Sunday Star--Modern doc: Changing Trends of Medical Practice in Malaysia... By Datuk Dr LEE YAN SAN

Modern docs

By Datuk Dr LEE YAN SAN

Sunday Star:  January 16, 2011

Changing trends of medical practice in Malaysia.
AFTER graduating in medicine from Australia, I started medical practice at the beginning of 1969. I have witnessed vast changes in medical practice. I came home to Malaysia at the end of 1971 before completing my postgraduate training in teaching hospitals in Sydney when my father took ill.

Back home, I joined the government service in Taiping Hospital and then University Hospital in KL for nearly five years. Then I went for post-graduate studies in Edinburgh before returning to Malaysia to start my own private practice.

I have therefore been through and seen the changes of medical practice in Malaysia for over 40 years. Recently, there have been many changes affecting medical practice and therefore I feel this will be an interesting topic, which I am qualified to write on, especially being a past president of the Malaysian Medical Association (MMA) and a council member of the Malaysian medical Council (MMC).

 

Medical practice is also now greatly influenced by new laws governing the way doctors should practise their profession.

Clinical practice to investigative practice
Doctors are now depending more on machines and are no longer are as good in diagnosing using clinical acumen, with the help of basic clinical examination tools.

I predict that in the not too distant future, stethoscopes may even become obsolete!

Clinical practice to investigative practice must be the most obvious change in medical practice. The actual practice of medicine has changed tremendously, and doctors are now depending more and more on gadgets and procedures rather than their clinical acumen.

In the past, without the easy access to such modern diagnostic tools, doctors had to be trained to rely mainly on their clinical skills to diagnose diseases. Experience and knowledge are important.

Unfortunately, these days, doctors no longer bother to go through basic examinations to come up with a diagnosis, as it takes more time and effort. All they need to do is to order a non-invasive brain CT or MRI scan to make the diagnosis. Some young doctors, through force of habit, do not even bother to listen to the lungs of patients complaining of chest symptoms, but just send them for a chest x-ray.

In the past, doctors were also trained to accurately diagnose heart defects purely by listening for typical heart murmurs, but now, with new gadgets such as the echo-cardiogram, this is no longer routinely practised.

But is it all good? Depending on gadgets may not create any problem if you are practising in places with such equipment available to you, but certainly, the doctor will be at a great disadvantage if such equipment are not available. This also increases cost, which may not be necessary.

Changes in medical training
Medical teaching and clinical training have changed greatly due to the vast increase of medical schools, with insufficient number of teaching hospitals and qualified teachers, which are of real concern.

Nowadays, due to the large number of medical schools, both locally and overseas, there are too many medical graduates produced annually, leading to insufficient facilities and patients to train them adequately. Some housemen do not even have the opportunity to learn to deal with emergencies.

The housemen will therefore not get sufficient experience and training as the hospitals and consultants are not able to cope with such large numbers.

The Government must seriously look into the declining standards in the training of housemen as the quality of medical care in the future depends on them. Internship is crucial to allow graduates to put medical training into practice under the supervision of senior doctors.

There is concern that many graduates from medical schools with inadequate teaching facilities will not have adequate core knowledge to treat patients.

New laws governing doctors
Malaysia used to have only the Medical Act 1971 to govern the medical profession. There are now new laws governing medical practice in place.

The scenario in private practice has changed drastically. Until recently, to start a private clinic, a doctor did not need to have a business license as medical practice was not considered a business and doctors were trusted to do the right thing, and that was looking after the health of the community. To start a clinic, a doctor only needed to register with the MMC to make certain they are qualified to practise as a doctor. They did not even need an annual practising certificate.

The main routine work was to keep decent medical records, a precise record of drugs stocked, and maintain an accurate financial account for the Inland Revenue Board.

Today, it is not easy to set up a private practice, especially a general practice. In the past, the doctor could just concentrate on his role as a healer. A doctor now has got to be a good administrator as well. Doctors now have to handle various issues such as rental, building requirements, and so on. The doctor has to answer to various government agencies that include the local council, the labour department, the statistic department, the fire and building departments, the pharmaceutical department, and if you happen to own an x-ray machine, the physics department as well, just to name a few.

More recently, the Private Health Care & Facilities Act was enacted. The Act dictates in great detail what doctors must do and should have in their clinics, many of which are unrealistic, and quite unnecessary.

Doctors in this country are practically accused of being greedy, immature, unscrupulous, and unethical, with the threat of heavy fines and jail terms if they don’t toe the line.

I hope to see the Government giving private doctors some breathing room. Some “black sheep” in the profession have caused mistrust, and this has led the Health Ministry to think that the private sector needs to be supervised in a stricter way. Doctors are all against those unscrupulous doctors who tarnish the reputation of their profession. Those doctors have no regards for ethics or law, but the rest of the medical practitioners should not be made to suffer because of them.

Surely it is more economical, more efficient, and fairer for the authorities to try and weed out the black sheep and deal drastically with them.

The Medical Act is already there and sufficient to control the doctors and to punish any in a fair way. If not, new amendments to the Medical Act can see to that.

Already, many general practitioners in solo practice are not doing well, so much so that doctors nowadays prefer to specialise, which is another new trend. This is an unhealthy trend as family (general) practice still plays a very big role in the healthcare of our country, and the authorities should do all they can to encourage it and not cause it to be less attractive by imposing too many rules.

Increase in the number of specialists
Forty years or more ago, there were hardly any specialists in private practice. The family doctor had to refer his patients to government hospitals if they needed specialist care. Now, one big change is the vast increase in the number of specialists in private practice.

Nowadays, specialists tend to specialise only in a particular and limited field. In the past, we had only general physicians and general surgeons. Medical knowledge and treatment procedures have advanced so much that it takes many years of training just to become such a specialist.

For example, for Internal Medicine alone, there are no longer general physicians who are trained to handle a wide variety of diseases. Instead, there are now physicians specialising only on certain parts of the human anatomy, such as cardiologists, gastroenterologists, renal physicians, dermatologists, neurologists, and endocrinologists, just to name a few. Surgery also follows this trend.

Changing scene in private hospitals
As mentioned earlier, the private healthcare scene has changed greatly. Because of this, cost of treatment has also escalated steeply.

In the past, doctors were in control in most of what they did when practising in private hospitals, but now, due to the commercialisation of private hospitals, which started about 20 years ago, doctors are no longer in control and have little say in the daily running of the hospital.

In the past, it was the medical superintendent, a doctor, who saw to the whole running of the hospital. Now, hospitals are run like a business concern, often by a group of businessmen who are not doctors. The administrators make the final decision. Doctors are just employees to make money for the hospitals, unlike in the past.

Private hospital practice is now getting more and more commercialised and less personal in many ways, including the doctor-patient relationship. This is due to the involvement of Managed Care Organisations (MCO). Cost of private healthcare has increased tremendously, partly due to this trend. It is really sad to see such penetration of commerce into the province of medical practice. In 1999, the Government was even considering privatising public hospitals. The plan was fortunately put on hold after the MMA protested. Privatisation will be disastrous for the poor, especially if the country does not have a suitable national health insurance scheme in place.

Managed care was first introduced in the US to cope with increasing healthcare costs more than 40 years ago. Now it no longer serves such a purpose, and has in fact become a big source of commercialisation of medical care, causing marked increase in healthcare costs.

