bulk of his heart muscle tissue is no longer functioning due to the heart attack. If at all there was any possibility of active treatment of his heart attack, it would have been early thrombolysis (administration of medication to dissolve the clot that was causing his heart attack) with the hope that the heart muscles that were starved of oxygen were not totally dead, which happens pretty quickly. Thrombolysis is not always possible, as there strict criteria and many contraindications (things that would make him unsuitable for it).

Based on what the doctors at the Taiping hospital told your relatives at the emergency department (that he had a heart attack, and that his heart was weak) and the classical sequence of events on his condition, it seems to me that they conducted the relevant tests, did the relevant examination, and concluded that he had a heart attack and a resultant heart failure very early on. The diagnosis of an acute coronary syndrome is not inaccurate, as it is a broad umbrella of a number of conditions where the heart is/was starved off oxygen, which includes what your dad had - which is likely to have been a heart attack.

In someone who is 94, even if he was quite fit and able otherwise, if it was even a slightly delayed presentation with no chance of busting the clot (thrombolysis), CCU and ICU would not be the right thing to do. ICU in simple words would be for those who need full-time monitoring and treatment for an acute problem that is very likely to be remediable (not the case in your dad unfortunately), and CCU for those who need active constant cardiac monitoring due to the potential need of immediate cardiac intervention usually signaled by cardiac arrhythmias (irregular beating of the heart) or monitoring after recent intervention which could cause arrhythmias (like if your dad was thrombolysed).

Admitting him to a standard ward was thus the most appropriate place for your dad from a medical point of view, and if your dad had the same problem in the UK under the exact same circumstances (with the assumptions I have made) - it is exactly what would have happened. Inotropes is not something I would have given and was not going to be the appropriate treatment for him at any point in time unfortunately. I am guessing that the CCU and ICU option which you were very keen on may have been standard practice in the past when you were practicing hospital general medicine which I assume you no longer do.

Touching on his diet - I don't know what his swallowing ability was like on admission. If his swallowing was assessed and it was thought that it would be safe for him to have a solid diet - I see no contraindications for him to have enjoyed whatever food he wished for during his last days. If he had problems swallowing food safely, then a suitable diet would have needed to be considered further. A heart attack and/or a chest infection on its own or even in combination is not a contraindication for a normal diet.

I see many patients who are 94 or older, and in all cases, it is vital for doctors to make rational decisions on medical management which take into account not just the patients age, but also underlying diseases and pre-hospital quality of life (ie. self caring, self-feeding, self-cooking, mobility, etc). It seems to me that the doctor did tell your sister what your dad was suffering from and that your relatives needed to be informed, which was correct, but perhaps a more polite approach and further explanation on exactly what he had and why it was not reversible, why CCU and ICU was not an option, and why she had to tell your relatives sooner rather than later would have helped clarify things.

Communication is key - and it is something very, very strongly emphasized on in the UK health system and health education, and I think can be improved on significantly in Malaysia. I have had to tell patients relatives on many occasions that their father/mother/brother/sister/friend/son had days/hours to live, what exactly was wrong, what the management plan was, and why it was not curable, and it has always worked in keeping relatives calm, in the know, and making them feel part of the team looking after their loved ones.

A drip being absent in your fathers case is a good sign. If he had a drip with fluids running through, I assure you it would have accelerated his death and you may not have made it in time to see him alive. What could have possibly helped his breathing would be some diuretics to get rid of the excess fluid, however this would only prolong his life very marginally, as his kidneys would have likely been on the verge of not functioning at that point. Moving your father to any other ward during his final moments would not have brought your father back to how he was before he was ill - not even close to how he was.

We try very, very hard not to move elderly patients who are clearly at their final days or moments in life as it disorientates and distresses them and confuses all those looking after them creating room for errors, and does not change the final outcome in any way. An emergency trolley, CPR, and intubation again are out of the question, as it would not have changed the final outcome, and at best it would have given him many broken ribs only to die in pain and possibly choking. I am glad it was not attempted and would have been a serious error in judgment if it did.

The doctors could have however come to your aid sooner, but the aim would have been to explain things to you more clearly and ensure your dad was kept comfortable by means of palliative medication rather than to attempt any heroic measures. I take it that your dad was not very alert/responsive when the doctor arrived hence why they shone the light in his eyes - which is the correct thing to do. That the doctor denied your request for him to be intubated was neither pride nor ego but was likely to have been the correct medical decision, as it would have at the very best made things worse.

Touching on the issue on the time of death, it is acceptable for the doctor to record the time of death to be the time at which he pronounced him dead or the time at which another treating health professional saw him lifeless. Even if there was pretentious resuscitation by the doctor for 20 minutes, if the doctor felt that all this was only stopped at 20:17 and at that moment examined him to find no signs of life - it is correct for him to have recorded the time of death to be 20:17. To give you an example of an unrelated situation, if a nurse finds a patient lifeless at 6am, and calls the doctor to pronounce him dead, the time of death will be 6am even if the nurse thinks the patient had passed away at least five hours before being found.

The doctor can even chose to write down 06:30am if that's when he arrives to see the patient, and he is not confident that the nurse made adequate assessments at 6am to be absolutely sure that the patient was dead at 6am. This is not uncommon especially for deaths through the night when the exact time is often not known.

In your father's case, particularly when he was beginning to be breathless and distressed and was clearly near the end, what should have been initiated was a morphine, midazolam, and hyoscine continuous infusion just under the skin, with doses of each drug dependent on what exactly was the distressing issues. At one of the hospitals where I practiced, we used what is called the Liverpool Care Pathway which is a very good guidance and checklist on the management of patients at their final moments of life (which can be up to days or weeks even).

You could hopefully Google it, and I think it should be widely implemented in Malaysia if not already so. On the issue of a post-mortem, this I'm afraid I cannot comment much on as policies can vary greatly from place to place for different reasons.

