Friday, December 19, 2014

The Star: Confusion over GST and healthcare ..... by Dr Milton Lum

Confusion over GST and healthcare

by dr milton lum

The Doctor Says
The Star: Sunday December 7, 2014 MYT 12:00:00 AM         
Our columnist wades into the murky waters of what is exempted from GST and what is not in the private healthcare sector.

THE private healthcare sector is amorphous with various modes of organisation, ownership and payment by patients. Most interactions between the public and this sector are with clinics and/or hospitals, which is what this article is about.

Some clinics are stand-alone , while clinics in hospitals may or may not be physically and/or administratively linked to the hospitals themselves.

Meanwhile, hospitals can be single entities or part of a group, and are owned by limited or public companies.

Healthcare services are provided in clinics and hospitals, while some general practitioners provide such services at the premises of large organisations.

Clinics are operated by solo doctors who are general practitioners or specialists, or groups of doctors.
There are also groups of clinics, the owners of which are solo doctors, partners, limited or public companies.

Specialists practising in hospitals may be self-employed or employed by the hospital. They may be full-time or part-time, i.e. visiting during certain hours to provide services in accordance with a contract.

Payments made by patients comprise consultation fees; procedure fees, if any; investigations e.g. laboratory and radiology; medicines; and hospital accommodation and services.

Many general practitioners charge a composite fee for the services provided.

Specialists, general practitioners and hospitals have separate charges for the various services provided.

Doctors’ professional fees in clinics and hospitals are regulated by the Private Health Care Facilities and Services Regulations, but private hospitals’ charges are not regulated at all.

Prime Minister Datuk Seri Najib Tun Razak, in his 2014 Budget speech on Oct 25, 2013, stated that education and health services were to be exempted from the GST (goods and services tax).

In his budget speech on Oct 10 this year, he stated that: “Transportation services, such as bus, train, LRT, taxi, ferry, boat, highway toll, as well as education and health services are exempted from GST.”

The Customs department has taken steps to implement the GST. During the past few months, its Guide on Healthcare Services ( has been issued (and reissued) on Oct 29 and Nov 16 and 19.

The proposed implementation of the policy has been somewhat different from that announced by the
Prime Minister though.

Essential medicines
The Health Ministry (MOH) has an essential medicine list, NEML (, which is based on the essential medicine lists for adults and children from the World Health Organisation (WHO).

The WHO’s combined list, after allowing for replications, contains 359 medicines by generic names.

All medicines registered by the Drug Control Authority are currently exempted from sales tax.

However, GST will have to be paid for medicines that are not on the Customs essential medicine list when it is implemented on April 1, 2015.

The Customs department’s gazetted list ( contains about 2,900 items with 208 medicines.

This came about because the same medicine is listed under its various doses and manufacturers. For example, paracetamol, a common pain killer, is listed 107 times in the Customs’ list, compared with three times in the MOH’s NEML.

Other commonly used medicines like metformin, for diabetes; atenolol, for high blood pressure; and doxycycline, an antibiotic, are listed once in the MOH’s NEML, but 22, 19 and 19 times respectively in the Customs’ list.

This means that the Customs gazette list is markedly shorter compared to the MOH and WHO essential medicine lists.

Patients will be additionally burdened as they have to pay more for many essential medicines for common conditions like infections, high blood pressure, diabetes and pain.

The extra price will be due to the GST itself, as well as the cost of administering the GST.

This will lead to dissatisfied patients; decreased productivity; increased morbidity and mortality arising from the use of, and change to, different medicines, or patients foregoing some medicines due to increased prices; and increased workload at public clinics and hospitals.

Hospital services
The Customs guideline states that GST is exempted only for services provided by doctors employed by private hospitals.

It also states that the professional fees, clinic rentals, etc, of part-time specialists in private hospitals are subject to GST.

The vast majority of doctors in hospitals, especially the specialists, are not employed by the hospitals and provide healthcare on contract. Therefore, their consultation and procedural – including surgical – fees would be subject to GST.

The Customs guideline states that the following are also subject to GST:
  • Rental of operation theatre and medical equipment
  • Sale of medical aids like crutches, wheelchairs, artificial limbs, hearing aids, etc
  • Consumable medical products
  • Ambulance services
  • Management services
  • Medical opinions sought from foreign specialists
  • Traditional and complementary medicine services

“Acquisition of goods by private healthcare facility in terms of machinery, equipment and medicines (which are not zero-rated) will be subject to GST” with exceptions for certain medical equipment approved by the Customs director-general. The Customs guideline does not state the process.

Hospital bills are paid either out-of-pocket or by employers or third parties, i.e. insurance and managed care companies.

Payments by third parties involve deductions for processing and management fees, before payment is made to the hospital, and subsequently, the doctors. The processing and management fees could be subject to GST.

Add the various exempt, zero-rated or standard GST rates to the amorphous private healthcare sector, and the inevitable result will be various permutations of complex scenarios.

The view that those who access private healthcare can afford it, and hence, should pay GST is at best, an inaccurate perception.

Many seek private healthcare because the public sector is unable to cope with the demand, and this is reflected in its long queues and waiting lists for procedures, as well as short consultation times.