Increasing drug prices
The tremendous rise in drug cost has affected medical practice to a great extent. In the past, medicines were very cheap, costing less than 10 sen per tablet, and many doctors practising in private clinics were able to even absorb the cost of medicine in their fees.

Now the price of medicine has escalated by leaps and bounds. In fact, some regularly used routine medicines such as those for diabetes, high blood pressure, or lowering cholesterol drugs, which you need to take regularly, cost up to RM5 to RM7 a tablet, which is a 50-fold increase! The cost of medicine now forms the main proportion of the total cost in a doctor’s bill.

Private doctor income
The changing trend of medical practice in Malaysia has affected the doctor’s income in private practice. Group practice is now more popular than solo practice. The general practitioner’s ability to earn a decent living is very much affected. This is due to the vast increase in overhead expenses, yet their charges have not significantly increased over the years.

Inflation has seen rising costs of materials, rental, electricity, and drugs, and this has affected the general medical practice.

Salaries for clinic assistants and nurses have also risen. Expenses now also include contribution to SOCSO and EPF, which have also risen. Rental and other bills such as water, electricity, and repairs have also increased.

In spite of all these, a doctor’s consultation fee has hardly increased. Consultations charged by doctors are now much lower than any other profession, including taking your pets to a vet surgeon, or your electrical appliances for repair!

Other professions, except doctors in general practice, have increased their income substantially. Even TV and car repair men are charging more than 10 times the previous rates. Food price certainly has increased tremendously. For example, a plate of char koay teow, which used to cost 30 sen, is now over RM5; thus an increase of nearly 20 times.

The great increase in the number of general practitioners has also affected their income. Even the increase in the number of specialists in private practice have also contributed to this due to patients going directly to see a specialist instead of their general practitioner first.

The Government’s effort to increase the doctor-population ratio unfortunately did not take into consideration the distribution of doctors, which tend to be concentrated in urban areas. There are already too many doctors in the urban area, and the Government’s effort to attain so many doctors in so short a time is affecting the quality of medical practice in urban areas.

The Government must be realistic in its target so as not to compromise quality.

Defensive medical practice
The practice of medicine is also heading towards defensive medicine due to more lawsuits and complaints. This has caused a marked increase in premium for medical insurance due to increasing claims and liabilities.

It can also make even the best doctors become too careful for fear of making mistakes. This will eventually also lead to increased investigations, referrals, etc, to avoid taking any risk, and thus will affect the quality of patient care. Because of this, medical insurance premiums will continue to rise steeply due to increased claims and liabilities.

Unfortunately, even the most careful doctor can make mistakes. There is too much expectation of doctors in general. Patients and even doctors themselves have created an impossible expectation of perfection, which makes it impossible and difficult for doctors to admit to mistakes and thus learn from them.

Society demands a perfect outcome from doctors. Even an isolated case of a mistake by a doctor will be sensationalised by the press. Other professionals do not face such expectations from the public.

Everyone is always so quick to blame doctors whenever there is a mistake. This is even so when the error was not directly due to doctors but their auxiliary staff.

In the US, nothing less than a perfect outcome is acceptable to consumers. It was reported that in 1993, an estimated 84% of US physicians practise defensive medicine to protect themselves from potential lawsuits. This also accounts for more problems arising from unnecessary tests, x-rays, and procedures, which in the long run will be even more harmful. For example, normal vaginal delivery has been replaced with caesarean sections at the slightest indication of difficulties.

Every procedure or treatment carries a certain amount of acceptable risk. Doctors should take every care to do his best in the performance of his duties to avoid being accused of negligence. It is important for doctors to have good communication with his patients.

Looking towards the future
The practice of medicine has certainly changed substantially. However, doctors should not abandon the old ways of spending more time with their patients; take more time to examine their patients, and take good history. Although the use of the latest equipment may be necessary, doctors should avoid being too dependent on them.

Doctors should make every effort to find ways to resist commercialisation of medical practice.

Before implementing any new rules affecting doctors, the authorities should seek the opinion of doctors who are well informed and knowledgeable of their own profession for discussions. This is in the best interest of the public as well as the medical profession.

There has been increasing pressure for doctors to adopt business strategies, which is in direct conflict with our professional ideals. Doctors must be trained and persuaded to resist such trends. Medical ethics must never be compromised and is a priority for doctors.

Hopefully in more years to come, we can still be respected as compassionate healers and not businessmen. Only those who have the passion to heal should become doctors.

Dialogue with Health Minister: MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

YB Dato’ Sri Liow Tiong Lai, Minister of Health,

Thank you very much for agreeing to have a timely dialogue with doctors and the MMA. I also wish to thank Mr Lim Eng Leong for facilitating this dialogue, which many of our MMA members have called for.

As is now quite well-known to you YB Dato’ Sri, there has been a lot of confusion, anger and fear among many private sector doctors, especially GPs (General Practitioners) throughout the nation when the issue of 1Malaysia Clinic was first broached by the Prime Minister during his Budget 2010 speech in October 2009.

MMA Supports Universal Healthcare for All, especially ready and affordable access for the poor

At the very outset, let me as President of the MMA, reassure the public, the government and the MOH that the MMA has never opposed whatever measures which may bring better access of healthcare to the rakyat, especially the poor and the marginalized, whether in the urban or rural locations.

We fully support every effort to ensure that the poorest among us, as of every citizen of Malaysia, must have easy, affordable and high quality healthcare, as a human right for all.

We fully appreciate that for many decades now, many world authorities, have praised Malaysia’s primary healthcare structure as being among the best among developing countries, the world over. We are proud that nearly every citizen of Malaysia has relatively easy access to a healthcare facility under a radius of less than 5 km.

Therefore, we recognize that this new endeavour by the government to provide 50 re-branded klinik kesihatan as easy-to-access “1Malaysia clinics” to the urban poor, is laudable and is in line with its caring concept.

However, while the MMA supports better, affordable and more accessible healthcare facilities to the public, the manner in which this has been announced, where they are to be sited, as well as the fact that these clinics were to be manned by medical assistants and nurses, took many doctors by surprise.

1Malaysia Clinics Manned by Non-doctors Cause Concern of Quality, Safety for Patients

Initially, my personal opinion is that just 50 clinics around the country would have very little impact on any doctor’s rice-bowl, although the MMA has reservations that opening these in urban areas appear redundant, because we already have so many GP clinics in almost every town in the country.  Datuk Dr Mah Hang Soon of Perak while visiting the soft opening of these clinics, alluded to the fact that there were already some 319 GPs in the four towns where these 1Malaysia clinics have been sited!

What we did not realize is that, many GPs are much angered by this move, which at first glance appear small and inconsequential to some of us. There has been much anxiety and confusion among many GPs from Johor Bahru to Penang, Kota Bharu, Kota Kinabalu and Kuching.

Many Doctors Confused and Angered

I have received literally, no less than hundreds of angry and condemning sms’s and emails demanding that the MMA address this issue, which they felt has been set up to unfairly impact on their services once again. Such was the general impression that they are once again bearing the brunt of perceived one-sided governmental action, following so closely on the heels of the Private Healthcare Facilities and Services Act and Regulations.

The major peeve/concern is the manning of these clinics by non-medically registered personnel, i.e. medical assistants and nurses rather than doctors. This approach appears to many GPs and doctors as taking many steps backward, despite reassurances that there will be oversight and supervision by some doctors from afar.