Finally it is sad to see many respondents attacking the medical conduct of the doctors involved in this situation as well as attacking the practice of medicine in Malaysia, particularly the government hospitals. I will not make comparisons to the UK health system due to my current position and obligations, but I have to say that Malaysians should thank the government many times over for the standard of healthcare they receive. Some may ask why I am in the UK and have not returned to Malaysia - the reasons are personal, and is unrelated to the quality of Malaysian health care in any way.

I cannot find much fault in the medical care of your father in terms of which ward he was in, what he was allowed to eat, that he did not have a drip with fluids running, was not given inotropes, not intubated, not in CCU or ICU, and not actively resuscitated - which were all the right treatment measures. Again, I emphasize that communication is often key, and poor communication is often the cause of many misunderstandings and unhappiness, and can make a big difference in a patients management.

The most successful doctors and consultants I have come across have not been the smartest and most knowledgeable, but are often the best communicators, and I hope all doctors who are reading this, even if they ignore everything else in my response, just pay a little more attention to this aspect of their practice.

GP SUMMIT 2010: GPs AT THE CROSSROADS 14-15 August 2010

GP SUMMIT 2010

THEME: GPs AT THE CROSSROADS

14-15 August 2010, One World Hotel, 1Utama, PJ

Over the past several months, the Primary Care Providers’ Coalition (PCPC involving MMA, AFPM, PCDOM, Qualitas, KDM, & Society of FMS) has met several times to discuss the mounting challenges afflicting the GPs, which have arisen in the recent past few years. A GP Summit was felt to be timely and necessary to help focus our attention as to the realities of these challenges and problems.

The PCPC felt that this GP Summit should come together to help evolve a robust yet nimble but cost-effective primary care-led healthcare system. This Summit should provide the initial impetus to establish a strong network or coalition of GPs who can provide the highest standards of General Practice, within a restructured healthcare system. We must come together collectively and represent ourselves with one voice rather than to become divided and self-serving. We must establish strong lobbying power to help protect our profession and our position from unreasonable challenges and top-down regulatory oversight which are unfair or which are too micromanaging or potentially discriminating.

We have planned a programme with the objective of getting as many like-minded primary care doctors as possible to come together to share their thoughts and viewpoints as to what these problems are, how we perceive these changes or challenges and how these can impact on our livelihood and future. Perhaps we need to come together to redefine what constitutes a GP for the future. We must reiterate our strengths and contributions, our worth, rather than to be saddled with perceived weaknesses that have been dumped against us. But we must be prepared to change for the better, for higher quality primary care practices.

The ultimate goal is to arrive at some form of a consensus statement or document, which we can then present to the government, to convey our frustration, our viewpoints and some possible solutions, even suggest some possible alternate plans for restructuring.

Among the more worrisome challenges are:

1.     The impact of the implementation of the private healthcare facilities and services act and the continuing effects on GP practice;

2.     The possible implementation of newer regulations and Acts which can impact on our practice, e.g. Medical Act 2010, Medical Devices Act?

3.     Changing position of the MOH on the future of Private Primary Care Practice; 1Care for 1Malaysia Health reform, single payer system (NHFS).

We also need to comprehensively review of the current and future challenges of the GP's.

By looking at cross border experiences, we can review alternative approaches, which encourage greater physician buy-in of the reform plans. We need to explore the possible contributory roles of government agencies (MOH, EPU, MOF etc.) to extend financial assistance in the form of outright start-up or matching grants, tax relief or incentives or exemptions, and see how these can support efforts to raise the standards of care delivered in the private sector. Simply mandating changes, regulations or threats would not help to create a collaborative atmosphere of cooperation or synergy.

We also need to get the authorities to clearly define the role of MOH in the private sector, more specifically in the sector of Primary Care. How would the proposed integration of primary care services be implemented? Would the government’s public sector amenities be corporatised or privatised to an outside agency with the MOH reducing its role to that of regulatory function? Would public sector amenities be given priority in the distribution of patients, at the expense of GPs. Would GPs be marginalized?

We also need to send a very clear and strong message to the government concerning the problems the private GP's are in and what needs to be done. Let’s all rally together and unite for a common good!

Supported by a generous unrestricted educational grant from Sanofi-Aventis (Winthrop)

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GP Summit 2010: Programme

Saturday, August 14, 2010

7.30 – 8.30 am:                                    Arrivals & Registration

8.30 – 9.00 am:

P1 – Overview (Dr David KL Quek, MMA)

Why are we here? What’s expected of this first GP Summit? Where do we see our future as medical practitioners in Malaysia? Should we agree to the proposed integration of the primary care service? Does the government via its various agencies need to incentivise the GPs to enhance our services? Roles of EPU, MOF, MOH, matching grants or tax incentives, breaks for EHR (H/CIS); Quality enhancement programs; structural or allied health improvement programs; seamless CPD programs; Objective of Summit: Develop a consensus blueprint document to present to the MOH and Minister

9.00 – 9.30 am

P2 - GPs: Past, Present and Future (Dato’ Dr Noorul Ameen)

Scanning the Scenario for GPs—past to future of primary care providers; Shrinking income, Diminishing pie, growing intense competition, Realities vis-à-vis current challenges; Regulations, Funding, Training, Patient Safety, Quality issues; Public Private Integration, likely scenarios, uncertain future

9.30 – 10.00 am

P3 - Whither the GP? MOH’s Perspective (Dr Safura)

Role of GPs in the 1Care for 1Malaysia Health restructuring; Integration of GPs into Public Sector Primary care—how, who, when? What are the roles of Family Medicine Specialists, Members of Academy of Family Physician diploma?  Are they to be de facto in charge, controlling other GPs? If this is selective and not inclusive, why should the public contribute to an untried system, which reduces choice, and may not ensure fairness and equity? Would all GPs be required to become a FMS? Isn’t this potentially increasing healthcare costs? If so why should GPs buy into such a system? What goals and objectives have not yet been achieved, since GPs now look after about 60% of all primary care patients in the country? Are there indicators, which have shown inferiority of our current system compared with other countries’? Credentialing—another layer of bureaucracy? MSQH? Who pays who? How much? Co-payment for prescriptions, for ‘special care’, chronic disease management?