Delays in treatment and non-treatment of illness results in, among other consequences, decreased productivity.

In its present form, GST will impose additional financial and administrative burdens on healthcare providers, patients and payers.

The above complex scenarios can only lead to multiplier effects with patients having to pay more for the same service when GST is implemented.

Health, like education, is a public good. No one chooses to be sick.

This alone makes a strong case for all healthcare goods and services to be GST-exempted or zero-rated.

Dr Milton Lum is a board member 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 organization the writer is associated with.

Thursday, October 16, 2014

MedPage: Ebola and Hospitals: How Great Is the Threat?

Ebola and Hospitals: How Great Is the Threat?

Published: Oct 15, 2014
News that a second Texas Health Presbyterian Hospital nurse has Ebola -- and that she was already slightly febrile when she boarded a flight Monday from Cleveland to Dallas -- has heightened anxiety about the true risk of Ebola in the U.S.

As events unfold, many healthcare workers, especially nurses, have expressed concern about their safety when treating Ebola patients.

Participants in a webcast sponsored by National Nurses United vented about their frustrations, concerns, and fears involving inadequacy of hospitals' response to the Ebola situation. Nurses from throughout the U.S. told consistent stories of their hospitals' lack of planning, training/education, and protective clothing for nurses and other healthcare workers.

A nurse from Florida claimed that she was suspended from her job after officials at her hospital learned she had contacted the CDC to request information about preparations and precautions for Ebola.

The Nurses' Story
Typical of that concern is this statement from Patricia Mungovan, an RN and regular MedPage Today reader who works in Chicago.

"Today yet another healthcare worker has been diagnosed. Dr. Tom Frieden has lost the confidence of the healthcare workers in the country with his blame the victim statements," Mungovan told MedPage Today.

She noted that the CDC has now initiated more detailed protocols but worried that action is coming too late. "But look at all the harm and ill will his self-serving statements produced. We deserve better in this country."

Vernon Dutton, RN, who has 35 years' experience as an acute care specialty nurse, said issues surrounding Ebola isolation are symptomatic of a much larger problem that has "been a long time coming."

The key, according to Dutton, who divides his time between two New Orleans hospitals, is symptomatic of system-wide failure.

"The nurses were pressed into taking that patient before they were ready," Dutton said. "No hospital is ready for Ebola. There's no continuity of care.

"The problem in Texas would have happened anywhere in the country. Isolation isn't the problem in and of itself. It's the hospital. [And] there's no standardization in isolation protocol," Dutton added.

In an interview with Brian Short, RN, president and founder of, he said his organization surveyed 3,000 members and 74% said they didn't feel safe or prepared to deal with a potential Ebola outbreak or patient, and 73% said their hospital hadn't provided them with training to handle a patient infected with Ebola.

Short, who had an public relations person present during his interview with MedPage Today, said the organization conducted the survey before it was known that the first infected healthcare worker was a nurse.

"I'm sure that's going to raise the anxiety of the healthcare workers now. All this level of awareness of the nurses not feeling safe and prepared," Short said.

Short said plans a follow-up survey for next week. "It's a great way to get a pulse on what nurses are feeling."

"The main thing that we can take away: nurses understand the risks that come with their job. They're willing to do their job, but they need the proper equipment and proper training to do the job effectively and safely," Short added.

Indeed, the ability to care for an Ebola patient is far from simple, according to nurses from Emory Hospital, which was the first U.S. hospital to treat Ebola patients.

In an article in, Carolyn Hill, MSN, RN-BC, nursing director of the serious communicable disease unit at Emory, detailed the experience she and 20 of her nurses shared while treating two U.S. aid workers who were flown to Emory from Sierra Leone.

This excerpt from that article stands in stark contrast to the simple personal protective equipment (PPE) and private room advice that the CDC has been offering:

"While treating the first two patients simultaneously, there were three nurses on duty at all times wearing PPE -- one in each room with a patient, and one in the adjoining anteroom. Instead of 12-hour nursing shifts, the team switched to 8-hour shifts with one break, Hill says. After 4 hours in one of the three rooms, nurses would doff their PPE, take a shower, and then break for 30 to 45 minutes while physicians relieved them, Hill said. Then the nurses returned for the 18-step process of donning the Tyvek suit -- a 25-minute task that included putting on eye protection, two pairs of gloves, a plastic apron and protective booties. Another critical step included checking the gauge for the powered air purifying respirator, which cleans air before it is inhaled."

In the ED
Seth Trueger, MD, MPH, an emergency medicine physician at the University of Chicago, put it this way, "Everyone has made the assumption that there was a protocol violation that comes with the assumption that if you self-contaminate, you did something wrong. But no matter how good you are, there's an inherent failure rate."

Corey Slovis, MD, chairman of emergency medicine, Vanderbilt Emergency Medicine, voiced what many have been saying in comments sent to MedPage Today: "I'm disappointed that the CDC did not get to Dallas quickly, and disappointed that they are not clear enough on what and how is best to prevent disease -- including why we are not going to disinfect our hands like Doctors Without Borders."