We thank YAB Prime Minister for trying to reassure us that our doctors will not be impacted, and that these clinics are simply basic ones to cater for monitoring diabetes, hypertension and some simple ailments. YAB PM left the question of expansion of these clinics opened, depending on the success of its popularity… Hence, our concerns remain.

No Real Doctor Shortage, Better Deployment the Answer

MMA believes there is no real shortage of medical doctors. The MMA feels strongly that doctors should be deployed to man these clinics. We understand the logistical problems, which have arisen time and again due to doctor reluctance to be relocated to more rural or remote situations.

Proper and fair deployment with guaranteed career paths for further training or preferred posting after such rostered ‘hardship’ postings will allow greater participation by ambitious younger doctors. Also if these 1Malaysia clinics are now to be part of the expanded public healthcare system, then the MMA believes that even more public sector doctors would be willing to be deployed in rotation or as part of a training initiative for an enhanced family practice/general practice vocation. Even rural or suburban ‘klinik kesihatan’s can be upgraded to doctor-manned clinics which would enhance the overall standard and quality of care for everyone, urban and rural.

Question of Legal Implications of Clinics to be run by Non-Doctors

Almost every one doctor who had complained, believes that this is wrong in law. Our Medical Act dictates that any health/medical clinic should be run by registered doctors only, yet while this is so for the private medical practitioners, there appears to be another law for government-backed facilities where this requirement can be waived!

That there appears to be one law for private doctors and another for the government or MOH has provoked a sense of injustice and deep anger, especially because quite a number of doctors who had fallen foul of this law had been severely punished recently. Some have openly asked why they cannot also employ MAs in their clinics, to look after simple basic health issues too, while each doctor can oversee a few clinics without being physically present!

Of course, the MMA does not and will not condone or encourage any doctor to break the law. There lies our dilemma of such a perceived differential application of the rule of law, which is increasingly questioned by more and more of our more vocal citizens.

If all these 1Malaysia clinics can be manned by doctors, even house or medical officers (registered medical practitioners) then this degree of unhappiness would be much dissipated. The MMA urges an overall upgrading of these clinics to that manned by at least a registered doctor. We believe this will help defuse the situation.

Safety & Quality of Care Concerns are real, likely to be better with Doctors

With such a move, there will not only be improving access to the poor but also ensuring safety, higher quality of care, possibly fewer errors, lessen medico-legal mishaps, despite the payment of only RM1! Of course, we can harness the special capabilities of the MAs and nurses to offer quicker access, but one that is supervised by a doctor. With such a move, the question of legality, more appropriate therapies, timely referral and even medical chits can be resolved.

A recent report by a group of doctors in Penang (Dr Jayabalan T and others, The Star, 07 January 2010, pg N45) stated that “A study in 2009 revealed that medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe.”

They concluded that “It must be noted that medical assistants are trained to assist medical officers and not to provide treatment in the same manner as medical officers.” Therefore, safety issues must always be considered. This is not to say that doctors cannot make mistakes, but with far more comprehensive training and education, these errors are expected to be fewer. Medical defence insurance, when taken up by doctors, also helps to ensure greater patient protection.

MMA shares World Medical Association (WMA) Concerns about Uncontrolled Task-Shifting

For many of us in the MMA, the delegation of duties in the 1Malaysia clinics to non-doctors despite its noble intentions of trying to reach out to more of the urban poor, is a form of task-shifting from the medical doctor, which is much feared and roundly cautioned by medical professionals around the world.

While some poorer nations with very short supply of doctors have resorted to task-shifting some of health care to nurse practitioners or health assistants (even encouraged by WHO), this is not the usual exercise for countries aspiring toward a higher standard of care. This contrasts starkly with our vaunted new approach to encourage greater Medical Tourism initiatives, and could lead to questions of uneven healthcare standards, and possibly safety issues. This could unfavourably impact our efforts to promote health tourism from safety conscious foreigners.

It is true that in Australia, UK, USA and some northern European countries, some of these paramedical practitioners have been tasked to look after screening and continued care of some chronic ailments such as diabetic or hypertension control, these are very closely controlled with very clear lines of responsibilities. There are also very different career paths for these health professionals who are usually degree holders with higher educational capacity and they also undergo further clinical practice diploma training.

Importantly, these do not replace the need for doctors, they assist them to help free up more time for more consultative, diagnostic or more special therapeutic roles. This exercise should never be an exercise for economic or other purposes. Safety and Quality of healthcare must always be our prime concern. I enclose here, the two recently passed resolutions and statements by the WMA for your perusal.

Utilise our Extensive GP Network

Our GP clinic network is extensive in the urban setting. All towns small and big have perhaps too many GP clinics. In major cities these are now even excessive and oversupplied. Many clinics are having concerns of viability and under-utilisation. Perhaps, some of these are not sufficiently popular because of poor preparation or other reasons, but most can be improved upon with proper distribution or dispersal of patients.

Therefore, many GPs have asked why they have not been roped in to help out in these clinics for the poor, if only the MOH or government can help reimburse these clinics to help out. We understand the differences in expectations, amenities and perhaps problems with reimbursement protocols, but these can be worked out for the benefit of all. Our GPs stand ready to be incorporated into a partnership, even an integrated system for better primary care for all our citizens.

The MMA is leading a primary healthcare workgroup to coordinate measures to raise the standards and quality of patient care among all our GPs and/or family physicians. This will enhance the quality of care even higher for our citizens. We are also working with the MOH to see how we partner or integrate the primary health care system in the country. Again differing standards of expectations, logistics and reimbursement mechanisms need to be sorted out.

In this context, the MMA welcomes the statement by the Prime Minister in his opening of the Kampung Kerinchi 1Malaysia Clinic yesterday, that ....”cases from here (1Malaysia clinics) will be referred to them (private doctors) for further examination or treatment...” and we hope that this will be implemented as quickly as the 1Malaysia clinics have been set up.

MMA Expects Greater Consultation & Shared Purpose for the Way Forward

Perhaps, less appreciated by government and MOH authorities is the fact that health matters and policy changes affect many sectors, including healthcare providers led by doctors, who should be the natural partners for consultation and engagement for the greater good of the public, the rakyat. The MMA is ever ready to be steady partner for working closely and supportively with the MOH, but we must not be taken for granted.

The MMA is not arrogant, although at various times, we have been accused of being too placid by our increasingly demanding members. We have been trying very hard to work with the MOH over many matters of shared interests—during the increased outbreaks of dengue fever, and the H1N1 influenza, we have been tireless supporters of many MOH initiatives which are not universally shared by some sectors and the public. Together, we believe the end results have been much better than we had feared despite initial uncertainties. Our rakyat’s overall confidence without panic seems to be the final result, which benefits all Malaysians. The pandemic flu second wave appears so far to have been kept in check.

Sometimes our differing methods of implementation may appear to have crossed purposes, but this is mostly due to misunderstanding and lack of communication. Although because of the rising doctor population, our percentage representation has declined to around 32%, the MMA still represents sufficient doctors in the country, in fact it remains the largest representative body for doctors with the longest and arguably the most dependable history of doctors’ interests and health concerns.