10.00 – 10.30 am:            

P4 – Comparative GP systems – US, Australia, Singapore (Dr IS Ludher, AFPM)

A review of what’s happening around good established GP practices in the region. Credentialing, CPD/CME programmes, HIS/EHR systems, scopes of practice, reimbursement mechanisms, GP fees and remuneration

10.30– 10.50 am:                     MORNING TEA BREAK

10.50 am – 12.20 pm: 

P5 - Whither the GP? Perspectives from GPs

Views, practical and reality bites from representative GPs from Sabah, Sarawak, Kedah, Johor, Kuala Terengganu, KlangValley

12.20 – 1.00 pm:                        LUNCH

1.00 – 6.00 pm:       SANOFI-AVENTIS-WINTHROP MEDICAL SYMPOSIUM

1:00 – 1:30 pm:             Keynote Address (Dr David Quek)

1:30 – 2:00 pm:             Managing Allergic Rhinitis in a Primary Care Setting (Dr Ong Chun Chiang)

2:00 – 2:30 pm:            What they don’t teach you in Medical School  GI Fellowship – The Role of Diet in Gut Dysfunction (Dr Yin Thing Phee)

2:30 – 3:00 pm:             What’s your legal standing in Malaysia today? (Dr Milton Lum)

3:00 – 3:30 pm:            Q&A

3:30 – 4:00 pm:             Tea Break

4:00 – 4:30 pm:            Men’s Health: Sexually Active Men with LUTS – Is there hope? (Prof George Lee Eng Geap)

4:30 – 5:00 pm:             Metabolic Issues in the Primary Setting (Dr Alex Tan)

5:00 – 5:30 pm:             Non-alcoholic Fatty Liver Disease (NAFLD) – What physicians should know (Dr Ong Tze Zen)

5:30 – 6:00 pm:            Q&A            

6.30 – 10.00 pm            Prayers, Breaking of Fast Dinner (Courtesy sanofi-aventis)

Sunday, August 15, 2010

8.30 – 9.00 am:                 

P6 – Quality & Patient Safety Issues in GP/FP (Dato’ Dr M Thuraiappah, AFPM)

Quality In Practice, AFPM diploma, Family medicine specialist diplomas, CPD programmes

How can the GP improve further, evolution of smart clinics, chronic disease management, clinic clusters

9.00 – 10.15 am: Breakout Session 1 Workshops: Groups of 30-50 GPs

WS1: Scope of Practice (Value-added services/income streams/gatekeepers?)

Dr Inderjit Singh Ludher & Dr Ravi Naidu

WS2: Reimbursement & Fees (including Capitation vs Fee-for-service, grants for upgrading of services)

Dato’ Dr Noorul Ameen & Dr S R Manalan

WS3: Training & Quality (QIP, Accreditation, Credentialing, CPD/CME)

Dato’ Dr M Thuraiappah & Dr Noor Azizah Tahir

10.15 – 10.45 am:                                    Morning TEA BREAK

10.45 – 12.00 pm: Breakout Session 2 Workshops: Groups of 30-50 GPs

WS4: How do we move forward? (How do we as GPs improve ourselves & our livelihoods?)

Dr Sudhananthan

WS5: National Health Policy (Integration, Restructuring & Change, are we ready, agreeable?)

Dr David Quek

WS6: Health Information Systems (Electronic Health Records (EHR) & Information technology enhancements in GP practice; Common platform for National HIS framework?)

Dr Molly Cheah & Dr P Vythilingam

12.00 -1.00 pm

Report of Workshops, Summary, Plan of Action, GP Summit Consensus Declaration, Dispersal

1.00 – 2.00 pm                                    FAREWELL LUNCH

Private or public wings are but a fallacy... by JT

Private or public wings are but a fallacy

Letter by JT, in Lim Kit Siang's blog

It appears that yet again, CAP’s SM Idris has decided to go on a frolic of his own. This time by stating that Private Wings in Government Hospitals are the wrong things to do. Sometimes one really have to suspect if this guy truly knows what he is talking about or goes about criticizing everything and anything sundry just to occupy his time. There are only three components to a hospital bill: 1) Doctor’s fees 2) Hospital charges (Bed, Nursing, Utilities, Investigations, etc) and 3) Consumables (Medicines, gloves, catheters, stents, etc).

This government has been benevolent enough in providing and perhaps in the case of Sabah trying to provide, items 2 and 3 but cannot match up to 1. Idris wants equitable healthcare for everyone. When he says equitable what does he mean? If he means placing a few GTN tablets under the tongue for a heart attack, or placing a plaster of Paris cast for a broken tibia, or delivering the 3rd child in a mother with no co-morbidities, or putting up a drip for a dehydrated patient or placing a few stitches on a wound caused by the neighbor’s dog, that’s fine. This government would have no problems accommodating them.

But if he is talking about plating/nailing every fracture of a victim of a high speed polytraumatized patient, reconstructing all the facial bones in an accident victim, or doing a bypass for a coronary patient with recurrent pain or ballooning and placing an emergency stent in a patient with a heart attack or doing a liver transplant in a patient with liver cirrhosis, then Idris must surely know that even all of Malaysia’s GDP and PETRONAS’s reserves will not be able to cure this country’s health woes. The US belatedly learned that medical technology and its ensuing advanced care can indeed bankrupt the nation causing Obama to desperately apply the brakes on its run away healthcare program that is highly sophisticated but yet cannot provide for almost 40 million Americans.

The reason why the government cannot match up to No. 1 is simple. To train specialists and retain experienced ones is not a simple issue. There are only so many who can operate on the brain or heart safely, a few who can carry out liver transplants with little mortality and even fewer who are interested in doing and following up bone-marrow transplants or manage and handle complex equipment to save critically ill neonates. Yes, these specialists can choose to go to the private sector or emigrate to the Western world but many would prefer to serve. But the service conditions and pay, really, for lack of a better term “suck” – especially the service terms.