But, Eric J. Adkins, MD, MSc, medical director of emergency services, Wexner Medical Center at The Ohio State University, had high praise for the CDC. "In my opinion, the CDC has been very out in front on this initiative. It appears that they are doing everything possible to respond appropriately to the Ebola outbreak," he said.

Adkins said that, at his hospital, they have had "dedicated sessions to practice use of PPE. We have worked to secure adequate supplies of the appropriate equipment and are ensuring it is readily available in our emergency department. We have recently performed simulated 'mock' patients with Ebola viral disease to test our response and have had much success with identifying how we can improve the readiness of our staff."

Ednan Bajwa, MD, director of the infection control unit at Massachusetts General Hospital, noted that information now being shared by Emory has been very helpful but more information from Texas Health Presbyterian would be "most informative. They had the sickest patient. They have not shared their experience."

Bajwa speculated that concerns about possible lack of protocols at the Texas hospital has been a barrier to that information sharing.
From his perspective he said the concept of early treatment, like what was done in Nebraska and Emory, was most interesting."They showed that early treatment was critical. Every patient treated early has done well. If you pay attention to early aspects of Ebola this is not a lethal illness. It is clear Dallas made mistakes ... Emory and Nebraska had protocols in place," Bajwa said.
In Canada
North of our borders, Canadians are running their own preparedness drills.
Niranjan Kissoon, MB, vice president for medical affairs at BC Children's Hospital and Sunny Hill Health Centre for Children in Vancouver, B.C., told MedPage Today, "Key departments have been advised to purchase a minimum of 24 hours of Hemorrhagic Fever PPE (different than the Decontamination PPE) and have been provided the list of equipment necessary."
The British Columbia health service "has been working with us to ensure that the warehouse will be consistently stocking of all of these items and after-hour contacts with HSSBC are in place for departments to rush order."
Moreover, Kissoon said, "Infection Control has been working diligently to ensure training is available to all staff on proper PPE donning and doffing procedures. They have recently finished a training video they are making available as well."
The Eyes of Texas
Meanwhile, across Texas major cities are responding with their own Ebola plans.
The Houston Chronicle reported that during a City Council meeting "health and first responders have taken inventory of what equipment they would need in the case Ebola came to Houston and have a plan in place. The key, Persse said, is to assume the city will see an Ebola case and prepare accordingly."
Similar scenes have played out in media reports from Austin and San Antonio, which, along with Dallas and Houston, make up the four largest cities in the state. All four are within 250 miles of one another, and the state's fifth largest city, Fort Worth, is just 30 miles west of Dallas.
Telephones have been busier than usual at the Texas Biomedical Research Institute (TBRI) in San Antonio, which has conducted Ebola vaccine studies for the past 10 years. According to the San Antonio Express-News, TBRI officials have fielded calls from health officials and media representatives throughout the world.
At the University of Texas Medical Branch (UTMB) at Galveston, a statewide referral center, President David Callender, MD, said in a statement that UTMB does not anticipate receiving any Ebola patients but nonetheless has a contingency plan.
UTMB houses one of the two National Biocontainment Laboratories in the nation (the other being at Boston University Medical Center), charged with conducting high-level studies of infectious organisms and diseases. Work at the two national centers is supplemented and complemented by a dozen regional biocontainment laboratories, all under the auspices of the National Institute of Allergy and Infectious Diseases.
And, Gov. Rick Perry established a statewide infectious disease task force charged with developing recommendations and a strategic plan for responding to infectious disease threats, such as Ebola. The task force has scheduled its initial meeting Oct. 23 in Austin.

Wednesday, September 3, 2014

Bad News, Ebola Outbreak likely to get worse... says CDC director

Centers for Disease Control and Prevention (CDC) director, Dr. Tom Frieden just returned from West Africa to get a bird’s eye view of the West Africa Ebola Virus Disease (EVD) outbreak, the largest since the virus caused the first outbreaks in 1976.

Public domain image/Mondo Magic
Public domain image/Mondo Magic

In a press conference yesterday (LISTEN here), Dr, Frieden offered his thoughts and observations on the outbreak that has infected more than 3,000 and killed more than half.

“The bottom line is that despite tremendous efforts from the U.S. Government, from CDC, from within countries, the number of cases continues to increase and is now increasing rapidly. I’m afraid over the next few weeks; those numbers are likely to increase further and significantly. 

“There is a window of opportunity to tamp this down, but that window is closing. We need action now to scale up the response. We know how to stop Ebola. The challenge is to scale it up to the massive levels needed to stop this outbreak.”

Frieden went on the call the Ebola situation in West Africa an “epidemic”. “This is really the first epidemic of Ebola the world has ever known. By epidemic what we mean is it’s spreading widely through society but not spreading through new ways according to everything we know.

 It’s spreading from just two roots – people caring for other people in hospitals or homes. And unsafe burial practices where people may come in contact with body fluids of someone who has died from Ebola.”

That is really the achilles heel of this virus. We know how it spreads. We know how to stop it from spreading.  The challenge is to do that everywhere that’s needed. In order to do that effectively, speed is key. The number of cases is increasing so quickly that for every day’s delay, it becomes that much harder to stop it”, Frieden notes.