Although not always evident, most doctors do depend on MMA’s leadership to articulate some physician concerns, which are not so easily conveyed to the authorities. As civil and government servants, public sector doctors are bound by government orders and hierarchical levels of authority which implicitly gags many from raising legitimate concerns and criticisms. MMA thus fills in this unenviable void to voice concerns and doctors’ interests, without fear or favour because that is our remit, although this may sometimes be seen to be irritating and perhaps too ‘garang’.

We recognize that the government and MOH policy makers need a degree of autonomy to enact certain regulations and laws, but without adequate and proper feedback from the doctors or stakeholders on the ground, the implications might be unforeseeably difficult. Indeed many regulations are now seen to be fraught with real-life difficulties and incongruities, which have to be modified and streamlined.

The MMA believes that no authority or government can produce perfect policies, laws and legislations; we can help modify these regulatory frameworks, which ultimately work best for all concerned, in a win-win approach—we and other physician groups, should be engaged and consulted with, for the best cooperative approach to enhancing our healthcare system.

GP Woes are Real and Mounting

Many other problems remain to be resolved, which cannot be achieved by any party alone. Our private sector doctors and GPs are also concerned with many other competing issues such as feeder clinics, wellness health screening centres, pathology laboratories posing as clinics; MCO, third party payer or insurance discounting and selection, etc.

There are also rising complaints and perceived sporadic harassments from MOH officers implementing the PHCFSA, although these are supposedly for guidance for existing clinics, as was the understanding with previous Ministers of Health. Such pressures make the beleaguered GPs very sensitive to these threats on their practice, they seem to have been assaulted from all angles, with more coming on-stream, even before the other has gone away.

Glut of Medical Graduates Coming Sooner than Later

With the rising number of medical graduates, there is genuine fear too that very soon even the MOH cannot sustainably employ all these doctors. There would simply not be sufficient posts for the coming glut of doctors.

By 2015, there is a real possibility that there would be some 40 to 45,000 doctors. Some 1200 to 1500 medical graduates are graduating from our 23 local medical schools. Another 1000 or more foreign trained doctors are returning yearly, and these seem to be rising with each passing year.

Where will these doctors go to practice? Will the public sector be able to absorb all these doctors? We are already experiencing oversupply of house officers in all our major hospitals this year with some of these young doctors having to share a patient, and some departments allowing them to do shift work, quite unheard of before in the past!

Will the GP sector too be saturated in due time? Will there be any moratorium to stay the production of so many doctors, at least within the country? Will we become a diploma mill for medical graduates who would no longer have any career certainty of employability? Would we be following the path of the Philippines, Indonesia or India where surplus doctors have retrained to become more sort-after nurses to work in first world countries, This would be a great waste of our resources and severe drain of our citizens hard-earned savings.

Greater Challenges ahead, Let’s work together

We urge the MOH to work with the MMA to recognize and address the many legitimate concerns of the medical practitioners in the country that are mounting. We have to develop a much more refined and planned system of health care and all its encompassing concerns and provider needs.

Otherwise a potential crisis of unimaginable proportion could arise, which could unleash even greater problems both for disgruntled healthcare providers including very expensively trained doctors, who may have too little to do or even unemployed!

Let doctors have greater and more meaningful input to help resolve some of these issues to help bring about the best health care system for our country.

Dr Rahul Parikh: Health Reform Should Be About More Than Money

Health Reform Should Be About More Than Money

Dr Rahul K. Parikh
OCTOBER 7, 2009 10:00AM

There is plenty to criticize in our bungling trek toward health reform.  Leaders on the right, left and at 1600 Pennsylvania Avenue  have sidestepped the crucial conversation of controlling the cost of care, in favor of partisan rhetoric about "death panels" and  "rationing care."  Worse, the entire focus of reform has centered on spending billions of dollars on technology solutions that will only make marginal changes in the cost and quality of care Americans get.

I want to refocus the debate on what matters most: relationships.  Let's reinvest in the sitting down with, listening to, empathizing with and touching patients.

America has the most advanced healthcare system in the world. But in our haste to research, develop and invest in high-tech medicine, we have lost sight of the very basics of good doctoring. The first things we learn in medical school are: ask, listen and touch. Doctors do not do enough of this any more.

As has been made painfully clear, most doctors are rewarded for doing all manner of procedures.  This is true from the earliest moments of our career. As a resident, even when faced with the most basic medical problems,  I was grilled by my attending when I didn't order the full battery of tests, or contact all the specialists available to consult on a patient. Thus, over-testing and over-treating becomes a knee-jerk response from the get go.

This is how doctors practice medicine today. Some of us do it this way because it's how we get paid. Some of us refer our patients to specialists because we don't have time to sit down with them ourselves. Some of us rely on tests and procedures because we're fearful of malpractice lawsuits. And most of us have just lost sight of the most powerful tools in the doctor's arsenal: our hands and our minds.

I'll illustrate this with an example. Once while still a medical student, author Dr. Sandeep Jauhar evaluated a man with chest pain whose lab tests and EKG suggested he was having a heart attack. The patient was admitted to the ICU. Hours later, the patient was in severe pain and his blood pressure had dropped. The resident in charge ordered another EKG and prepared to intubate and place a central line in the patient.

In the midst of this, Jauhar took the patient's blood pressure. For reasons then unclear to him, the resident instructed Jauhar to repeat the exercise -- on the patient's other arm. Jauhar tried, but above the din of beeping monitors and barking doctors, he couldn't hear the pulsing sounds through his stethoscope. Jauhar "shrugged and let it go."

Sometime in the night, the patient underwent a CT scan. The next morning Jauhar learned his patient hadn't suffered a heart attack, after all. Instead, it was an aortic dissection - a tear in the wall of his aorta, leading to severe internal bleeding. Worse, with the time lost to the misdiagnosis, the dissection was now inoperable. The patient died later that day.

I use this example because the diagnosis ultimately confirmed by a $1,000 high-tech CT scan would have been evident from the low-tech hands-on procedure Jauhar  shrugged-off. A discrepancy in blood pressures between the right and left arm is a classic indicator of aortic dissection, and easily distinguishes the condition from a heart attack.

Consider that a blood pressure cuff costs just a few dollars, compared with the hundreds of thousands of dollars in sophisticated ICU and ER equipment that the medical team employed trying to solve the riddle of the patient's condition. These same high tech tests and procedures also led the medical team down the wrong path. So much for the certainty we believe technology gives us.

If Jauhar had employed the basics of physical exam might the patient have lived? Possibly. In my own recent experience, I saw a young boy whose mother told me he seemed to be clumsier than other children his age. She had mentioned this to previous doctors, as well. When I examined him, I noted very brisk reflexes and an unusual flapping motion in his feet. This is called ankle clonus. I referred the mother to a pediatric neurologist. I learned shortly thereafter that her son wasn't just clumsy. He has cerebral palsy. This is a diagnosis that must be made clinically; oftentimes an MRI or a CT scan cannot detect CP because there are no discrete visible findings. The happy ending is that physical and occupational therapy can ameliorate the boy's symptoms.

My point is that not all of the system's ills can be solved with high technology - nor should they be. If you believe that reforming health care is essential for our country's future - and if you're at all mindful of our fiscal state -- then you've got to be open to other strategies besides throwing billions of dollars at the problem.

We can start by leveraging the basics. For doctors like me, this means re-learning value of the patient history and the head to toe physical exam. It means weaning ourselves off our dependence on technology, tests and procedures.

