malaysiakini: 1Care outpatient scheme - middlemen didahulukan?... by Drs Ong, Haniffah & Palaniappan

1Care outpatient scheme - middlemen didahulukan?

Drs Ong, Haniffah & Palaniappan
Apr 19, 2011, 2:29pm

 

The government is introducing a new financing scheme for primary care (1Care for 1Malaysia) by forming a private company/corporation to act as an insurance company and managed-care organisation (MCO). We believe this company will:

i) collect funds from all working adults and employers

ii) pay for all primary care expenses ie. for outpatient visit, test and medication at both private and government clinics

In theory this scheme will save consumers from having to pay out-of-pocket for their primary care and thus protect them from excessive healthcare expenses. In reality the new company may become a middle man profiting from patients and their caregivers, with the result that healthcare costs go up, standard of treatment may drop and the public is burdened with a new healthcare tax.

We foresee these problems may arise:

i) Doctors will be paid an annual fee to look after a designated number of patients on their list. This fee is for medical consultation and service only, excludes drugs and tests, and is fixed annually.

If the needed medical attention exceeds the capitation amount, patients have to pay out-of-pocket. At the same time, doctors can continue seeing other fully paying patients.

The experience world-wide is that a fixed capitation fee per patient will lead to inadequate and under-treatment since physicians tend to conserve resources to prevent financial loss. Although patients do not directly pay for their treatment, they are still indirectly paying since a portion of their income will automatically be deducted and given to the insurance company running this program. Instead of spending only for their healthcare, patients are actually contributing to finance the operation of a private insurance corporation

ii) To qualify for the scheme, doctors may have to buy computers and programs from a designated supplier. Doctors also may have to pay an educational provider who will then certify them fit to enter and continue in the scheme. The educational provider may have a monopoly on assessment. No other form of present activity such as journal reading, conference attendance or presentation, will be considered appropriately educational for participation in this scheme.

This appears to be a business model guaranteeing profit for the computer/program seller and the body providing education/certification of doctors.


iii) Patients do not pay for drugs, which will be prescribed by doctors only from a standard list, and can also be dispensed at participating designated pharmacies. Clinics and pharmacies will then collect payment from the insurance corporation. Patient treatment will be limited to only these approved drugs, and any other drugs used will be paid fully by the patient out-of-pocket.

Patients need not pay, but quality of treatment will drop since range of drugs available is limited. There is a monopoly in deciding which drugs get onto the approved list and profit will be guaranteed for the company supplying and manufacturing these drugs.

iv) Patients will be registered with a particular doctor, and treatment must be only from this doctor. If patient chooses to see another primary care doctor, or if specialist treatment or hospitalisation is needed, patients will again pay out-of-pocket.

Patients can no longer seek a different primary care doctor, even if they travel to another town or if the initial treatment is ineffective. Since the scheme does not cover specialist and hospital costs which are far higher than primary care charges, patients may actually end up paying large out-of-pocket fees despite contributing to the new insuring company.

v) Hospitalisation cost actually accounts for the bulk of a country's medical expenditure. In Malaysia, in 2008, the government is responsible for 78 percent of total hospital beds in the country and accounts for 74 percent of total admissions.

Yet the government spends only 44 percent of the total healthcare expenditure in the country; private hospitals see only 26 percent of total admissions, yet use up 56 percent of total healthcare spending. Under-funding and excessive work has led to unsatisfactory patient service in government hospitals, forcing patients to seek attention from private healthcare. If efficiency and service in the government hospitals improve, patients will not have to seek treatment from the expensive private sector.

The government must improve service in their hospitals. If government hospitals can cater effectively to patient needs, the private hospitals will be forced to lower prices to compete and attract patients, as has happened in Singapore.

A national healthcare financing scheme that increases investment in public hospitals will thus automatically lead to a lowering of fees in the private hospitals. This will then greatly reduce total healthcare spending for the whole country since hospitalisation accounts for the bulk of healthcare expenses.

To seriously reduce national healthcare spending, the government must develop a financing scheme to increase public hospital investment and improve its service. How can the setting up of a private corporation to act as an insurance company cum MCO reduce overall health spending? Have not hospital bills in the private sector escalated with increasing health insurance and middle-man MCOs?

In no other country in the world has the government started a financing scheme for outpatient clinics before dealing with the more expensive and more important problem of hospitalisation cost.

Suspicion is thus raised that this scheme may be to benefit a few private companies at the expense of patients and their medical caregivers. When healthcare expenses go up, everyone suffers.

Workers take home a smaller income since an increasing portion of the salary will be deducted, while business costs will rise since employers will also be forced to contribute to the operation of the private insuring company.

Details of the 1Care scheme have not been fully revealed but we list above our concerns and urge the government to engage all parties, including patients and the public, to respond to valid questions.

The poor must not end up the big loser as we saw recently when the Private Healthcare Act was used to close down charity dialysis centres. It is our duty as responsible citizens to try to look after the sick irrespective of income level. Since the government derives its revenue from all tax-payers, it must not seek to profit from its activities, but develop a system to protect the health of all, especially those unable to pay for their own needs.


This is a joint letter by Dr Ong Hean Teik and Dr Haji Haniffah b Haji Abdul Gafoor, former presidents of PMPS (Penang Medical Practitioners' Society), and Dr SP Palaniappan, former chairman of MMA (Penang branch).

My letter to my medical students.... by Assoc. Prof Wong Yin Onn

My letter to my medical students

by Assoc. Prof Wong Yin Onn, Monash Medical School, JB

To all of you my medical students,

You are very important. The future of many lives and families depend on what doctors do and SAY. I hope this realisation will uplift us with a sense of our remarkable place in the world as doctors.