The director went on to describe the 3 things required to get this under control– “The first is more resources.  This is going to take a lot to confront. The second are technical experts in health care and management to help in country. And the third is a global coordinated unified approach because this is not just a program for – this is not just a problem for West Africa, it’s not just a problem for Africa, it’s a problem for the world and the world needs to respond.”

Frieden’s visit to the three West African countries led to some dire statements. “Everything I’ve seen suggests over the next few weeks it’s likely to get worse.  We’re likely to see significant increases in cases.”

Medical negligence — a doctor’s insight.... by DATUK DR N.K.S. THARMASEELAN,

Medical negligence — a doctor’s insight 

by DATUK DR N.K.S. THARMASEELAN, The Star, 03 September 2014

THE public has long held doctors in high esteem. True to the Hippocratic Oath, doctors always did what was thought to be in the best interest of their patients.

A generation back, lawyers were unwilling to assist in suing members of a fellow profession.

Even when sued, the judiciary was often benevolent towards doctors. There was much reluctance to find doctors guilty of negligence.

Over the past few decades, the high pedestal on which doctors stood, has slowly been eroding. As patients’ rights movements gained momentum, the dust and clouds created have made the “halo” around the doctors less visible. They have realised that doctors are mere mortals too and reverence to them was misplaced, as was done by their earlier generation.

More patients are questioning their doctors and are prepared to sue their regular family doctor of many years. The doctor-patient bond has now been replaced by an unemotional, commercial business-like link.

There is no dearth of lawyers who are more than willing to act on behalf of a patient even on frivolous grounds. We cannot fault them as they are just doing their job. The judiciary too, has become less benevolent and has increasingly taken serious views of the cases before them. The awards are unbelievable and have been sky-rocketing over the years.

They now follow the standard of care, as reflected in Rogers vs Whitaker where the courts ultimately decide on the issues at hand, rather than following the principles in Bolam where the profession were left to decide whether a fellow professional had breached the standard of care for advice.

The Whitaker decision is now followed in Malaysia as pronounced in the Federal Court in Foo Fio Na. With the judiciary becoming more assertive and proactive, the awards are expected to multiply.
With the increasing settlements and awards handed out by the courts, litigation costs and premiums for indemnity coverage and insurance have risen exponentially.

Can we blame anybody for this scenario which has caused turbulence and turmoil within the medical fraternity?

Doctors are now less inclined to specialise in certain areas due to exorbitant indemnity premiums. We may not have doctors becoming obstetricians or spinal surgeons soon. Ultimately it affects patient care.

As the standard of living rises, expectations rise in tandem. The Internet revolution has delivered medical information to the doorstep of every home. This information comes from various sources, some of doubtful origin.

This has led to unrealistic expectations by patients. Patients expect perfect results when they seek treatment and are less likely to accept side effects and complications even if adequately informed before commencement of treatment.

Not only are expectations influenced by dubious Web-based information but also by “well-read” relatives and friends. Sometimes an “unintended” incendiary remark by a colleague causes unwarranted confusion to an already agitated patient.

Doctors sometimes justify errors with statistics which is of irrelevance to the patient. A 1:100,000 mortality or morbidity which appears insignificant to the doctor is usually a 1:1 for the patient and relatives.

Routine procedures are not viewed in the same manner. A simple lumbar puncture is viewed and construed as major surgery by some patients. The patients’ views and understanding of a medical problem are different from those held by doctors.

The doctor is often tried by the media and this inflicts a lifelong deep abrasion on the doctor’s reputation. Knowing the impact of negative publicity, patients and even lawyers make inappropriate demands on doctors.

The media attention towards medical errors has encouraged the layman to proceed with litigation as he knows that he will be able to “avenge” a wrong done to him or his relative.

It is not only the patient who suffers, the doctor too is subjected to tremendous mental stress and agony. Some senior doctors have given up the practice of medicine on account of a single misadventure. A litigation exercise has devastating effects on his career and personal life. Even if they win the battle in court, they are bruised during the proceedings and remained scarred for life.

Doctors suffer and as a result the patient too suffers in the long run. The strong bond is broken. Doctors begin practising defensive medicine and the patients will have to ultimately bear the cost.

A strong family-like bond is turned into a business-like proposition. The patient is no more a patient, he becomes a customer just as in any business transaction.

Medical paternalism has given way to patient autonomy. The patient is the focus of treatment without whom the doctor has no role to enact.

Doctors and patients need to work as partners in order to restore the trust and confidence of yesteryears.

Effective communication is essential and a vital tool in providing high quality care for patients. Doctors must spend more time communicating with their patients to create a more congenial atmosphere in the medical arena.

Patients should understand that doctors are not God and to err is human. This understanding will probably earn more respect, create a stronger bond and hopefully reduce litigation.

Tuesday, September 2, 2014

Doctors Beware, Caveat Venditor: Doctor Jailed for medical manslaughter

There has been a trend to charge doctors for medical manslaughter... Caveat Venditor, supplier beware, patients expect not just adequate care but also expect that the goods be delivered without the worst outcomes no matter how unrelated, or risks explained...