In a better system, doctors won't be rewarded for doing everything.  Instead, they will be rewarded for doing the right things. They'll use their heads and hands to decide how to spend our healthcare dollars - and I can promise you they'll spend less of them in the process.

This is how we could do it. This is how we should do it. Simply by re-prioritizing medicine's hands-on basics we can make great strides toward improving healthcare, without spending a dime on more technology.

--------------oooooooooo0000000000ooooooooooo----------------------

My Comments:

I have been very vocal about this for a long time. In this day and age of high-powered diagnostic tools and advanced technical instruments/skills, our growing dependence on these have crippled our clinical acumen. 

We are giving less and less time to our patients and allowing techniques and technology to replace our professional skills. Partly because, doing more tests or procedures means more reimbursement, so that we cannot be truly objective about our conflict of interests, our moral hazard. 

Perhaps, it is time to reward good clinical medical practice while saving some costs, and perhaps help reducing the risks and discomfort of some procedures which may be redundant or superfluous...

Breast Cancer
Today, one of my patients who is a  very health conscious woman, returned for her BP review after she had lumpectomy for breast cancer. Her cytochemical HER3 was positive, but oestrogen and progestin markers were negative.

This cancer was discovered on routine mammography about a few weeks ago; she had been faithfully having mammography annually for more than 15 years. Her late mother had breast cancer at 80 years, and she was worried that she could inherit this risk. 

She also had a CT angiogram done at another centre because a friend recommended this, because she was worried about her atypical chest pains. A few years ago she had a total body CT scan, again for health screening purposes--found some cervical and lumbo-sacral spondylosis, which made her nearly worried to death about her possible limp and neck/back ache. 

Since menopause, she was on hormone replacement therapy for 5 years, stopped for a year or two and then restarted on MHT/HRT for a further few years, only to stop when she developed hypertension about 4 years ago. She is now just 66 years old. Now she is contemplating further chemotherapy...

I just wonder if her breast cancer could have been the result of all her radiological exposure (MSCT thorax has been calculated to increase cancer risk in women in some recent studies), her hormone replacement therapy (WHI, NEJM), her stress levels, a multiplicity of risk factors, just enough to tweak her small genetic risk a little to manifest earlier, as potential co-carcinogens. I wonder...

Perhaps. less done might have been less harm...

MMA: Treading between Advocacy & Professional Balance

MMA: Treading between Advocacy & Professional Balance

President's Page, MMA News, October 2009

“There is no career nobler than that of the physician.  The progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession than with the status of any other class...” ~ Elizabeth Blackwell, M.D., 1889

Medical Professionalism and our Caring Vocation

As medical professionals, our patients should be our raison d’être, our sine qua non for existing.

However, as is becoming more evident, daily societal developments pose severe challenges to our medical profession. Our role as physicians sometimes appears to come into conflict or competition with society’s other demands—some social, while others, political.

Yet, we must choose a careful path, treading a thin line between strident but necessary advocacy and rational professional balance on the other. Above all, we must remain steadfast as our patients’ strongest advocate—their health interests must precede all others. 

During the start of my term of office, I had highlighted that I would emphasise the more humane aspects of the medical professional, that kindlier face of the doctor as we interact daily with our patients. As physicians, we must strive to always practice our craft without that edgy touch of cynicism, jadedness and/or burnout.

We must project that long-forgotten intimate encounter which makes us the most trusted and respected amongst professionals. We must re-ignite that fervour to make this a daily reality for our patients and all those whom we connect with through all walks of life.

But this must be through one’s personal conscious effort—it does not come naturally to most of us… The good thing is that we can learn and adapt until this becomes a part of our attitude, our persona.

My personal daily goal is to see if I could get each and every one of my patients to leave my consultation room with a contented smile; yes, despite the fees, the test results and burden of illness. The hospitalized patient poses a rather more difficult problem—many are too ill or too discomfited to be satisfied, but he or she can usually be consoled, especially when we show that we care. And most patients can actually sense our sincerity and our empathy.

But this is by no means a given. We all have our off-days, days when we are troubled by our own unresolved nagging tribulations and private burdens. Just to shake off these deep-rooted weights would make most of us sullen, poorly communicative people, who would not normally be expected to make good counsellors or empathetic muses!

Yet, that is expected of us, to perform even in the midst of personal distress and overbearing internal conflicts. I have striven to do this for some years now, but sometimes this just isn’t possible. Undoubtedly, this will increase our stress level which is now recognized even by our own citizens! In a recent poll, Malaysians had voted doctors as the second most stressful job among the professions, the PM's position being the one to beat!

How do we inform seriously ill patients that their ailment is life threatening, or even terminal? How do we get the patients and their loved ones to come to grips with the dire prognoses, the possible huge treatment costs, and the uncertain outcomes for some illness? How do we sometimes admit our limitations that even we do not have all the answers?

Yet on the more mundane aspects, how do we continue to inculcate a sense of shared intervention and commitment to some therapeutic regimen for some chronic ailments such as hypertension, diabetes, etc.? We need to constantly urge even ‘gently berate’ our patients to stay on treatment for the best outcomes in the long term, especially when the symptoms are covert, apparently nonexistent, or even silent?

As doctors, we must regularly remind ourselves that among the professions, we are perhaps the only one that demands a caring value system. We must constantly remind ourselves of this duty.

Yet again there are other issues, which demand our action and our input, at least this is what I have pledged to do. There are problems with some of our health care services such as our forensic service, which has been under the spotlight recently.

Careless and callous attention to detail has created great public uncertainty, dismay and disbelief, which undermines the critical function of our forensic pathology services. The MMA naturally would stress that forensic health care is every bit as essential for the final truth and professional determination of causation of death or injury, especially of anyone under detention—as is demanded of us the medical professional, in WMA’s Declarations of Tokyo and Istanbul.

 

Let us practice the noble art of medicine as has been enjoined upon us from time immemorial.  Let us engage more meaningfully and help shape the kind of medical practice that we would all be proud of. 

Ongoing Challenges

Just 4 months into the fiscal year, and the MMA continues to face new or resurgent challenges. Some of these are simply perennial issues, which surface periodically when political awakenings rekindle them into topical issues of importance of the day. Others are the result of unforeseen or poorly planned policies that have now come home to roost with outcomes that seriously impact our profession and our practice.

1. Competition is becoming more intense than ever. We continue to have complaints of community pharmacies posing as clinics, providing discounted medicines to unsuspecting patients who have elected to purchase their medications without prescription. This continues to take place, despite MMA’s consistently vocal stance that safety issues and laws have been breached.

We also have the understanding from the Malaysian Pharmaceutical Society that it is trying hard to rein in their pharmacies, their members. But the MPS has also repeatedly called for a greater if total separation of duties—to let each professional earn his/her true value and worth.  The MPS continues to urge that perhaps doctors can start by being a little more transparent in their prescribing and dispensing habits. We are trying to resolve some common interests through greater dialogue, which may benefit both parties as a win-win approach—but we are a long way off a final agreement or compromise.

In most urban centres, there is a glut of side-by-side clinics, thereby causing intense competition for patients both from self-paying patients as well as for panel contracts or even third party payer MCOs, which are demanding depressingly low capitation fees for services.