And that is also why I keep on harping that Doctors MUST not be Wallpapers!

Please remember that Doctors had always stood at the forefront of change in society… those of you training under me MUST not only be skilful in diagnosis and management but also in social skills and leadership. It is your heritage that you cannot deny!

But the practise of Medicine is in trouble. Blatant commercialisation, rampant blood tests done without any doctors ordering or supervising, scans and probes of all kinds, are being conducted by laboratories and some doctors misguilded by wants rather than needs.

Hope lies in every one of us doctors, present and future, for the sensible management of patients; YOU remain the hope for untold numbers of patients in the future. Sadly some doctors see patients not as patients but as a disease that needs treatment which provides our source of income. This is nothing new, physicians like Osler had repeatedly cautioned against not forgetting the man behind the disease, and medicine as a calling rather than a business.

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish”.

~ Sir William Osler

Many doctors are unhappy with their work or simply too busy to talk, console or listen. Many just treat the disease and completely ignore the person who has it. We hear endless tales carried by patients of doctors who grunt instead of talk, who are capable only of monosylable conversation and who zip patients in and out of the consultation room with a speed that will make Superman jealous.

The reasons are complex. But one reason may simply be that some of us doctors have forgotten why we became doctors in the first place, and the wonder of caring for fellow humans. Some may be a bit burnt out. We had in our careers, seen and taken care of more pain and misery than most people. We saw prostitudes, drug addicts, criminals and the worst of humanity.

We also treated decent human beings, doting grandmothers and innocent children. No doubt, the demands on our skills and the medical-legal complexities that accompany our practise would have made even the greatest of our medical ancestors shudder. Yes, we deserve some rest from our weariness. But let’s not let go of the calling. Rather than try to correct the system which is basically dictated by our political masters, a system undeniably sick, we need to repair ourselves.

Yes the system only makes it more painful. Regulations as thick as a medical text. Pharmacies selling controlled medicines like sweets. To change that will require one of us to be the next Prof Virchow, plunging head on into politics to make a difference. For the vast majority of us struggling on as individuals practising medicine, we hopefully don’t need much repairing; but to recall why we first fell in love with medicine, and why we wanted to become doctors.

In school we rose above the hoard, we were thecream de la cream. We obtained results the envy of most and we strove with pride to enter medical school. We sacrificed parties and dates to study for those results, we read volumes. In medical school we worked like ants on a long march. We reeked of formalin, we stared at slides till we saw mitochondria in our dreams and memorised volumes of facts
and figures. We did tough postings, survived the strictest professors, rounded in the pre-dawn drudgery of crowded wards, worked till hypoglycaemic on medicine rounds, performed every procedure required in the book, and passed our exams reasonably well. We stayed late, studied hard and looked at X-rays until our eyes turned red.

We finally graduated and became houseofficers. Yes, that year made the second world war look like a walk in the park but we survived. A few years later, we picked a specialty, from paediatrics to surgery, family medicine to cardiology, internal medicine to radiology, and shuffled off to more clinics, rounds grand or otherwise, work and studies. And MORE EXAMs.

During post grad training, we had exposed ourselves to the dangers of infectious disease, exhaustion, depression and violence. Operative instruments became flying daggers that we dodged in OT when the surgeon grew frustrated. I still recall with trepidation managing the very first patient admitted to our hospital with AIDS. We knew very little but feared a lot. As registrar, it was my duty to examine him. But again we survived. And learned. Now at almost every bedside teaching, I see patients with HIV.

Fear can be turned to compassion. We drained fluid filled tuberculous chests, placed central venous lines, resuscitated the dying. We obtained consent for a thousand procedures, pronounced people dead, wrote enough case summaries to make ‘War and Peace’ look like short fiction and was almost ‘form-ed’ to death by the endless forms the admin would have us fill.

Our youthful enthusiasm and dedication well deserved the applause of our patients, when there was any. Weren’t we incredible then, if only because we came back to the wards night after night, day after day for emergencies, calls, rounds or simply a ’tissued’ drip. “Bengkak” the nurse will phone and we leave our dinner to struggle with chemo wrecked veins for IV access.

We as doctors must hold onto that commitment, that wonderful calling. Then we see another world – the realm of the business of medicine, where every disease is a “case” to be investigated.

A very senior Professor tells me she had seen doctors ordering investigations before even taking a history! Here is also the world of the grunting and monosylable doctor, the superman of 2 minute consultations and management. True, the superb rare genius of a diagnostitian may well have obtained all the data that he needed sub- 2 minutes, but the poor human called ‘the patient’ needed at least 6 minutes of compassionate conversation. (By the way, that is why your OSCE exam is 6 minutes long, or SHORT from your examinee viewpoint.. now you know how the patient will feel when the consultation is even shorter than this!). Recall that the only reason the woman in labour remembered us the attending medical student is because we held her hand while she screamed.

In the midst of all that we call Medicine, let us always remember the human behind the disease.
Let us recall that our work is a wonderful calling, a great gift. We are the descendents of Aescalapius, the inheriters of all that is noble in the Hippocratic oath. We may fail to change the ideas of many doctors however we may preach from some illusive high moral ground. But as individuals let us try not to lose our ideals.

Don’t let the system, colleagues or patients burn us out. Go for a holiday, trek lonely mountains, meditate, pray, sing, chant or simply relax. The sick is the reason for the practice of medicine, their care is why we became doctors! If we keep our mission clear, and our calling intact, we’ll care less about money and in all probability still make all that we need. By all means earn what is deservedly ours, but never forget the human who is paying. He is called the patient!

And in the process we can teach and inspire the next generation of doctors, ie you and all your friends. If we tell our students that the learning of medicine is through their apprenticeship to us their seniors, then we better be sure that we are good role models.