Patient safety and outcome now form the new norms of expectations... physician inattention and neglect, and failure to take appropriate and quick life-saving measures may be deemed manslaughter if patients die or suffer egregious consequences in an unexpected way!

David Sellu trial: Jail for doctor in manslaughter case

David Sellu's care was 'far below the expected standard', said prosecutors
A senior doctor at a private hospital in north-west London has been jailed for two-and-a-half-years for killing a patient.

Surgeon David Sellu was found guilty at the Old Bailey of manslaughter by gross negligence of a patient.

James Hughes, 66, died in 2010 at the Clementine Churchill Hospital in Harrow, having suffered a
perforated bowel after a routine knee replacement.

Sellu ignored his condition and carried on with his clinic, the court heard.

After Mr Hughes's knee operation on 5 February 2010, the retired builder from County Armagh, Northern Ireland, developed abdominal pain and was transferred to the care of Sellu.

'Terrible consequences'
The Old Bailey heard he "simply ignored" the urgency of the potentially life-threatening condition and instead of operating on Mr Hughes carried on with his scheduled appointments.

Mr Hughes died on 14 February.

Elizabeth Joslin of the Crown Prosecution Service said Sellu's care "fell far below the expected standard, with terrible consequences".

"This doctor's actions were not mistakes or errors of judgement but negligence so serious that he has now been convicted of a criminal offence," she said.

Mr Hughes's widow Ann Hughes said the family had been subjected to a "tortuous purgatory" only brought to an end by "truth and justice".

She said: "Our trust in normal processes, authorities and structures of society was shattered by the
inexplicable, callous and deceitful actions of the medical profession entrusted with the most basic
responsibility to protect human life."

Sellu, 66, had denied gross negligence manslaughter.

He was was found not guilty of perjury after he was accused of lying to the victim's inquest under oath.

Monday, August 18, 2014

Advice From a 101 Old Doctor! by Dr Shigeaki Hinohara

Advice From a 101 Old Doctor!

Dr. Shigeaki Hinohara, Japan, turned 101 on 4th October 2012
As a 101 year old Doctor, he was interviewed, and gave his advice for a long and healthy life.
Shigeaki Hinohara is one of the world's longest-serving physicians and educators. Hinohara's magic touch is legendary: Since 1941 he has been healing patients at St. Luke's International Hospital in Tokyo and teaching at St. Luke's College of Nursing.

He has published around 15 books since his 75th birthday, including one "Living Long, Living Good" that has sold more than 1.2 million copies. As the founder of the New Elderly Movement, Hinohara encourages others to live a long and happy life, a quest in which no role model is better than the doctor himself.
Doctor Shigeaki Hinohara's main points for a long and happy life:
* Energy comes from feeling good, not from eating well or sleeping a lot. We all remember how as children, when we were having fun, we often forgot to eat or sleep. I believe that we can keep that attitude as adults, too. It's best not to tire the body with too many rules such as lunchtime and bedtime.
* All people who live long regardless of nationality, race or gender share one thing in common: None are overweight. For breakfast I drink coffee, a glass of milk and some orange juice with a tablespoon of olive oil in it. Olive oil is great for the arteries and keeps my skin healthy. Lunch is milk and a few cookies, or nothing when I am too busy to eat. I never get hungry because I focus on my work. Dinner is veggies, a bit of fish and rice, and, twice a week, 100 grams of lean meat.
* Always plan ahead. My schedule book is already full until 2014, with lectures and my usual hospital work. In 2016 I'll have some fun, though: I plan to attend the Tokyo Olympics!
* There is no need to ever retire, but if one must, it should be a lot later than 65. The current retirement age was set at 65 half a century ago, when the average life-expectancy in Japan was 68 years and only 125 Japanese were over 100 years old. Today, Japanese women live to be around 86 and men 80, and we have 36,000 centenarians in our country. In 20 years we will have about 50,000 people over the age of 100...
* Share what you know. I give 150 lectures a year, some for 100 elementary-school children, others for 4,500 business people. I usually speak for 60 to 90 minutes, standing, to stay strong.
* When a doctor recommends you take a test or have some surgery, ask whether the doctor would suggest that his or her spouse or children go through such a procedure. Contrary to popular belief, doctors can't cure everyone. So why cause unnecessary pain with surgery I think music and animal therapy can help more than most doctors imagine.
* To stay healthy, always take the stairs and carry your own stuff. I take two stairs at a time, to get my muscles moving.
* My inspiration is Robert Browning's poem "Abt Vogler." My father used to read it to me. It encourages us to make big art, not small scribbles. It says to try to draw a circle so huge that there is no way we can finish it while we are alive. All we see is an arch; the rest is beyond our vision but it is there in the distance.
* Pain is mysterious, and having fun is the best way to forget it. If a child has a toothache, and you start playing a game together, he or she immediately forgets the pain. Hospitals must cater to the basic need of patients: We all want to have fun. At St. Luke's we have music and animal therapies, and art classes.
* Don't be crazy about amassing material things. Remember: You don't know when your number is up, and you can't take it with you to the next place.
* Hospitals must be designed and prepared for major disasters, and they must accept every patient who appears at their doors. We designed St. Luke's so we can operate anywhere: in the basement, in the corridors, in the chapel. Most people thought I was crazy to prepare for a catastrophe, but on March 20, 1995, I was unfortunately proven right when members of the Aum Shinrikyu religious cult launched a terrorist attack in the Tokyo subway. We accepted 740 victims and in two hours figured out that it was sarin gas that had hit them. Sadly we lost one person, but we saved 739 lives.
* Science alone can't cure or help people. Science lumps us all together, but illness is individual. Each person is unique, and diseases are connected to their hearts. To know the illness and help people, we need liberal and visual arts, not just medical ones.
* Life is filled with incidents. On March 31, 1970, when I was 59 years old, I boarded the Yodogo, a flight from Tokyo to Fukuoka. It was a beautiful sunny morning, and as Mount Fuji came into sight, the plane was hijacked by the Japanese Communist League-Red Army Faction. I spent the next four days handcuffed to my seat in 40-degree heat. As a doctor, I looked at it all as an experiment and was amazed at how the body slowed down in a crisis.