Latterly, there were reports of some private medical centres/hospitals expanding their coverage with feeder clinics and wellness centres. Undoubtedly, these are patently to recruit more patients for their services, their laboratories and their hospital facilities. 

We have recently sent notice of our displeasure to the press, and urge the authorities to nip these practices in the bud!

 

2. ‘1Malaysia Clinics’ & Task Shifting

There have been some global trends toward professional task shifting, now increasingly contemplated and advocated worldwide following WHO initiatives to reach out to very poor countries, which lack properly trained medical personnel.

This essentially means that so-called ‘simpler’ healthcare responsibilities would be shifted down to lesser (more specifically and focussed) trained, cheaper to maintain personnel e.g. nurse physicians, medical assistants, pharmacist assistants, etc.

And now during the recent Budget 2010, we received yet another shockwave to the equanimity of our urban GPs—the just announced ‘1Malaysia clinics’ to be manned by medical assistants! One would have thought that this model is a relic of the past!

In the pre-1980s, it is true that we had utilized medical assistants and ‘jururawat desa’ to help out in more remote rural clinics. They certainly provided a great much needed service then.

But, these are now increasingly scaled down so that doctors can oversee more and more of these services to enhance greater quality and service even to our rural or more remote locales.

Therefore, MMA has immediately opposed what we feel is a hugely retrogressive approach to health care. We are saddened that this approach had been suddenly sprung upon us. We understand that sometimes ‘pork-barrel’ goodies need to be dished out, but we envision these so-called ‘1Malaysia clinics’ as simply exercises to exude political goodwill. This may temporarily salve some very poor urbanites, but we fear that in the longer term, this exercise may be shortchanging the less discerning marginalized public. Regulatory and medico-legal aspects, potential abuses and unethical practices remain to be ironed out.

However, we have counter-offered that our already very available and plentiful GP clinics be tapped to help provide these outsourced MOH initiatives, as more suitable alternatives. We are made to understand that the Minister of Health sympathises with us in this, although it would appear that the MOH has to contend with other Cabinet portfolios for ‘public service’ projects and financial resources…

For our country, which continues to produce so many new doctors—some 2500 per annum, this will be catastrophic for our younger graduates, who might in future not have enough jobs to function, and whose remuneration may be sharply reduced. We need to enlighten the government that this may not be the best approach. Standards of health care cannot be compromised or made expedient just to accommodate to some economic or short-term considerations.

3. CPD/CME & MSQH Accreditation Standards

Another issue regarding professional standards has also to be resolved. As doctors, we must constantly be upgrading our standard of care and professionalism, as well as our currency of our medical knowledge, i.e. we must keep up with CPD/CME activities.

Our clinics and amenities must be enhanced and modernized in keeping with public expectations, keeping cost-cutting measures at a minimum so as not to jeopardize the public perceptions that GPs are only mercenary and venal, and too profit-orientated!

The Malaysian Society for Quality in Health (MSQH) has been set up to help modernize the standards of health care in Malaysia. As a very dynamic entity, it has been working hard to enhance its value by being a lot bolder in its push for more if not all clinics to be accredited as of sufficient quality. This aggressive approach may pose yet another round of regulatory burden on us, the private medical practitioner.

As an initial founding partner, the MMA appears to have been rather silent, in the past. Perhaps to be fair, some of these exercises and progress of the MSQH reach have been hitherto understated, and its potential for burdening the GPs not fully realised. As president just recently exposed to the intricacies of the MSQH exercise, I will work to address such concerns so that doctors will not be subject to any more regulations and new Acts.

Furthermore, we need to work with the Academy of Family Physicians (AFPM) to see if we can re-organise the frame of reference of upgrading and updating our GP/FP practices. At the most, we will accept MSQH as a reference standard purely on a voluntary basis, which should in no way reduce our acceptance with any distribution of work or panels or third party payer contracts or business opportunities.

Most importantly, the MMA needs all your support and members must all come forward to be bold in defending this stand.

Let’s work together to ensure that we provide the best to our patients without overburdening our capacity to cope. Let’s come together to self-regulate and engage in self-improvement techniques, credentialing exercises and standards attainment, which are the hallmarks of mature medical systems the world over.

In this way, we can together persuade the authorities and policy makers that we can be trusted to provide the best and most professional healthcare for all our patients without fear or favour, and certainly not at our professional expense!

H1N1 flu: Insurance companies should reimburse for hospitalisation costs

Insurance companies should reimburse for hospitalisation costs even if due to pandemic flu...

The Star highlights the plight of some ill flu patients who could not get reimbusement or coverage

A(H1N1) virus continues to spread worldwide, more deaths reported

A(H1N1) virus continues to spread worldwide, more deaths reported

BEIJING, Aug 15 — The death toll from the A(H1N1) flu pandemic continues to rise as the new virus persists in its advance around the world, health officials say.

The European Center for Disease Prevention and Control said in its daily situation report on Wednesday that 873 new A(H1N1) flu cases were reported in the European Union and European Free Trade Association countries. The number of cases there now totals 35,025, according to a report by China’s Xinhua new agency.

The European Union Health Security Committee has agreed on a coordinated EU approach to A(H1N1) flu regarding school closures and monitoring of travellers.

The French government has prepared to close schools on a case-by-case basis if the A(H1N1) flu becomes a nationwide pandemic, Education Minister Luc Chatel said on Wednesday.

France so far has recorded around 1,000 A(H1N1) flu cases and one death.

The government fears that the spread of the virus could accelerate when the new school year starts this fall.

In Greece, the A(H1N1) flu cases totalled 1,424 as of Wednesday, including 422 additional cases confirmed during the past week.

Finland on Wednesday confirmed the second case of the flu in its Defence Forces, according to a statement released by the military.

In Latin America, where the flu began in April, more deaths have been reported in the past two weeks.

Mexico has registered 17 more deaths over the past two weeks, raising the total death toll there to 163, Health Minister Jose Angel Cordova said Thursday.

He also said the government is ready to apply the first A(H1N1) flu vaccines to cope with the virus.

Brazil remains the country with the third largest number of A(H1N1) deaths, after the United States and Argentina. It registered three more deaths from A(H1N1) flu Thursday, raising the death toll to 277.

The Brazilian Health Ministry has decided to postpone polio immunizations scheduled for Aug 22, fearing that crowding in hospitals could lead to more flu infections.

Meanwhile, Chile confirmed a total of 105 A(H1N1) deaths on Thursday while the number in Argentina stood at 386 on Wednesday.

Nicaragua on Wednesday confirmed its first A(H1N1) influenza death, a 30-year-old woman, the Health Ministry said.

The disease also was spreading to high officials in Latin America.

Costa Rican President Oscar Arias is being quarantined at home and is in stable condition after testing positive for the A(H1N1) virus, official sources said Wednesday.

Ecuadorian Policy Minister Ricardo Patino was also diagnosed with the flu, the Health Ministry reported Thursday. He is now being treated with anti-viral medicine at home.

In the northern hemisphere, the A(H1N1) virus continued to spread across the hard hit United States.

The death toll from the A(H1N1) flu by Wednesday had reached 104 in California, the most populous state in the country, with 1,057 people hospitalised, the California Department of Public Health said.

Meanwhile, the state of Lousiana, one of the few states that had reported no deaths or few confirmed cases of the flu virus, confirmed on Thursday its first death from the disease.