Attending umpteen mindless meetings with no endings, going for compulsory ceramahs and believe it or not, even assembling in the sun to witness flag raising ceremonies just after clocking in and putting up with lunatic, disinterested head of departments interested only in conferencing and resorting wears your patience – precious time that could be well spent managing and treating patients. Idris and CAP should look closely into the poor management styles of our government hospitals wherein all our healthcare problems actually lie.

Our Government hospitals are akin to state hospitals in the UK that Aneurin Bevan, Britain’s NHS architect, once had to put up with after World War 2 before Margaret Thatcher straightened out their managements in the 1980s by converting them to Trusts. Even though Bevan had famously won over doctors “by stuffing their mouths with gold”, rampant mismanagement and poor accountability in hospitals continued till the time Thatcher stepped in. The fault of mismanaging our health resources lies not with the Prime Minister. It does not lie with Parliament, the Cabinet, the Public Services Department nor the Public Services Commission, but entirely with the Ministry of Health or elements within it. Failure to correct these faults is causing healthcare delivery in Malaysia dear.

Tell me Idris, why do we need a “Director-General” of Health. Are we still in wartime? Hospitals must be professionally managed by CEO’s with a strong founding in hospital administration, law and human resource. Ask any hospital group worth its salt out in the private sector, be it Pantai, KPJ, Parkway or Fortis what they look for in a capable Hospital CEO. You can also take it from me that none of these fellas will employ an ex-Kementerian Kesihatan Pengarah to run their hospitals simply because you must be well-versed with customer requirements, billing, accounts, auditing, purchasing, cash-flows, budgets, maintenance, training and dealing with specialists and staff. Can you name even one Government Hospital here in Malaysia that is run by such a CEO? If you don’t manage an outfit professionally, this healthcare nightmare you and your organization keep harping about is never going to end.

The Institute Jantung Negara (IJN) is run by a pro and they do function efficiently. However there is no one in accounting at the Ministry of Finance (MOF) to whom the hospital belongs to, who have the ability to check the IJN’s double and sometimes quadruple billing. The MOF has learnt the hard way what a health monopoly can do to your budget. Irate MOF officials suggested that IJN’s management be hived off to Sime Darby’’s health arm who are tough on accounting so that the leakages can be plugged and the savings be used to help even more patients. But an ignorant public only saw IJN as a government hospital and Sime Darby as an evil money machine.

Similarly, do you really think all these massive hospital infrastructure and expensive medical equipment are properly researched before being requisitioned? The answer is of course an emphatic NO! Due to both political and corrupt leakages, precious money meant for treatment is hived off. The Public vs Private divide is but a fallacy. There never was nor is there such a divide. The only distinction one has to make is the level and quality of healthcare delivery and who has to pay for it. Make the service efficient and get the government to pay for it. It works pretty well in the UK. There is no Einstein involved in this at all.

And how do we do that? The best way to avoid a Full Paying Patients’ program (FPP) is to make certain our hospitals are professionally run. There are only three hospitals in this country that are not run by the MOH (excluding the Armed Forces Hospitals and the Orang Asli Hospital). They are the University Malaya Medical Center (UMMC), HUKM (Hospital University Kebangsaan Malaysia) and HUSM (Hospital University Sains Malaysia). All of them have private wings. The private wings at both UMMC and HUKM are doing much better then HUSM. But private wings only form a portion of the income these hospitals survive on. Other sources of income include rentals to food and sundry outlets, income from parking fees, from pharmaceuticals, research grants and from the various courses and conferences conducted by the lecturers.

It’s true that there is subtle soliciting by some specialists; it’s true that some of these specialists are posting their cases even earlier then they should and it is also true that they delegate some of the work at the public wing to their Registrars. It’s further true that even top doctors applying to be lecturers are sometimes blatantly prevented from joining the University for fear their capabilities would “cut” into their private income, to the detriment of patient care as a whole for the University. But a sharp CEO can put a stop to all this easily. Private hospital CEO’s manage these sought of problems on a daily basis. But the system has undoubtedly worked for these universities. You see, unlike the bottomless pit of unaccounted money that government hospitals are usually lavished with, all these hospitals under the Ministry of Education now have to look for additional sources of income to keep their operations afloat. And this process is teaching them to be efficient.

Key to their goals are the retention of their top doctors by incentivising them so that they still remain to provide at least the input and expertise in teaching both undergraduates and postgraduates in addition to providing good patient care. The nursing standards in the UMMC in particular are excellent and with all the paramedical support available at this hospital, patients who make it to this hospital are indeed a privileged lot. The care provided in this particular hospital has got a lot to do with the design of the hospital itself and the training programs laid down by its pioneering founders.

But the specialists are a different matter altogether. Their numbers are limited and their expertise even more scarce, which means an astute CEO, must know how to utilize their abilities to the maximum for the benefit of as many patients as possible. Contrast this with the specialists at the MOH who keep getting transferred every now and then. How in heavens is this going to benefit long term patient care and follow-up? Further, private wings were built at these University hospitals to not only retain the current specialists but in the hope that even private, experienced specialists will bring in their expertise to collectively benefit patients in exchange for help in teaching. But this remains largely an unfulfilled pipe dream.

Everyone forgets that almost half the country’s most senior and experienced specialists available in the private sector take on only not so ill patients because they cannot match the infrastructure required and available in Government Hospitals for such patients. At the same time, these same experienced specialists are not available to the very ill patients being managed by less experienced specialists in government hospitals. How do we tap their expertise and amalgamate them into the government healthcare system so that all Malaysians benefit?

Private wings in University Hospitals have remained largely the personal domain of University Specialists, defeating one of the key aims of the hospital’s investment effectively reducing both income and the incorporation of external expertise into the University. A tough CEO would have put this right. Similarly if Private Wings in government hospitals are going to be for the exclusive use of only government doctors, then expect another hijacking of the facility by government doctors with no external doctors using the facility. Again it will be a monopoly and with monopoly will come all the other unsavory practices associated with it.