As medical students and future doctors, you all are the hope of the febrile, the breathless and the pregnant. And let us old froggies never forget the calling that we answered after decades of preparation from school to university to hospitals.

Do not let what you see in the misadventures of some doctors discourage you. Instead let them be teachers to you for you now know what you do NOT want to be like.

When a doctor have taken medicine to be a business or trade, he will ask what are his achievements — material success, cars, wealth, etc..

When a doctor has taken medicine to be a calling, he will ask what has he become — his character.

I hope we doctors can discern and reflect on what we have become in the practice of medicine, and teach all our young charges, delivering them safely through the long 5 years of protracted labour into a reasonably sane medical world.

Thank you
Your lo si,
Associate Professor Wong YO.

Sunday Star: Quality first, not quantity... By Dr MILTON LUM

Quality first, not quantity

By Dr MILTON LUM

Sunday Star, 09 Jan 2011

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

ONE of the basic principles taught to all medical undergraduate and postgraduate students is Primum non nocere, ie, first do no harm. It is a reminder to doctors to always consider that an intervention can lead to harm to the patient, however well intentioned it may be.

This principle is even more relevant today than in yesteryears.

Prior to World War II, the doctor’s responsibility to the patient was relatively simpler. It involved making a diagnosis and prescribing a treatment, which the patient may or may not respond to, depending on the patient’s physical state, and the illness he or she was suffering from.

 

 

In spite of the fact that there was, and still is, a marked shortage of medical educators in Malaysia, the expansion of medical schools has continued unabated.

It was not very different from a lottery. Medical knowledge and the range of diagnostic and therapeutic modalities then were limited. Specialists and other healthcare professionals, apart from nurses, were almost unheard of, and their services were only available to the well heeled.

There has been an explosion in medical knowledge, and the range of diagnostics and therapeutics has increased tremendously. Healthcare is one of the fastest growing sectors of many economies and is provided in many instances by a team of healthcare professionals, led by the doctor.

Specialists and specialty services are available in almost every nook and corner of the country, and if not available, access is provided by the state through ambulances and flying doctor services in the more remote areas.

Modern healthcare, however, is not without risks. The publication of To err is human by the Institute of Medicine in the United States in 1999, and similar reports from the United Kingdom and Australia, drew attention to adverse events that resulted from medical errors, the causes of which were human factors and system failures.

It is now generally accepted that the incidence of adverse events from hospitalisations is about 10%, with single digit figures for mortality and morbidity.

This was summed up succinctly by Sir Cyril Chantler in 1998: “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

There are currently 24 medical schools providing undergraduate training for Malaysia’s population of 28 million. Countries with similar populations like Australia (22 million), Taiwan (23 million) and Canada (34 million) have 19, 11, and 17 medical schools respectively. – Source: United Nations

Recent media focus on the number of housemen and the attitudes of some of them raises questions about the quality of medical education, and by extension, the quality of healthcare patients will be receiving in the future.

The solutions announced to date are interim measures that do not adequately address fundamental issues which have their genesis upon the students’ admission into medical school. This article seeks to draw the reader’s attention to some of the issues and challenges that need to be addressed.

Learning medicine
There are more applications for entry to medical schools worldwide. Many young people want to become doctors, whether of their own volition, or at the behest of their parents.

High academic qualifications are the sole criteria for admission to all public medical schools in Malaysia, except University Sains Malaysia (USM), which requires an interview as well.

In general, the private medical schools also require high academic qualifications and an interview as well. Some also require applicants to pass an aptitude test.

Although the minimum academic qualifications for entry into medical schools are prescribed by the Malaysian Qualification Agency (MQA), there are claims of non-compliance by some private medical schools. There are also claims that some private medical schools take in more students than permitted.

The situation in foreign medical schools is varied.

Medical schools in advanced economies adhere strictly to high academic requirement, as well as assessments of the aptitude of the applicants.

However, some medical schools in developing countries admit students whose academic results would not even qualify them to enter a university in Malaysia for other courses with lesser entry requirements. Many of such students gain entry through the agencies of these medical schools.

It is necessary to emphasise that selection for entry into medical school implies selection for the medical profession. Findings from studies worldwide confirm that although some students have achieved the academic standards required for entry into medical school, they are not suitable for a career in medicine. It is in the interest of the public and such students that they should not gain admission, rather than to have to leave the course or the profession subsequently.

The issues and challenges that need to be addressed include:

● Should academic qualifications be the sole criteria for entry into medical schools?

● What is the role of interviews and/or aptitude tests?

● How robust is the monitoring of the compliance of Malaysian medical schools to the MQA’s minimum entry qualifications?

● How robust is the monitoring of the adherence of foreign medical schools to the MQA’s minimum entry requirements?

● What should be done to Malaysians admitted to local and/or foreign medical schools without MQA’s minimum entry requirements?

Medical schools
There are currently 24 medical schools providing undergraduate training for Malaysia’s population of 28 million (Source: International Medical Education Directory). Countries with similar populations like Australia (22 million), Taiwan (23 million) and Canada (34 million) have 19, 11 and 17 medical schools respectively (Source: United Nations).

Although there was a dichotomy between public and private medical schools in Malaysia previously, the margins have been blurred in the past few years. Some public medical schools have established twinning arrangements with universities abroad and the fees for students who enrol in such courses are not different from that charged by private medical schools in Malaysia.

Our ASEAN neighbours, Indonesia, Singapore, Thailand, and Philippines with populations of 238 million, 5 million, 67 million, and 94 million respectively have 35, 2, 12, and 41 medical schools respectively.