The deadly virus has also hit Middle Eastern countries. Israel registered its eighth victim of the pandemic on Wednesday, according to the Health Ministry.

Saudi Arabia confirmed two new deaths from the flu Thursday, bringing the total death toll there to 11. The Palestinians have confirmed only one death so far.

In Africa, the situation is more delicate given widespread poverty and diseases such as HIV and tuberculosis that make people more vulnerable to the virus.

The South African government has launched an intensive information campaign to help people cope with the pandemic, Health Minister Aaron Motsoaledi said Thursday.

He also said the country so far had 1,910 confirmed cases of A(H1N1) flu and three deaths.

The pace of the virus has not eased in Asia, either.

Malaysia reported on Thursday seven more deaths from A(H1N1) flu, bringing the total number of deaths there to 51.

On Tuesday, Thailand’s Public Health Ministry announced 16 more A(H1N1) – related deaths, raising the country’s death toll to 97.

The flu has so far killed 22 people in Bangkok, 10 in Singapore, and two in Vietnam.

On the other side of the Pacific, Jim Bishop, Australia’s chief medical officer, said Thursday that the number of A(H1N1)-related deaths in his country has reached 102.

He said 449 people are hospitalized with the flu across the country, 109 of them in intensive care.

Even the small island nation of Tuvalu has not escaped the pandemic. Its first six cases of influenza A(H1N1) were confirmed Thursday, Radio Tuvalu reported.

The flu has caused 1,462 deaths worldwide since it was first detected in April, the World Health Organisation (WHO) said Tuesday. – Bernama

Health DG says doctors must assume all flu cases to be H1N1

Health DG says doctors must assume all flu cases to be H1N1














Live videocast of the interview...

Pharma-Physician Relationships Rethink...

Industry gift bans slammed for overreaching

Some physicians criticize the bans as going too far and harming innovation.

By Kevin B. O'Reilly, AMNews staff. Posted Aug. 10, 2009.

---

Pressure is mounting on Capitol Hill to reveal the financial relationships among doctors, drug companies and devicemakers through the Physician Payments Sunshine Act.

Six states already have enacted payment-disclosure laws or bans on gifts to doctors. Meanwhile, more medical centers are restricting doctors' and students' interactions with industry, as calls grow for medical societies and educators to turn down drugmakers' dollars.

But now some doctors and physician organizations say the push to police financial relationships with industry has gone too far.

In late July, a new organization called the Assn. of Clinical Researchers and Educators held its charter meeting before a 200-plus crowd in an amphitheater at Brigham and Women's Hospital in Boston. Participants assailed conflict-of-interest rules that they argue impede physician-industry collaboration.

Recent statements from organizations representing cardiologists and endocrinologists also have defended the value of industry funding in helping to develop better treatments and improve medical practice.

Massachusetts has the nation's most restrictive law on industry gifts to physicians.

One ACRE founder, Thomas P. Stossel, MD, said critics of physician-industry relationships are "pharmascolds" who aim to bring about a "conflict-of-interest police state." ACRE represents the views of many doctors who had steered clear of the public debate, he said.

"There's been this unanswered barrage of criticism saying that physician-industry interaction is corrupt and harmful to patient care," said Dr. Stossel, a professor of medicine at Harvard Medical School and director of translational medicine at Brigham and Women's. "The tipping point came when some of these states started to pass confusing and demeaning laws, and when the academic health centers started telling people who they can associate with."

New Massachusetts regulations -- the most restrictive in the country -- took effect in July. They bar drug- and devicemakers from providing gifts to physicians and require public disclosure of most payments exceeding $50.

What especially has some physicians upset, Dr. Stossel said, is the Assn. of American Medical Colleges' 2008 stand that industry-sponsored speakers' bureaus not include medical faculty. Many ACRE leaders have been paid by drugmakers for research, speaking and consulting.

"These rules are not helping patients, and prohibitions are being imposed on activities that have real social value," Dr. Stossel said.

ACRE has not yet taken positions on issues such as the Sunshine Act, though members said they generally favor transparency, if it is not used to demonize physicians who work with industry. On its Web site, ACRE said it wants "to reverse policies instituted curtailing or minimizing interaction between industry and physicians, educators and researchers."

The trend of increasing Industry support for CME reversed in 2008.

One of the speakers at ACRE's charter meeting was Carey Kimmelstiel, MD, director of the cardiac catheterization laboratory and interventional cardiology at Tufts Medical Center. He said industry-funded quarterly educational meetings of interventional cardiology fellows in the Boston area have been put on hold indefinitely, thanks to the state's new regulations.

"The funding's dried up," he said. "In the current environment, where physicians are squeezed every which way, if you lose industry funding, it's very difficult to make that up on your own with your own dollars."

Nationally, industry support for CME fell 14% from $1.2 billion in 2007 to $1 billion in 2008, according to a July report from the Accreditation Council for Continuing Medical Education. The 2007 figure was a quadrupling of the $302 million spent in 1998.

The AMA House of Delegates has twice in the last year considered Council on Ethical and Judicial Affairs reports aimed at ending industry influence on CME. CEJA will take up the matter again in late August.

Meanwhile, AMA policy on gifts to physicians says it's OK for doctors to accept items from industry that are worth less than $100 as long as they are related to care and benefit patients.

An April 1 Journal of the American Medical Association article called on medical societies to aim for zero dollars from drugmakers.

This didn't sit well with American College of Cardiology President Alfred A. Bove, MD, PhD. Such proposals "assume [physicians] all are easily influenced by relations with industry and need to be regulated," he wrote in a July editorial in the Journal of the American College of Cardiology.

"There must be a middle ground," Dr. Bove wrote. "Physicians should be able to conduct industry-funded clinical trials or consult with industry without being tainted with an assumption of lifelong misbehavior."

The American Assn. of Clinical Endocrinologists and the American College of Endocrinology issued a joint statement in June saying, "There is no inherent conflict of interest in the working relationship of physicians with industry and government."

Houston endocrinologist Steven M. Petak, MD, led the task force that developed the statement. "There have been some abuses, but for the most part, physicians have the best interest of their patients in mind," he said. "We are concerned about insulating physicians from being able to learn about new products and how they fit into their armamentarium, and that patient care will suffer because patients will be locked into a certain set of choices that may not represent the best choice for that individual."

Denying problems?

Defenders of doctor-drugmaker financial ties are operating on a flawed premise, said Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch.

"There is this total denial of any systemic problem, or any real reason to be cautious or concerned or have any real guidelines that have any real teeth in them," said Dr. Brody, author of Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry. "I just wonder, 'What planet are these people living on?' "

Nothing is stopping physicians from working with drug- or devicemakers, Dr. Brody said. "There's absolutely nothing in any of these guidelines or recommendations that prevents fruitful exchanges of information and knowledge between anyone in academia and industry. All we are talking about is when you line your pockets as a result. If what you want to do is, in fact, discover new drugs, no one's stopping you."

The print version of this content appeared in the Aug 17, 2009 issue of American Medical News.