Thus far the MOH has been hoodwinking this government and public by throwing this Public vs Private divide. All invitations to “help out” are insincere or come with strings attached such as “You must be MMC registered…. and 10 other conditions in fine print”. The challenge in fact is to not only get these specialists to lend their expertise for instance through private wings but also to open the door to even foreign specialists in the areas of expertise this country lacks in. This way Malaysians get the best care as both infrastructure and the expertise becomes available. Our Sultans need not go to Singapore for treatment nor our kids to India for surgery.

The reality of the manpower situation is, this country is extremely short of qualified, experienced technical staff. It’s high time the government takes the role of computing costs diligently including the various fees for doctors and other medical professionals now widely published in various government and insurance schedules.

Every Malaysian patient must have the availability of the best medical care this country can offer. And every Malaysian patient need not pay a cent. You only need to properly manage the system. Surely we don’t need to call in Margaret Thatcher to help us do that. For intelligent accountants, like PETRONAS ex-CEO, Hassan Merican, matching the infrastructure to manpower would be a cinch. Surely there are many more accountants of Hassan Merican’s caliber that can lead the Health Ministry in providing efficient services.

The Academy of Medicine and the various colleges incorporated in it including the MMA and its subcommittees have tried in vain to match and incorporate the entry of this country’s experienced and senior consultants in the private sector to the sometimes excellent medical infrastructure the government has invested in but invariably failed.

Perhaps the CAP or other similar organizations can do what thus far the Academy of Medicine and MMA have failed to accomplish. Keeping the public and private divide wide apart is detrimental to the healthcare delivery in this country. Equitable access to quality healthcare care paid for by the government is what CAP and other NGOs should target for. And this can only be achieved by aggressive integration of both the public and private sectors with the government footing the budget.

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My Comments (DQ):

The above perspective while arguably passionate about what has gone wrong with our health care system, does not really provide concrete answers or models with which to offer our Malaysian public. 

The arguments put forth contain many errors as well as misconceptions about our health care system. It appears that the author's perspective is full of biases with sketchy patchy understanding of what's really happening out there. It is easy to skim on the surface of health care issues and slant it one way or the other to back up one's viewpoints. 

However, the overall slant is towards greater extension of the private sector to keep highly qualified expert doctors happy, but which should be open to competition, and not limited to public service doctors. This is a flawed and simplistic take on how to retain  doctors in service, as well as trying to rationalise greater market-driven system of heatlhcare.

Yet there is little perspective about the rising costs of unfettered health care and how we can rein this in. It appears that the author feels and assumes that the bulk of our health care cost must be borne by the government, yet earlier in the debate, he or she acknowledges that no one nation can afford all these modern therapies. How should we find the money, if our public is so disdained at contributing or paying more. We still do not have a dedicated social contribution fund or tax to cater exclusively for health care.

So other than some possibly genuine concerns and brickbats about why some of the models we have adopted so far, may be wrongly applied, I truly cannot find any worthwhile or pragmatic solution(s) in this article, which can meaningfully help reform our health care system... At best this is a distorted cry for a better system, but unfortunately the polemic is superficial, fractured and incoherent.

The Star: DGH Ismail Merican: Ensuring access to healthcare

Ensuring access to healthcare
At Your Service by TAN SRI DR ISMAIL MERICAN
The Star, Saturday March 20, 2010

In responding to ‘Serving 1Malaysia’, especially towards ensuring equitable healthcare, the ministry has boldly moved towards initiating a major reform of the delivery of healthcare

The saying “health is wealth” holds true in every sense. Indeed, being the director-general of health, it is my responsibility to set the direction and course for the entire health system.

Having been both a healthcare professional and administrator, it has always been my priority to ensure equity (in health) by eliminating disparities in its provision. Our goal is for every individual to get the highest quality of care possible. Prudent investments in health are vital for national growth, human development and poverty reduction. The importance of a healthy population cannot be more strongly emphasised. It will improve the quality of life and increase productivity.

Equity in health implies that everyone should have a fair opportunity to attain his or her full health potential and that no one should be deprived of care when it is needed. In 2007, the London School of Economics reported that Malaysia’s public health sector has been relatively successful in providing equitable healthcare. To a large extent, access to healthcare is dependent on how healthcare is organised.

Historically, after Malaysia gained independence in 1957, the system was largely funded by the government. Patients only had to pay a nominal sum for access to outpatient and hospital admissions. In the 1980s, the service transformed from a system that depended heavily on the government to a dichotomous parallel system – the other player being the sizable and thriving private sector, for whom the Government has given strong encouragement for growth.

The private sector is, in fact, playing an ever-increasing role in the provision of healthcare for the country. However, as in most countries, the private sector, responding to market forces, has been concentrating its facilities in the more economically-developed regions. This contributes little to equity and social justice as such services mainly cater for patients who are able to afford them.

Nevertheless, the country’s health system has continued to perform relatively well over the years, despite the expanding dichotomy. The World Bank World Development Report published in 1993 stated that Malaysia was one of the countries where public health spending was biased towards the poor.

Truly, the government health services have benefited all. There is a strong consensus that subsidised public healthcare, if it continues to be properly tailored and targeted, can further the goal of promoting equity. Nevertheless, inequalities exist for many reasons such as distance, socio-demography, cost and transport problems. Therein lies the future challenges for our health system.

Based on current economic circumstances, the government is concerned about its ability to continue sustaining such levels of expenditure towards ensuring fairness in financing and the continued protection of the general population, and more so, the disadvantaged and vulnerable groups.

Demographic and epidemiological changes continue to alter demand for new healthcare services, whilst increasing affluence heightens expectations for care of even better quality. It is the primary objective of the government to have an efficient system that maximises well-being at the lowest cost to society.

The Health Ministry is in the process of examining reform options to ensure healthcare remains accessible, affordable and relevant. The role of the ministry must shift towards a stronger stewardship function – focusing on policy-making and enforcing regulations across both the public and private health sectors to ensure continued targets of equity, affordability and appropriateness of care are met.