With the establishment of more medical schools already approved by the Higher Education Ministry, Malaysia may soon join the ranks of countries like Germany, Italy, and the United Kingdom who have 41, 42, and 44 medical schools respectively for populations of 82 million, 60 million, and 62 million respectively.

The issue is compounded by the fact that the government recognises more than 370 medical qualifications worldwide. The list of recognised medical schools was inherited from our colonial masters and added to over the years.

In addition, graduates from unrecognised medical schools can sit for the Medical Qualifying Examination (MQE) of the Malaysian Medical Council (MMC) and, upon passing, will be registered. The examination is the final year examination of the Universiti Malaya, Universiti Kebangsaan Malaysia, and University Sains Malaysia who conduct the examination on behalf of the MMC.

There are some who question the validity of these examinations. However, they have not provided any material to substantiate their suspicions. An analysis would reveal that those who fail the MQE usually have very poor results at SPM and STPM levels.

In spite of the fact that there was, and still is, a marked shortage of medical educators in Malaysia, the expansion of medical schools has continued unabated. Some private medical schools have teaching staff who are mainly foreigners from Myanmar, the Indian sub-continent, and the Middle East. Some of them do not speak any of the local languages, and some have no previous teaching experience.

It is not only the number, but also the quality of medical educators that is crucial in producing doctors that will make a positive impact on the public’s health. Medical educators are role models for students. It is well known that a deficient doctor is reflective of a deficient teacher; just as a child’s conduct is reflective of the parent’s.

Local medical schools are given time-limited accreditation after assessments by teams comprising representatives from the Malaysian Qualification Agency, Health Ministry, and the MMC.

However, it is impossible to accredit all the foreign medical schools recognised by the Government for manpower, logistical, and financial reasons.

Most governments in developed economies recognise their limitations in assessing the quality of medical education of foreign medical graduates. They require all those who want to practise medicine, particularly foreign graduates, to pass a licensing examination.

Many Malaysian doctors who have practised abroad, particularly those above 40 years, have passed these licensing examinations without difficulty simply because of the quality of medical education they received.

Many in the medical profession have stated publicly their concern that there is more emphasis on the quantity instead of the quality of the graduates. The consequences in other areas of studies may not be significant, but in healthcare, it can be a matter of life and death for a patient or potential patient, which means all the population.

The issues and challenges that need to be addressed include:

● How many doctors does the country need, and by extension, how many medical schools does the country need?

● What is the quality of medical education in recognised local medical schools, and how robust is its monitoring?

● What is the quality of medical education in recognised foreign medical schools, and how robust is its monitoring?

● Should not all medical graduates, particularly those from foreign medical schools, whether recognised or unrecognised currently, be required to pass a licensing examination before they are permitted to practise in Malaysia?

● What is the role of agencies of foreign medical schools and how robust is its monitoring?

Housemenship
During the course of the newly graduated doctors’ future practice, there will be continuing advances in medical science and clinical practice, healthcare delivery and financing, increasing expectations of patients and the public, and changes in societal attitudes.

The MMC has listed five basic ingredients of Good Medical Practice. They are professional integrity, communication skills, ethical behaviour, treating patients with dignity, and being a team player.

By itself, the basic knowledge and skills taught in medical schools is insufficient. The housemenship period is the time to make a start in the development of the ingredients of Good Medical Practice.

Young doctors have to develop his or her professional competences, skills, and behaviours so that they are better placed to serve and improve the care and health of their patients. They have to learn to always put the interests of their patients first and that the doctors’ professional practices affect the experiences of patients and their families.

The skills of continuing professional development have to be developed so that their practices can advance in accordance to changes in medical knowledge and practices.

In short, the housemenship period is a time when the newly graduated doctor transitions from theory to practice.

Learning during the housemenship period is not only from books and journals, but also experiential, with the latter playing a significant role. There has to be sufficient quality teachers for this aspect of the young doctors’ training. The teachers, who are usually specialists, have a crucial role to play as they are role models for young doctors.

There has to be exposure to sufficient numbers of patients for young doctors to gain the experience required for independent practice. For example, they have to be exposed to the different ways in which the common conditions, appendicitis and urinary tract infections, present. Failure to make an accurate diagnosis will lead to threats to life, in the case of the former, and long term consequences, in the case of the latter.

When there are few patients relative to the many housemen, it will, inevitably, have a negative impact on the latter’s training.

The statement of Sir William Osler, the father of modern Medicine, is particularly relevant: “Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the books. See and then reason, and compare and control. But, see first.”

Many specialists report that they find it increasingly difficult to cope with the dual tasks of providing care to patients and training housemen, with the former always having to take priority over the latter. It is disconcerting to hear some specialists state that they do not even know the names of some housemen assigned to their wards and clinics “because there are so many of them!”

The issues and challenges that need to be addressed include:

● How many housemenship training hospitals does the country need?

● How many specialists are needed for housemenship training?

● What is the quality of housemenship training and how robust is its monitoring?

Too many doctors?
With the current rate at which Malaysian doctors are graduating from medical schools, both locally and abroad, the country will reach its overall doctor population target of one doctor for 600 population within three to four years, and a ratio of one doctor for about 400 population or less by 2020.

There will have to be 5,000 to 7,000 Medical Officer posts in the public sector available annually within the next five years for the young doctors after completion of their housemenship training, and after that it will be anybody’s guess.

If there are insufficient posts, how many can be absorbed by the private sector, which is already saturated in many areas?

There will be no employment problems for doctors of good quality, but the prospect of unemployment is a possibility for the mediocre, and possibly, some of the average ones.

When the costs to the state or to the individual of producing one doctor are considered, the question arises whether it makes economic sense to flood the market with doctors. The laws of supply and demand do not apply to doctors simply because doctors are not only suppliers but also play a significant role on the demand side of the equation.