* Find a role model and aim to achieve even more than they could ever do. My father went to the United States in 1900 to study at Duke University in North Carolina. He was a pioneer and one of my heroes. Later I found a few more life guides, and when I am stuck, I ask myself how they would deal with the problem.
* It's wonderful to live long. Until one is 60 years old, it is easy to work for one's family and to achieve one's goals. But in our later years, we should strive to contribute to society. Since the age of 65, I have worked as a volunteer. I still put in 18 hours seven days a week and love every minute of it.


Wednesday, August 13, 2014

Best Doctors? Indeed How should one measure up?

Top Doctors? Indeed How should anyone measure up?

A recent post in the NY Times posit this very relevant id puzzling question. 

Indeed, how often is it that we've been asked to refer to the best doctor in this or that discipline? Just this morning, one of my long-time patients called and asked if I could refer her to the best orthopedic doctor in a nearby hospital nearer her home. I was instantly flabbergasted, as I've just read the post attached below, last evening... 

Indeed, for that matter, how should I or we as physicians, know? Would our so-called professors in the academic centres, our past mentors and teachers know any better? Does this mean that the more academically inclined or brilliant or up-to-date physician would be the better doctor for any discipline or surgery or special care? 

Perhaps, I would guess we do so based on or by virtue of our own biases, depending on our usual coterie of friends or kindred-spirited colleagues whom we've shared or co-referred patients. Otherwise, we might become aware through some sort of 'connection' via academic or shared interests groups...  Or even because of quid pro quo... because that colleague has treated you or another member of your family, and therefore, we are obliged to cross-refer back as a sort of a goodwill gesture, a thank you... 

But of course in our own little niche of practice and circumstance, we've become accustomed or knowledgeable about this or that doctor whom we think has been good, excellent or technically brilliant or kind, or whichever traits or skills that might fire up our more intimate or inner connection. 

But really I would think that this is indeed very arbitrary... is the physician with the most citations in research be a top doctor in his or her field? Is that media-savvy doctor being the most recognisable be the best? Is someone who's heading a medial society or discipline the best or top doc? Or is another fully dedicated physician totally immersed in teaching in academia the best?

Finally how do we personally measure up in the esteem and eyes of our colleagues, our peers, our patients?

Food for thought indeed. 

Top Doctors, Dead or Alive
NYTS AUGUST 11, 2014

The official letter is sitting on my desk, announcing that a relative of mine has just been named one of the world’s top physicians in his area of expertise. Once he confirms his biographical details, he is guaranteed inclusion in online and print directories of similarly honored peers (“not only a tribute to your success, but also a valuable resource for potential patients”).

I can clearly imagine his reaction had he opened the letter himself: a combination of amusement, dismay and just a small hint of pleasure. However, since he has been dead for 16 years, his widow passed the envelope over to me, and I got to experience all those emotions myself.

The amusement and dismay speak for themselves. The pleasure lay in this really superb demonstration that skepticism should attend all interactions with services promising to lead you through the thickets of subpar and merely average doctors directly to best of breed.

The methodology of these enterprises varies. Some, evidently, cull names and addresses from obsolete phone directories. Some poll doctors themselves for the biggest luminaries of their acquaintance. Some rely on patients’ reviews, operating under the premise that a doctor who delivers a five-star health experience for one will do so for all.

It is easy to dismiss them all as just so much advertisement and avarice, contributing yet more buzzy white noise to the already crazy-making din of health care. But a more nuanced and charitable view is also possible. These services may simply be trying, valiantly if clumsily, to remedy the single biggest mystery in all of health care: that we do not have a clue what makes a top doctor, let alone how to find one.

Is it nature (unusual intelligence, compassion, common sense)? Nurture (diplomas from prestigious and pricey institutions)? Self-sufficiency? (Patients say proudly, “My doctor never has to send me anywhere.”) A central location in a medical network? (“My doctor refers me to all the top people.”) Is it speed or deliberation, ability to follow rules or ability to break them? Exuberant personal charisma or a peaceful office that runs like a Swiss watch?