In addition, the ministry will continue to set and monitor standards to ensure suitable quality of care. The fundamental step towards achieving better equity will be to strive for maintaining and enhancing universal access to healthcare. Although the concept of universal access has been well entrenched over the years, more needs to be done. This can be pursued by introducing a more structured and integrated health system, with greater participation of the private sector, underpinned by a comprehensive governance framework.

The plan for a big and bold transformation of the healthcare sector seeks to integrate both the public and private sectors, initially, in the provision of primary healthcare (PHC) services. This is a logical step since the majority of patient contacts occur at this level. If we are serious in our philosophy to provide healthcare based on the principles of needs, solidarity and equity, and in a cost-effective manner, it is prudent to pool resources. This is very much in line with the call of the Prime Minister towards serving 1Malaysia aspiration.

Focusing on PHC has received very strong support from the World Health Organisation. The latter calls for all member states to strengthen this strategy, as PHC can provide a stronger sense of direction and unity in the current context of fragmented health systems.

Specifically for Malaysia, strengthening the capacity and capability of the primary care physician and the multi-disciplinary team of allied health personnel will go a long way towards undertaking a “gatekeeper’s role”.

The overall effects of such a move on health are positive. Over-reliance on specialists and hospitalisation can be reduced by filtering out unnecessary uptake. As a result, the costs of hospital care can be reduced, the duration of hospitalisation shortened and the quality of post-hospitalisation follow-up improved.

The issue of equity is challenging but not insurmountable. Pressures are building for health reforms but these need to be managed in line with the development of a comprehensive strategy, tailor-made for the country.

In responding to “Serving 1Malaysia”, especially towards ensuring equitable healthcare, the ministry has boldly moved towards initiating a major reform of the delivery of healthcare. In this transformation, the ministry will develop and foster a system which is wide-ranging, in terms of scope and delivery, yet equitable, affordable, effective and efficient.

By laying a stronger foundation, involving greater collaboration with the private sector, the ministry will be able to pool scarce skilled resources and share high-tech equipment towards ensuring greater fairness in patient services. Given the right environment and political support, adhering to the principles of solidarity and social responsibility, and embracing the ethos “Rakyat didahulukan, Pencapaian diutamakan” will enable Malaysia to provide equitable and quality health services for all.

Tan Sri Dr Ismail Merican is the Health Director-General

A (H1N1) Influenza Pandemic Response & the Malaysian Medical Association

1. How is MMA helping in this pandemic? Some doctors and the public have lamented that it does not appear to have done enough…

The MMA is a professional body, which represents the largest number of doctors in the country, but we are also responsible toward any health crisis or threat to the country and our citizens.

Right from the outset, the MMA has been invited as an important dialogue partner in the National Influenza Pandemic Task Force, the Inter-Ministerial Influenza Pandemic Committee, and even the National Emergency Council pertaining to this A(H1N1) influenza crisis. In fact, our participation started even before this, while the MOH was planning for the much-feared but still remote H5N1 bird flu possible pandemic, a few years ago.

Our views and input have been welcomed by health ministry officials, as we grapple with a clearly novel and previously unknown health threat. Clearly we are participating in every possible way to lend our expertise and strength of diverse knowledge to this national crisis.

When a country and its population are hit by a pandemic disease, in this case A (H1N1), everyone has to work together as a team and not individually to combat the disease. The main ‘leader’ is of course the Ministry of Health but the rest of us have to join forces with them to come up with a contingency plan.

It is becoming increasingly clear that this is no easy task, and translating policies down to proper and appropriate practical responses and ground-level implementation can be challenging, and would be less than clockwork precision.

The MMA cannot work alone on this. We do not have the regulatory clout nor the logistical machinery to enforce decisions, which have been formulated by the Ministry of Health, as our member doctors are distributed far and wide across differing terrains and locales.

However, we have been disseminating our information to all our doctor members the best way we can, so that collectively we can help ameliorate the more serious consequences of this pandemic. We are working closely with Association of Private Hospitals, the Academy of Family Physicians, and the Federation of Private Medical Practitioner Associations of Malaysia, to ensure that we are up to mark in offering alternative health care sites in the private sector to help treat this disease in as uniform a manner as possible, i.e. in private clinics and private hospitals, and have been doing this from the beginning.

Our private practitioner clinics are already working fulltime with the constraints of not being able to carry out confirmatory testing for the A(H1N1) flu, and also the very limited access to the antiviral drugs which were previously stockpiled by the MOH. It is only now, that we are able to purchase (still) in limited amounts the antiviral medicines for possible use in complicated H1N1 flu.

Many clinics in more remote areas are still finding great difficulties in getting supply of such in-demand specific medicines. Thus there is growing frustration and some sense of hopelessness and worry that we cannot act better and more promptly for our very ill patients.

We have already informed our members that they should be very prudent in using these drugs, because we do not wish to dish antiviral medicines out to just anyone who demand for it, and so encourage the wasteful and possible future development of resistant viral types.

GPs have also been giving out seasonal flu vaccines to those with higher risk of contracting the bug, although this does not necessarily help to protect against this new strain of A(H1N1). Higher risk patients may benefit from this prevention exercise.

Thus it is fair to say that the MOH and government cannot go solo in this, and private doctors have already been mobilized to help fight this disease. Logistic problems remain which undermines the best that doctors can do or respond most rapidly.

2. There is a perception that private doctors are not adequately engaged in the management of this A(H1N1) influenza pandemic. Are private doctors willing to pitch in if the situation gets out of control?

This is not true. Most of our doctors are actively engaged in looking after many flu-like illness patients, but find many constraints due to lack of access to specific treatment modalities. The lack of available and reliable testing and difficulty in confirming such illness as due to this A(H1N1) flu, compounds the situation, when many patients demand to know for sure. Doctors are thus left quite alone to firefight angry and worried patients with very few resources or reassurances or specific therapies.