Studies from the developed economies have shown that a small number of doctors account for the majority of complaints and medical errors, where human factors are involved. Poor quality doctors will inevitably contribute to medical errors, morbidity, mortality, and consequential increase in healthcare expenditure.

Going forward
The current problem of housemenship training has its genesis in medical schools. It raises questions and challenges about the quality and quantity of medical graduates, some of which have been discussed above.

The resolution of the problem can only be possible if a comprehensive approach is taken. Ad hoc measures will not solve the problem. Moratoria and increasing the number of hospitals for housemenship may be part of the solution, but they are at best, interim measures.

The fundamental issues have to be addressed before the situation gets out of hand.

Medical schools have to be held accountable for the quality of their graduates. The principle that society’s health is more important than profits has to be adhered to at all times, particularly by the private medical schools.

We owe future generations a healthcare delivery system founded on patient safety and quality of care in which quality doctors have a crucial role to play. The consequences of having significant numbers of poor quality personnel in other areas of human activity may not be significant, but in healthcare, it can be a matter of life and death for all the population.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

The Star: Higher Education, Health take steps to ensure medical grads are competent... By LOH FOON FONG

Higher Education, Health take steps to ensure medical grads are competent

By LOH FOON FONG
newsdesk@thestar.com.my

Tuesday November 30, 2010

PETALING JAYA: The Higher Education and Health ministries are working together to ensure a “satisfactory quality” of medical students graduating from abroad.

Health Minister Datuk Seri Liow Tiong Lai said the two ministries were working together to ensure a “satisfactory quality” of medical students graduating from abroad, he said, responding to concerns raised over the quality of medical schools abroad following a recent report in The Star.

Those intending to study medicine abroad must first get a “certificate of no objection” from the Higher Education Ministry, he said.

“This is to ensure the quality among our medical graduates,” he said.

The report highlighted that about 4,000 Malaysian students were expected to graduate each year from 350 universities worldwide in the coming years, resulting in a high increase in the number of housemen but not enough training hospitals.

Responding to the front-page report, several sources here said the increasing number of housemen was partly due to the Health Ministry allowing students to study in lesser-known medical schools abroad that offered lower fees to overcome the acute shortage of doctors.

One source said the move had resulted in a glut of housemen and – if not controlled – could also result in a glut of doctors in the future.

“Public hospitals now have housemen who lack the core knowledge and basic expertise,” said several sources.

“When we started accepting virtually ‘any graduate from anywhere’ such as from Russia, Crimea (an autonomous republic under the jurisdiction of Ukraine) and Indonesian towns such as Makasar in Sulawesi, there was absolutely no control over the quality of training these students received or the quality of housemen entering our system,” said a source.

“Under such circumstances, the training of house officers is hit with a ‘double whammy’ – first, many of them entering the system had received poor training during their student days, and second, specialists find it difficult to cope with the large number and are unable to pay enough attention to get them to the quality required,” he said.

Providing more training hospitals, as suggested by Liow, would not solve but aggravate the problem because hospitals were poorly staffed by experienced doctors, he said.

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.

Nutgraph: Private healthcare: Too expensive? by Ding Jo-Ann

Private healthcare: Too expensive?

The Nutgraph, By Ding Jo-Ann | 06 July 2010

(Pic by Jyn Meyer / sxc.hu)

IN 2008, Malaysia spent about RM35 billion on healthcare, more than half of it in the private sector. Malaysian Medical Association (MMA) president Dr David Quek says RM18.8 billion was spent in the private sector that year. Of that amount, Malaysians forked out RM10.8 billion from their own pockets for private healthcare. They can expect to fork out more in the years to come.

This may account for health director-general Tan Sri Dr Mohd Ismail Merican’s comments, in early June 2010, about private hospitals’ “exorbitant fees”. Merican said price revisions were necessary, and he would meet the MMA to develop a comprehensive and acceptable fee schedule.

But why is the government attempting to curb private healthcare costs when there is supposed to be a readily available and more affordable public healthcare system? Shouldn’t the government focus on improving the public healthcare system, making it an automatic price check on private healthcare?
After all, why would someone pay RM30,000 for a heart bypass if they could get quality care for minimal cost at a public hospital?

Political, economic ramifications
Universiti Malaya political economist Associate Professor Dr Terence Gomez says declining standards in government sectors have led the middle class to look for ways to bypass the public system.

“The promotion of medical insurance has led to private healthcare being more affordable for the middle class,” he tells The Nut Graph in a phone interview. Rising private healthcare costs, however, have led to higher insurance premiums, coupled with lower coverage.

Gomez says escalating private healthcare costs is therefore a political issue as well as an economic one.
“The government faces a potential backlash from the middle class who don’t want to pay huge insurance premiums and yet are not willing to return to the public health system,” he says.

“This is an issue of concern for the [Barisan Nasional] government, which is already facing declining middle-class support.”

Controlling businesses
But is capping private healthcare fees a sustainable way to ensure affordable and quality healthcare for all Malaysians?

Sunway Medical Centre chief executive officer Dr Chong Su Lin says running a hospital business is not as lucrative as imagined. “Our nett profit margins are only about 5%,” she tells The Nut Graph in an interview. “That is, if we do make any profit in any given year.”

Merican confirms this. Quoting Association of Private Hospitals Malaysia data, he says private hospitals’ profit margins are about 6%.

Dr Chong says forcing private hospitals to cap their charges could be a disincentive for businesses to remain in the medical market. She disagrees that hospital fees are “exorbitant”. “I’ve offered for the government to go through our accounts and examine the cost of every single item and tell us how we can price things differently,” she says.