---

ADDITIONAL INFORMATION:

Weblink

Assn. of Clinical Researchers and Educators (www.acreonline.org)

"President's Page: Relations With Industry: Thoughts on Claims of a Broken System," Journal of the American College of Cardiology, July 7 (content.onlinejacc.org/cgi/content/full/54/2/177)

"Professional Medical Associations and Their Relationships With Industry," abstract, Journal of the American Medical Association, April 1 (jama.ama-assn.org/cgi/content/abstract/301/13/1367)

"Conflict of Interest in Medical Research, Education, and Practice," Institute of Medicine, April 28 (www.iom.edu/cms/3740/47464/65721.aspx)

"PharmFree Scorecard 2009," American Medical Student Assn. (www.amsascorecard.org)

---------------------oooooooooooo00000000000oooooooooooo--------------------------

Are Doctors Violating Patients’ Confidentiality Rights?

This article is also published in the MalaysianMirror as a letter in reply, 16 July 2009














The National Union of Bank Employees (NUBE) had accused doctors of violating their patients' privacy, through various press releases on 13 July 2009.

Doctors are always faced with many dilemmas, when attending to patients who come to their clinics or hospitals for medical treatment, through a third party payer (TPP) mechanism. While we all have a duty and responsibility to attend to patients, with the strictest confidentiality, there are also reality bites which dictate that doctors have to abide by certain technical requirements.

One of these, is to complete insurance forms or Managed Care Organisation (MCO) forms, sometimes even before any medical consultation can begin. Oftentimes, there're also more forms to fill, post treatment or during treatment, estimations of costs, etc. when complications or prolonged stays are anticipated.

However, all of these forms require that the patient i.e. the employee, agree to and sign a formal consent for his/her medical condition and treatment details to be made known to the third party payer, which often serve as independent managers whose function is to help regularise and contain healthcare costs.

Whether this is to be construed as a conditional guarantee letters (GL) is subject to different interpretations by different people. But unfortunately, that is the process, which the employee has to work out, or agree to, with their employers as a benefit of employment. Like it or not, someone has to pay for treatment; even when self-paying, there is that implicit agreement that some payment is expected.

Panel doctors serve a similar function, at trying to keep costs reasonable and within ready checks and balances. However, disclosure of personal information about the employee’s health or medical conditions directly to the human resource department of the employer may sometimes be seen as breaching these confidentiality rules, and must be carried out with great circumspection and care.

The rationale for such disclosure is so that no frivolous or fraudulent claims can then be made, and the costing of some of these treatment schedules can be checked for consistency and that these are done in accordance with regulations and agreed reimbursement guidelines.

This is the reality that is the process of these third party payment schemes, which help to justify charges and reimbursement. Most employers demand such justification.

Strictly speaking, this exchange of information is purely to help the process of transparency and regularity of the billing process. Some insurers have on occasions even denied hospitalisation or treatment suggestions based on their so-called gate-keeping function to help curb cost and over-utilisation. In many instances, doctors have helped to smoothen some of these disputes in favour of the patient (employee).

Our doctors’ Code of Ethics dictates that one's health status and medical conditions are always personal and confidential, thus it is hoped that these third party payers would be willing to apply such strict confidentiality rules when interacting with the employers who are the ultimate paymasters.

Doctors will always support such strict interpretation of these confidentiality concerns, but we cannot be held responsible for what some of these third party payers would do if they breach these conditions, so as to justify payment claims.

While such information helps to put some substance into claims, to facilitate and validate the medical treatment process, it is not intended to and should not be used to disclose personal health records and data to the employers, unless expressly agreed to by the employee or patient.

Of course, it is possible for employers to place the fear of nondisclosure to mean non-approval for the intended medical benefit that is sought for by the employee. However, this arrangement and employer-employee agreement should be strengthened to strictly abide by such privacy concerns, and should never be used for victimization.

The MMA strongly believes that personal details should not ever be revealed to the employer, which may jeopardise their working conditions or promotion aspects. Moreover, when requested to provide medical reports to anyone other that the individual patient, doctors are reminded to stringently adhere by these confidentiality rules, and be very careful about divulging any information which has not been authorised by the patient.

It is good practice to show the patient a copy of the letter or report and allow him or her to keep a copy even, get a signed consent, before sending this off to the employer. Medical reports are almost always given only to the patient, and rarely to his/her designated agent.

Herein lies the problem with these insurance pre-admission or pre-medical check forms, which must be approved prior to the medical process. They must also accompany the bills, but which must always also mandate the patient's permission (as a required signature), usually witnessed in full view of the doctor or his assistant.

How the third party payer then uses this information is unfortunately not within the purview of the doctor. Of course, doctors always support confidentiality and privacy rules, which is every patient's right. Therefore, it is untrue to say that doctors work in cahoots with these insurers and the banking establishment or any employer for that matter, to violate these privacy rights of the employee or patient.

In fact, the MMA fully supports the view (and perhaps through an improved regulatory framework) that protects the patient's personal information such as health or medical status. We support that such information be considered as fully confidential and only used impersonally (without identifying details) for the above disbursement or checking procedures, and should not be divulged to the employers, unless agreed to by the patient concerned.

Are there any circumstances, which allow a doctor or a panel of doctors to reveal their employees’ medical backgrounds to their employers? Without an expressed consent, the answer is an emphatic NO!

Some pre-employment medical check-ups are conditional, and are within the prerogative of the employer, which will usually demand full disclosure of health status and history before confirmation of employment. Such is the right of the employer or employing agency, and is usually made well in advance for the employee to agree to and formally approve before disclosure. Thus, this is a pre-employment agreement that is made in full cognizance and fully consented to, by the employee.

In certain conditions which require prolonged recuperation or when there is a need to modify work conditions, such as following a heart attack, stroke or certain major surgeries, some explanation to facilitate the employer's agreement to such work-related changes may be required. These are often requested by the recovering employee and are fully supported by doctors. In other words, doctors have always been very sympathetic and empathetic to employees as patients, and will always place their interests first and foremost.

Therefore, the statement by NUBE secretary-general J. Solomon that "this is not only a form of harassment but a clear violation of basic human rights and infringes on their privacy...", while understandably frustrating, needs clarification.

However, it is mischievous of NUBE to label doctors as colluding with employers to harass their employees. This is almost certainly never the case. In fact in the past when such requirements were mandated pre-treatment, many of us physicians protested exactly on such confidentiality concerns. It was only then that the Third Party Payers (TPPs), came forward with the requirement of the employee to acknowledge and sign their consent for divulging their medical information to the TPPs, that doctors agreed.

As concerned doctors, we continue to maintain that such information be used strictly to help facilitate issues of cost-checking, medication or investigation consistency, and reimbursement guidelines. No personal medical detail should be disclosed to the employer, which may prejudice the employee’s employability or personal status, or which may be used against the employee.

In many instances, doctors have bent backwards to help and assist their patients to access certain medical tests and therapeutic procedures, which have earlier been denied by their gate-keeping third party payers (TPPs) such as Managed Care Organisations (MCOs) and insurance agencies.

The MMA is also working closely with the Ministry of Health to come up with some comprehensive Regulations and Act to ensure that these MCOs and TPPs function within the remit of the law and thus protect the patient's rights more comprehensively. We understand that the MOH is in the final stages of putting this Act through Parliament.

In the meantime, we urge the banks’ unions to work out more consistent and transparent agreements so as to safeguard their members’ interests, privacy and rights. But please, remember that doctors are your friends and not ogres that we’ve been made out to be!

This article has now been published as a commentary in malaysiakini 16 July 2009

------------------ooooooooooo0000000000oooooooooooooo------------------------

Dr David KL Quek
President, MMA