No one has the slightest idea. Even the terms of the question are undefined. Is a top doctor one who keeps you in top shape, hauling you up when you plunge down? Or is it one who encourages you to remain in whatever shape feels right to you, even if some of your habits might give pause to less enlightened observers?

A sedentary, seriously overweight patient I know cannot walk a block. She adores the doctor who cheerfully tells her: “Who needs to walk? You should ride!” To her, he is unquestionably a top doctor. To the rest of her family, not so much.

I contemplate various listings of top doctors, recognizing the occasional name or face, often residents I knew long ago. Many of them, I think, are probably quite good. But why should I think that? Do I really know what goes on when they are closeted with a patient who drives them nuts, or when they are running late and have theater tickets, or when they completely miss the diagnostic boat and land on an atoll somewhere in the sea of wrong assumptions, many leagues from where they should be? Do they acquit themselves in top-doctor style then?
In fact, nobody knows who the top doctors are, not even the top doctors themselves. It is safe to say that the very topmost doctors, confusingly, are probably not top doctors: They have become news media stars and household names through efforts that presumably leave them little time to hone those top-doctor skills. But otherwise, all is smoke and mirrors.

Can the average consumer glean any information at all from the top doc lists? Here is one tip: Pay attention to the source of the information. Traits that doctors prize in their colleagues may be different from the ones patients rank high. Consultants who will see any patient at the drop of a hat — referring doctors love that — may have jam-packed waiting rooms and move with the speed of greased pigs. The rock stars of modern medicine, experts who publish widely and lecture all over the globe, may spend most of their workweeks in flight, inaccessible for humbler purposes.

Otherwise, I suspect we are left with only a single unarguable definition of a top doctor: one who is not on the bottom. Top doctors are, for instance, not in jail. They have valid licenses. They are presumably enthusiastic about taking new patients (although you can never be sure how enthusiastic they’ll be about their insurance). I used to think that at least they were all living and breathing, but now I guess you can’t be sure of that, either.

© 2014 The New York Times Company

Saturday, August 9, 2014

Americans think that most physicians have it made. They’re wrong. by John La Puma MD

Americans think that most physicians have it made. They’re wrong.
KevinMD | AUGUST 6, 2014

There’s at least one hidden reason the health care system is failing people who just want some face time with a doctor: too many dedicated physicians are not just overwhelmed but burned out.

According to a 2012 JAMA Internal Medicine Mayo Clinic study, 46% of all U.S. physicians are emotionally exhausted, feel cynical about work or have lost their sense of personal accomplishment … or all three.

Americans think that most physicians have it made. But the reality is very different.

Many physicians have little control of their work.  They feel emotionally detached from patients and like cogs in a medical industrial machine. Slotted into 10 or 15 minute appointments, often double booked or more, without leeway to offer more time without penalty, physicians careen from one place to the next, like pinballs.   Endless new forms and electronic screens, a chaotic work pace, substantial debt, uncertain reimbursement and a perpetual concern about lawsuits are to blame.

Burnout also sickens physicians, who commit suicide more often, have more trouble with addictive drugs and alcohol, and divorce more frequently than other professionals. Some retire early or leave medicine entirely.  A 2012 study of 5000 physicians showed that 89% of practicing physicians would not recommend medicine as a profession to their children or other family members.

When physicians are unwell, patient care suffers. Referral rates for diagnostic tests and specialists rise, increasing risks for unnecessary and redundant tests and conflicting advice. Physicians interact with a computer screen instead of the patient. They take short cuts, follow procedures less, and can make serious mistakes.

Physician burnout may be one reason that the VA appointment waiting lists are so long: The newly approved VA bill provides for hiring more physicians, but in the current system, they too will be simply chewed up.

Primary care physicians have it worst.  There is a predicted deficiency of 45,000 primary care docs (and 46,000 specialists) by 2020. But the reason primary care is on the ropes is not because of too limited primary care residency training positions, as is currently thought in Congress. It’s because doctors are leaving medicine: A 2012 Urban Institute study of primary physicians found that 52% of those over 50 planned to leave practice within five years.

For new physicians, it is no better.  They owe a median of $170,000 upon medical school graduation, according to the AMA. Their residency training is not supposed to exceed 80 hours per week (in practice it is up to 50% more). Their salary mean is about $51,000 a year, for three years. They see attending physicians having to fight with insurers for care that patients need.  They spend, on average, but eight minutes with each patient. They see medicine as a job to be negotiated, not a calling to serve.

What can we do about physician burnout? Its causes are systemic, not individual. Yet most interventions are individual: meditation, stress reduction, self-awareness and reflection.  These interventions require more time, almost always unpaid, from the physician, already at wit’s end.

One solution is organizational change within health care systems. Organizations should allow physicians to structure more of their own work flow. They should teach and pay for time and training to avoid, prevent, recognize and improve burnout, and allow physicians to rediscover resilience and fulfillment.

Primary care especially requires innovation. Pharmacists and nurse practitioners could do routine primary care like checkups, screenings and explaining medication.  Primary care physicians could be better utilized for coordinating care, evaluating more serious conditions and helping patients make complex, personal medical decisions.