The Nut Graph asked Merican how the government would balance the competing interests of ensuring affordable private healthcare and the private sector’s profitability. In an e-mail response, he merely said:
“Private hospitals sustain their profitability by offering efficient and quality healthcare services and compete to attract patients by adding comfort and luxury. Smaller private hospitals may be at an advantage by having lower maintenance and overhead costs and can compete in terms of pricing. Practitioners can also help make services more affordable by reducing their professional fees.”

Merican adds that health tourism will also help private hospitals sustain profitability while generating foreign revenue for Malaysia. Neither response shed light on the question at hand.

Engine of growth?

Dr Quek argues that it’s in the government’s interest to ensure the private sector’s survivability because it shoulders a significant burden of maintaining public health.

“[Private] general practitioners see 62% of first-time ill patients, while private hospitals admit about 25% to 30% of hospital patients,” he tells The Nut Graph by e-mail. Despite this, he says, the private sector does not receive any allocation of the national healthcare budget, which is utilised exclusively in the public sector.

Dr Chong says the private sector fuels a whole sector of growth. “We do this by growing the labour force; we up-skill our staff and purchase a whole range of supplies and services – supplies, ambulances, equipment, drugs … it’s a whole ecosystem.”

Yet, she says, the government has sent the private sector extremely mixed messages. “On one hand, we’re one of the engines of growth; [but on the other hand], we’re the bad [person] because our prices are too high.”

Dr Chong says the government needs to decide if it wants to be more socialist and provide everything, or more capitalist and allow market forces to dictate prices. “Until that is decided, we can’t plan strategy.”

To complicate matters further, Dr Quek says the government, in fact, owns some of the large corporations that have entered the private healthcare business. “Khazanah Nasional owns 60% of the Pantai-Gleneagles group, while KPJ is wholly owned by the Johor state government. Since they’ve entered the market, they’ve been aggressively pushing profit margins higher and higher,” he says.

Merican acknowledges the private healthcare sector’s role as an engine of growth and says that steps will be taken to boost the health tourism industry. However, he did not expressly respond to The Nut Graph’s question on whether the government was sending mixed signals by talking about scaling back hospital fees, which may threaten their profitability.

Public sector, again
Gomez says the ultimate solution to ensuring universal quality and affordable healthcare is to get the public healthcare system back on track. There will be no quick fix, however, and a complete reassessment and revamp will take years to implement.

“There is a growing concern of the quality of healthcare, especially for the poor. There needs to be a significant amount of reinvestment in the public health sector. Training and incentives for [public sector] doctors also need to be looked at,” says Gomez.

Whether or not a government already in deficit will be able to afford the revamp is another question.
Merican says the public sector is heavily government-subsidised, and the increasing cost of healthcare will make these services difficult to sustain in the long term.

Dr Quek agrees that heavily subsidised services are not sustainable in the long run. “Currently, the public only co-pay 2% of the actual public healthcare costs,” he says. He adds that the financing of national healthcare will need to be reviewed and revamped to ensure affordable, quality healthcare for all, including end-of-life care.

If this revamp doesn’t take place, and public hospitals do not improve across the board, Malaysians will find it increasingly hard to afford quality healthcare when they need it the most.

NST-MSQH: 1MALAYSIA CLINICS: Have qualified indicators to improve service

1MALAYSIA CLINICS: Have qualified indicators to improve service

2010/01/26
DR M.A. KADAR MARIKAR, Chief executive officer, Malaysian Society for Quality in Health 

PREVENTION and promotion of health is the cornerstone of primary healthcare and the best and most affordable way to save lives and improve overall health.
The setting up of the 1Malaysia clinics should be lauded because access to affordable healthcare is an important dimension of quality healthcare.

The issue of 1Malaysia clinics being managed by senior paramedics (assistant medical officers and registered nurses) should be an acceptable measure in times of shortage of doctors, and the Health Ministry has given the assurance that proper standard operating procedures are in place to govern the roles, responsibilities and limitations of paramedics to make sure that safe and quality healthcare services are provided to the deserving.

Continuous education for paramedics is of equal importance in maintaining their skills and knowledge.

The 1Malaysia clinics should be regarded as a "triage centre" to lessen the burden faced by the Health Ministry's community clinics (Klinik Kesihatan) and the emergency departments of government hospitals. It is well known that the majority of cases seen in the emergency departments are minor cases. With the setting up of 1Malaysia clinics, the authorities should be able to manage such cases there.

The 1Malaysia clinics should also be able to play an important role in the wellness paradigm being expounded by the Health Ministry by providing more needed preventive and promotive healthcare services.

The majority of cases seen in emergency departments are minor cases that can be treated in 1Malaysia clinics.

As one of the main advocates of safe and quality healthcare in the country, we hope that quality indicators will be set up to monitor the provision of services by 1Malaysia clinics.

Quality indicators such as the number of patients who return to a 1Malaysia clinic with the same complaint or illness after 48 hours of receiving treatment and the number of appropriate referrals to doctors may be used to assess and improve the safety and quality of services.

They may provide important feedback on whether 1Malaysia clinics should be manned by paramedics or upgraded to clinics managed by doctors.

------------------ooooo00000ooooo---------------------

My Comments (DQ):

While it is good to urge for quality indicators to check on the performance of clinics, this should not be another exercise at maximising earnings for related industry players. 

The MSQH is a separate independent body which was initially set up together with MMA and APHM through the auspices and encouragement of the MOH, through an MOU signed in 1998. 

However, the MMA is undergoing a serious re-examination of its involvement due to somewhat 'opaque' processes and most importantly the procedural and ultimate goals and possible vested interests involved. 