Still, private doctors are already currently working very hard with the Ministry to curb this disease, so naturally they will do their part, under such unusual stresses. There has been good cooperation from all private doctors as far as the MMA is concerned. Clearly, there had been some confusion in the earlier phase of this outbreak, which was due to rapidly changing scenarios and policies. All of us are learning as we face this unprecedented disease on the run…

Some of our doctors and their clinic staff have even become infected by this flu, but thankfully so far we have not received any news of more serious consequences such as death. So private doctors are also exposed to this threat but continue to look after their patients, including very many people with flu-like illness.

Our private hospitals are already looking after some seriously ill patients, including some requiring intensive care or mechanical ventilation—so yes, we have been prepared and are aggressively managing this pandemic. We note that thus far, our flu patients have emerged well after their ordeal, at least those who have come to us in the main urban areas.

It is possible that smaller private medical centres may not be adequately staffed or equipped to handle more seriously ill respiratory failure patients, but this is also the similar situation in some smaller district hospitals of the public sector. Furthermore, some of these gravely ill patients would not survive despite the most aggressive treatment strategies, under any circumstances.

3. What are the current/potential problems doctors might be facing in combating the spread of the swine flu?

It would be good if every doctor keeps a constant and close tab on the H1N1 pandemic and remain fully aware of the developments and changes, which are evolving daily. Every doctor has to be learning on the trot, so to speak, to keep up with the progress of this outbreak and its management, so that we can serve our patients better.

Logging into the Internet regularly for more updated information will certainly help, instead of lamenting that not enough is being disseminated via the media thus far…. Every doctor has to be more proactive and practice more responsible and cautious medical professionalism during this trying period, which is expected to run into at least one to two years. Importantly, they must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for further more specialized care.

Easier access to antiviral drugs and their responsible use and monitoring would help allay public fears of delayed treatment, but this should be tampered with care and not with over-exuberance to dish out to one and all. There is genuine fear that the precious antiviral drug might be used indiscriminately, just for prevention – this would be a very bad move, which could inadvertently create a worse outcome of drug resistant bugs!

However, in the light of the very quick deterioration of some young patients who have died, it might be prudent to use antiviral treatment earlier and more aggressively.

We look forward to the specific H1N1 vaccine, when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front line, heart or lung patents and frequent travelers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types.

Health Insurances Agencies not willing to reimburse hospital care costs for Pandemic Flu

We are facing some problems with health insurance companies, however. This is especially the case in private hospitals, where many insurance companies are refusing to reimburse for the treatment because it appears that in the contract for medical insurance, pandemic illness is excluded. Thus we have lots of problems from ill patients having to find alternative sources of funding!

We strongly urge the insurers to be more magnanimous and empathetic and help out more under such crises. Corporate social responsibility should not be limited to only green or conservation issues—human lives and humane compassion should clearly be a greater mandate! It is good that Etiqa Health insurance has come forward to state publicly that the H1N1 flu is a reimbursable illness. We urge other health insurers to follow suit. Otherwise, our hands are tied somewhat in helping to deliver the best care possible.

4. Is the government’s current logistical capacity able to handle this outbreak or worse a second/third wave of the flu as predicted?

It is difficult to say at this time. Although we certainly hope that this second or third wave would not take place. It is almost a certainty that the community spread of the A(H1N1) flu in Malaysia would escalate, and more and more Malaysians will come down with this flu.

However, the MMA wishes to reiterate that most of these infections would be quite mild and require only symptomatic treatment, bed rest and close watch at home. Only a minority (perhaps 2-5%) may require hospital care or more. If these very severe complications occur in a staggered manner then, we can cope with the problem.

But if a huge unprecedented outbreak of very severe complications does take place, this can easily overwhelm the system. But contingency plans of converting general wards to intensive care capacities, or even field hospitals, have been made.

There are also more structured plans to increase the country’s intensive care bed capacity to at least twice the current number available now (which is around 300 beds only!) However, training sufficient staff and specialists to handle such expert care may require more time and expert guidance.

5. Have there been problems translating policy to ground-level implementation?

MMA’s concern is that although we have had some very detailed and stringent policies and directives in place, there may be logistical gaps in translating down these expected high levels or standards of care, horizontally.

We expect that there might be some variation in the care quality, appropriateness or speed of care delivery at more peripheral healthcare facilities, but this should be kept to a minimum when everyone has a chance to learn very fast and acquire the skills more quickly.

But because some flu patients appear to deteriorate so fast, we have to heighten our vigilance and react more urgently to try and save more lives. But even in most developed countries in the west, some people would continue to succumb to this illness (some 300,000 to 500,000 flu patients die yearly, especially during winter of seasonal flu, around the world).

How can we do this better? Very difficult. However, we urge everyone to be very alert and pay exceptional attention to this pandemic and its development. Doctors both from public and private healthcare sectors must be kept in the loop of information, continuous training and preparedness, so that they can deliver the medical care at the optimum level to help reduce complications and deaths.

6. Should all doctors advise their patients to self quarantine if they display symptoms?

Yes, this is the message that we have been advocating; it is best for all doctors to advise their patients to self-quarantine if they display flu-like symptoms. This is the first and basic step in curbing the spread of the disease.

Last week, I remember informing a young coughing patient who came to my heart clinic, that she should probably come back later when she was better, because her complaint was not serious, but she was incensed, and was upset when I told her to self-quarantine for at least one week. She flatly refused although I was willing to give her MC for the week. My concern is that my other heart patients might contract the ailment due to her less than prudent action, and then their conditions may compound to a higher risk for complications!

We have to encourage everyone to be more socially responsible. Wear a mask, don’t touch it too often, if you need to go out, or even to visit your doctor when you think you have possible flu-like illness. Wash your hands frequently or use hand sanitisers to reduce the contamination chances to others. Avoid shaking hands, perhaps practice the Japanese bow to acknowledge each other!

However, we should also not be too panicky. Be vigilant, be cautious, be socially responsible, and think of others too.