Practicing better lifestyle habits helps both physicians and patients: those physicians who exercise regularly recommend it more to their patients than those who don’t. Ditto for those who eat healthfully.

What would happen if physicians could practice more of what we preach about fitness and food, and physician’ employers helped them do it? Would patients’ blood pressures and cholesterol numbers improve?

Being a physician is a privilege and an honor. But even the best physician can burn out. It’s time physicians and health care systems shared the responsibility  to lessen the depersonalization and exhaustion so many physicians feel.

To fix the primary care delivery problem, we must fix burnout, and heal physicians.

John La Puma hosts PBS’ ChefMD Shortsand blogs at Paging Dr. La Puma. 

Saturday, August 2, 2014

BBC via WHO: Ebola crisis: Virus spreading too fast!

Ebola crisis: Virus spreading too fast, says WHO

Medical workers speak to families about how they can best protect themselves from the Ebola virus disease in Conakry, March 31Medical workers have been deployed to explain to residents how to protect themselves
The Ebola outbreak in West Africa is spreading faster than efforts to control it, World Health Organization (WHO) head Margaret Chan has said.
She told a summit of regional leaders that failure to contain Ebola could be "catastrophic" in terms of lives lost.
But she said the virus, which has claimed 728 lives in Guinea, Liberia and Sierra Leone since February, could be stopped if well managed.
Ebola kills up to 90% of those infected.
It spreads by contact with infected blood, bodily fluids, organs - or contaminated environments. Patients have a better chance of survival if they receive early treatment.
Initial flu-like symptoms can lead to external haemorrhaging from the eyes and gums, and internal bleeding that can lead to organ failure.
A US relief agency says will repatriate two of its American staff who have contracted the virus in Liberia.
They are believed to be the first Ebola patients ever to be treated in the US.
Hundreds of US Peace Corps volunteers have already been evacuated from the West African countries.
Separately, US President Barack Obama announced that delegates from affected countries attending a US-Africa conference in Washington next week would be screened.
"Folks who are coming from these countries that have even a marginal risk, or an infinitesimal risk of having been exposed in some fashion, we're making sure we're doing screening," he said.
An employee of the Monrovia City Corporation sprays disinfectant inside a government building in a bid to prevent the spread of the deadly Ebola virus (1 August 2014)Offices are being sprayed with disinfectant in the Liberian capital Monrovia to prevent the spread of the Ebola virus
Analysis: David Shukman, BBC science editor
Friday's summit should provide the kind of international co-operation needed to fight Ebola but the battle against the virus will be won or lost at the local level. An over-attentive family member, a careless moment while burying a victim, a slip-up by medical staff coping with stress and heat - a single small mistake in basic hygiene can allow the virus to slip from one human host to another.
The basic techniques for stopping Ebola are well known. The problem is applying them. Since the virus was first identified in 1976, there have been dozens of outbreaks and all of them have been contained. Experts point to these successes as evidence that this latest threat can be overcome too.
But working against them are suspicions among local people and the unavoidable fact that this is an extremely poor part of the world, much of it still reeling from conflict. Deploying the right equipment in properly trained hands is always going to be a struggle, one that is now extremely urgent.
Ebola since 1976
Graphic showing Ebola virus outbreaks since 1976
A map showing Ebola outbreaks since 1976
Dr Chan met the leaders of Guinea, Liberia and Sierra Leone to launch a new $100m (£59m) Ebola response plan.
The plan includes funding the deployment of hundreds more health care workers to affected countries.
"This meeting must mark a turning point in the outbreak response," Dr Chan said at the summit in Guinea's capital, Conakry.
"Cases are occurring in rural areas which are difficult to access, but also in densely populated capital cities."
She said the outbreak was the deadliest and most widely spread, and had also demonstrated an ability to spread through air travel, unlike past outbreaks.
A news chalk board in the centre of the Liberian capital, Monrovia is called The Daily Talk and is run by Alfred Sirleaf who puts up different headlines each day for discussion (Photograph: Jonathan Paye-Layleh, BBC) The spread of the virus is dominating the headlines in Liberia
A Liberian military police truck with warnings on its side door, one reading "Tell Everyone You Meet About Ebola" patrol through the streets to prevent panic over the Ebola virus in the city of Monrovia, Liberia (1 August 2014)Military vehicles in Liberia are displaying warnings and advice about Ebola to prevent panic over the spread of the virus
Separately, the Liberian government declared Friday a holiday to allow a huge sanitisation and chlorination exercise in government ministries and places of public gathering.
Information Minister Lewis Brown said "the intent is to let us come to the realisation that something is wrong and what is wrong is serious".
Up to 30 Commonwealth Games athletes from Sierra Leone, meanwhile,are considering extending their stay in Glasgow amid fears over the Ebola virus.
Ebola virus disease (EVD)
Coloured transmission electron micro graph of a single Ebola virus, the cause of Ebola fever
  • Symptoms include high fever, bleeding and central nervous system damage
  • Fatality rate can reach 90%
  • Incubation period is two to 21 days
  • There is no vaccine or cure
  • Supportive care such as rehydrating patients who have diarrhoea and vomiting can help recovery
  • Fruit bats are considered to be virus' natural host