Funding and spending processes must also be made more transparent, because this must not evolve into a personal-to-holder behemoth which is unanswerable to no one, least of all the medical profession and/or the authorities.

Malaysiakini: Ensure quality at 1Malaysia clinics by Chris Anthony

Ensure quality at 1Malaysia clinics

Chris Anthony
malaysiakini, Jan 18, 10, 3:36pm

 

The government's decision to set up 1Malaysia clinics to serve the urban poor is a laudable one that would be most welcome especially by those in the lower income group. Like in other countries, urban poverty has now become a major issue, which the government needs to address.

More planning and funds need to be channeled to provide for the basic needs of this group of citizens who are major contributors to the development of the nation. Neglecting them will only lead to many social ills in cities and major towns.

The 1Malaysia clinic concept is indeed a positive move in caring for the welfare of these urban poor. It comes at an appropriate time when the cost of basic health care is becoming beyond the reach of many wage earners in urban areas who are struggling to cope with the economic downturn.

However, are the 1Malaysia clinics really a priority and necessity now? Why the rush to establish them with much speed? We already have the hospitals and their satellite health clinics all in major towns.

In addition, the local city councils also run maternal and child clinics.

It would be more appropriate and economical to extend and improve these existing clinics instead of starting new 1Malaysia clinics to be manned by Medical Assistants (MA) and Staff Nurses (SN). The name itself gives it a political identity and it may well be the motive behind the move.

Meanwhile there are genuine concerns from the medical fraternity regarding the quality of care at these clinics particularly when paramedical staff and not qualified doctors man them.

Medical assistants and trained staff nurses may be able to carry out simple treatment like wound dressings, giving injections and screening tests for common diseases like diabetes and hypertension but are they competent enough to diagnose and treat minor diseases?
It must be borne in mind mesthat even treatment of minor ailments is not without major complications.

Furthermore there is no way one can stop major medical emergencies from being rushed into these clinics for immediate attention. What arrangements have been made to cater for these cases?

Are these clinics properly constructed and equipped according the stringent criteria as stipulated by the Health Ministry to handle such emergencies?

Otherwise, wouldn't an unnecessary delay at these clinics be detrimental to the prognosis of these dire emergencies?

The ministry must take into consideration all these factors as they also have medico-legal implications as well. Who is responsible for deaths in these clinics?

There are no doubts that many of our senior nurses and MAs are adequately trained, capable and experienced enough to treat simple ailments but can we say that of present day MA and nurses who are mainly trained in nursing care?

Today the training is very much different; the nurses and MAs are trained in nursing care and not so much in diagnosis and treatment of diseases as we have more than enough doctors to do that.
Entrusting the treatment of diseases however minor they may appear, will not be a wise move particularly when the people's expectations are high.

The Health Ministry must do its best to get medical officers to man these clinics as that would provide more reliable and acceptable treatment to the people today. It will be the only way to reduce the number of people going to the hospitals for minor ailments.

The Health Minister's contention that we are short of doctors is not acceptable with the incredibly large number of medical schools in the country that churn out about 4,000 doctors a year.
The reported shortage of doctors is only relative and with better management they can be distributed more evenly to cover these clinics.

At a time of rapid sub-specialisation in the various medical fields, it is unfortunate that we seem to be content with para-medical staff diagnosing and treating simple ailments.
Isn't it a retrograde step? Is it right to justify the move just because it involves the poor in urban areas?

The people are entitled to the best medical care from government facilities regardless of their affordability even for minor ailments. Its quality should not be compromised just because it is provided cheap for the urban poor.

Daily Express (Sabah): The 1M'sia clinics breach Acts: Docs

The 1M'sia clinics breach Acts: Docs

Daily Express INDEPENDENT NATIONAL NEWSPAPER OF EAST MALAYSIA, Established since 1963; Published on: Thursday, January 14, 2010

Kota Kinabalu: The four 1Malaysia clinics set up by the Health Ministry in Sabah so far is not a good idea, according to several practising doctors, here.

However, they said while the clinics' intention may be noble, they clearly contradict both the Private Facilities Healthcare Act (PFHA) and the Pharmaceutical Act (PA).

One doctor who wished anonymity said the fact that these clinics would be manned by Medical Assistants (MAs) and nurses makes the PFHA "look like a silly piece of legislation because it is clearly stated that only Medical Officers (MOs) with valid annual practising certificates can practise as doctors."

"Besides, these nurses and MAs will be functioning like paramedics at times when their ability to handle emergency situations is questionable.

They are also only supposed to dispense non-scheduled drugs. But what if they have to prescribe cough syrup or antibiotics which are scheduled drugs? Then they will be going against the Pharmaceutical Act." he said.

Another doctor who also wished anonymity said it would benefit undocumented foreigners more than ordinary Malaysians since this is the group that favours private doctors because they can get medical treatment for RM20-30 without being referred to the Immigration authorities.

"There is a standing instruction for all government doctors to refer illegal immigrants seeking medical care to the authorities for deportation.

Will this be done under the 1Malaysia clinics?" he asked.

A doctor at the government hospital, who now has set up his own private clinic, said in terms of the quality of service, the 1Malaysia clinics must not be exempted from complying with the health regulations.

Since they are set up under the Ministry, he said the 1Malaysia clinics should especially perform at the same level, if not better, than other private clinics in Malaysia.

He also queried the actual purpose of the clinics when the country is facing a shortage of doctors and professional medical staff.

The Government should firstly consider equipping various health centres in the State with complete facilities and manpower to better serve the needs of people in the rural areas as well as in the towns and city, he said.

"It is a shame the State and Federal Governments, especially the Health Ministry, that we still don't have a proper general hospital here in KK in this 21st century," he said.