7. How are private doctors/clinics kept informed about how to deal with A(H1N1) patients? (Some clinics claim they don’t receive anything from the MOH, while others admit to receiving some guidelines. This is very inconsistent). Is MMA doing anything to ensure that all doctors get the same information?

We have sent out MOH bulletins through our website, but not directly to each clinic or medical practitioner. Logistically, sending paper bulletins on a nearly daily basis is too cumbersome and costly, and likely to be not very helpful as these become obsolete so quickly. Members have also received clearer more defined updates in our monthly MMA News (Berita MMA), but these are usually not timely enough.

We urge members and doctors to check with the internet for more up-to-date news and modifications in guidelines to managing this pandemic.

Thus, there are no standardized bulletins as mentioned above. However, on the part of the MMA, we have been posting circulars, guidelines, important notices, etc to our doctors via our website – www.mma.org.my. There is also the official MOH site for the H1N1 flu, http://www.h1n1.moh.gov.my.

We have also informed our members to log-in to my personal blogsite for updates: http://myhealth-matters.blogspot.com/ Some of our other members have also been writing articles on the disease in our monthly newsletter – Berita MMA.

Besides, there is extensive coverage in the electronic and print media about the disease and its evolving status, daily.

We urge everyone to be more proactive and impress upon himself or herself, to look into more relevant information by themselves in the world wide web.

This pandemic situation is so fluid that one has to be keeping pace actively to remain engaged and up-to-date.

8. Would the MMA describe the current A(H1N1) Pandemic as ‘out of control’?

At this juncture, the MMA does not believe that the situation is out of control and that we need any health curfew. The Minister of Health yesterday announced that the government would only consider declaring a health curfew if the mortality rate due to Influenza A (H1N1) outbreak goes above 0.4 per cent. According to their calculations, currently, the country’s mortality rate is between 0.1 per cent and 0.4 per cent.

Some have suggested that we shut down the country by imposing a nationwide health emergency lock down. But this is quite futile, as the disease is already in place within the community. Also, how long should this go on, one week, ten days, or longer?

What about the economic implications and the day-to-day running of the country and businesses? Also what happens when another surge appears again? Do we need to have repeated cycles of national curfew? Therefore, it makes no practical sense to even consider this seriously at this time, the actual numbers while alarming to some, are still manageable.

9. So why do the growing numbers seem to imply that we are getting more and more infections, with what appears as a disproportionate number of deaths?

There is no clear or adequate answer to this. I do not believe that the MOH is to blame for the forthright transparency, which it has been practicing right from the outset of this outbreak. We have released all the data almost daily in full view of our public. In fact earlier on, it should be remembered that the MOH was accused of being too alarmist and even guilty of scaremongering, driving away businesses and tourists!

There is organisational acknowledgement that our viral testing may have been less than adequate, and there have been long queues and frustrations from many worried iflu-like patients. Some had also been sent home, where no tests were offered, and therefore felt abandoned and treated less than expected.

Thus, there were/are many ill flu patients in the community, where no confirmatory tests had been performed. This gross under-reporting would therefore to add to the lower numbers of laboratory-proved or confirmed A(H1N1) flu, reported.

The WHO has estimated that for every confirmed case, there are at least another 20 patients who would have been infected. This means that most of these are not serious enough to be counted—many would have had mild or even no symptoms. Thus, in this context, the actual numbers with this pandemic flu would have been grossly underestimated.

So, it is unfair to state that the MOH is manipulating the numbers to justify the growing death rate, which we have already predicted would happen simply based on the attack rate of this very contagious flu.

We must inform the public that this pandemic will continue for at least another year or two, with the intensity likely to become less serious and less feared with time, unless the dreaded second wave of reassortment into a more virulent form of the H1N1 virus takes place.

There is no indication that this second wave has taken place yet, even in Mexico, USA or UK or Australia.

Although Mexico has declared that its worst is over, it is probably more a local nationalistic perception than the actual truth—there are still reports of continuing flu-like illness being reported, but like most authorities the Mexican government has taken the position of not confirming the actual attack rate any more. This less than rigorous case reporting is mainly done to allay irrational public fears.

A recent report (Seeking lessons in swine flu fight, 10 August, 2009, NY Times) by a visiting American expert noted that in the Mexican/Latin American situation, the flu characteristics might have become less typical, with many not developing fever in as many as 30-50%, but that some of these still go on to develop more serious lung complications.

Dr. Wenzel, a former president of the International Society for Infectious Diseases, said he had observed a broad spectrum of illness from human swine influenza: people who experienced few or no symptoms to those who rapidly developed complications and died. Thus, like anywhere else, this flu will continue to exert its toll, but perhaps in a less alarming manner, once the public overcomes the initial fear and alarm…

Also the complication rates appear to have plateaued and most health authorities have learnt to cope with this, and the expected number of deaths. The scenario in Malaysia is probably still evolving with the peak still to come, but I would predict that the mortality rate would become less frightening as we cope with the complications better.

Even in the USA, the number of A(H1N1) flu is estimated to be in the millions as of now, but most are really quite mild disease and therefore not so scary. More worrisome in the northern hemisphere would be the winter months when this flu might exert its more serious effects, yet.

In Malaysia, it is possible that many more Malaysians have come into contact with this flu and are suffering very mildly from this, and most have got better without much concern. It is those few who seem to get complications so quickly that makes us so afraid, may be too afraid.

But, like most communicable diseases, we will overcome this outbreak in time, but we need to be patient, vigilant, be socially responsible and work together.

There is little to be gained from scapegoating anyone, be they the governmental machinery, the MOH, doctors or our politicians. We would all be better served by refraining from too many knee-jerk, alarmist or partisan responses.

The MMA is organising an urgent National A(H1N1) Pandemic Influenza Conference on 12 September 2009, to help disseminate and share more scientific and practical up-to-date information about this novel influenza. The mass media will be invited to participate and help learn and educate our citizens more about this dreaded outbreak.