Dr Jaina of Klinik Dr Jaina in Centre Point said there is nothing wrong about the clinics and that the low fees is a commendable effort by the Government.

However, she said it would be better if the Government could equip the 1 Malaysia clinics with complete facilities and medical staff, especially doctors, to make the move more effective.

Another doctor said that the move was rushed without much consideration for the people. "I think there is a political weight in the whole issue," he said, pointing out that if the government is actually concerned for the sick and needy, it should concentrate on equipping other clinics and hospitals in Sabah.

For another practitioner, the 1Malaysia clinics are good only for minor complaints such as cough and cold, whereas for major problems, hospitals are still the best place to go to for treatment.

"It is a good place to get first aid treatment, but the patient must quickly be referred to a bigger institution thereafterÉ in places where there are no clinics or hospital around, it is better than none," he said.

He said the fund used by the government in setting up the 1Malaysia clinics was poorly spent.

"If the allocation only involved thousands of ringgit, then it is acceptable as a market tester, but when it involves millions of ringgit, the Government should spend it more wisely to equip the clinics and all the hospitals available now.

"Perhaps the Minister is so busy fighting for the party (MCA) that he forgot to take care of the health industry and give more attention to healthcare in the stateÉ he should visit clinics and hospitals more often," he said.

State National Population & Family Development Board (LPPKN) director, Abd Halil Omar, said the 1 Malaysia clinics would benefit the people as they are highly affordable.

"This will enable people from all walks of life to enjoy better medical treatment regardless of where there are and what their status is," he said.

YB DOMINQUE NG: 1Malaysia Clinic team should be led by a qualified Doctor.

YB DOMINQUE NG:  1Malaysia Clinic team should be led by a qualified Doctor.

14^th Jan, 2010.

YB Dominique Ng, the ADUN for Padungan, has called on the Ministry of Health to post one Medical Officer to the 1Malaysia Clinic at Matang to provide reasonable professional service to the public. In this day and age it is not too much for the public to expect such a level of professional service, especially in the capital city of the state.

Though the new service outlet is to cater for minor ailments, it is certainly not uncommon for serious illness to present with common symptoms. Thus a qualified doctor (Pegawai Perubatan) should be able to provide more reliable diagnosis.

Further, he is of the opinion that for the clinic at Matang to depend on ambulance from Polyclinic at Mosque Road or Sarawak General Hospital is something less than satisfactory.

He made these observations after a visit to the said clinic yesterday. He was accompanied by En. Wong Huang Yu, Dr. Francis Ngu and En. Hung Sung Huo of Parti Keadilan Rakyat in Sarawak .  He had a brief conversation with the staff on duty.

The clinic is open from 10 a.m. to 10 p.m. and staffed initially by 3-4 persons. Patients are attended to by paramedical staff (Penolong Pegawai Perubatan) much as at remote rural clinics. Simple drugs for simple ailments are dispensed; certain minor surgery are also possible. In the first week of operation, the work load has already increased to around 100 patients per day, reflecting very high public demand for medical care which has existed for a long time at PetraJaya/Matang.

There is every possibility that the work load would increase greatly in the next few weeks, in which case there may be need for a couple more staff. There is likely to be much congestion, especially at night, at this clinic operating in a tight shop house setting.

Since 2006, YB Dominique Ng has in and out of the Dewan Undangan Negeri, Sarawak, repeated called for the provision of at least 3 specialist general hospitals and 3 large polyclinics in greater Kuching, to meet the fast worsening bottlenecks and congestion at existing medical facilities for a fast growing city population.

“ The single 1Malaysia Clinic is but a poor band-aid to a large service shortfall problem that is festering in Kuching and elsewhere in the State. I am now supported in my assessment of the widening needs-provision gap by Datuk Seri Wong Soon Koh, Second Finance Minister and Environment and Public Health Minister, who has belatedly put forth  a proposal to build 4 large polyclinics in greater Sibu under the 10MP.”

“Datuk Seri Wong and local wakil rakyat of Barisan National had better work on a PetraJaya-Matang Polyclinic and new general hospital as well,” advises Ng.

Health Care Reform and Plea for a return to better Clinical Culture

Health Care Reform and Clinical Culture

Posted by NEJM • August 26th, 2009 • 

It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients.

Doctors are already, by training, sophisticated decision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.


The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” There has been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all of which are small or modest. Absolutes are discordant with the realities of sickness and health.

There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor’s visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.


A second reform should be to limit malpractice awards so as to reduce physicians’ fear of lawsuits. Regardless of the arguments of defenders of open-ended malpractice payments, this insidious concern is a major driver of overtesting and overconsulting.

A third key reform would be to eliminate the time sink of the comprehensive exam and its lengthy documentation required by Medicare — a requirement that is likely to be adopted or exaggerated in any new codified system. Immaterial information is already cluttering the electronic medical record.

My survey of neurology notes, which I presume would be among the most thoughtful in medicine, shows that less than one fifth of the average note is taken up with analysis and discussion of the patient’s problem; the remainder is part of the “waste” in modern medical care.

Fourth, payment codes should be reduced to “simple” and “complex” — or at least the numerous billing levels and codes should be conflated, and payment should be based on diagnosis and time expended. Physicians should also be paid for their expertise.

Health care reform can redress slowly accrued and detrimental cultural changes, particularly the loss of reliance on clinical judgment. It would be a missed opportunity if practicing physicians (as contrasted to their representative bodies and societies) were excluded from the center of the conversation. The efficient use of the professional workforce will be more powerful than rules.

Allan H. Ropper, M.D.
Brigham and Women’s Hospital
Boston, MA
This article (10.1056/NEJMopv0907607) was published on August 26, 2009, at NEJM.org