Each issue of the Journal of the American Medical Association includes an excerpt from an issue of exactly 100 years ago (JAMA has been published continuously since 1883).
The May 7, 1910 issue of JAMA included remarks on how much physicians were paid and, by implication, how they were regarded in 2250 B.C.
Ability to pay and malpractice
According to the famous Babylonian Code of Hammurabi (“an eye for an eye”), a physician’s fee varied with the social status of the patient. There were three classes in ancient Babylonian society. The upper class included wealthy landowners, affluent traders, officials, and priests. Freemen were farmers, clerks, and craftsmen. And then there were slaves.
If an upper class citizen was severely wounded and a physician (using his “bronze lancet”) saved his life, the physician received 10 shekels of silver. If the patient was a freeman, the fee was five shekels. For a slave, the physician was paid only two shekels.
JAMA of 1910 benevolently describes this as “regulating fees according to the patient’s ability to pay.” One might also wonder, however, if there were any differences in the alacrity and quality of care.
Ancient penalties for malpractice also varied by social class. If a physician caused the death of a “man” (presumably either upper class or freeman) or destroyed his eye, the physician’s fingers were cut off. (See, malpractice policy could be worse.) For the death of a freeman’s slave, the physician was required to pay the monetary value of the slave. If it was just the loss of an eye, the penalty was half the slave’s price.
The esteem and remuneration of physicians
The JAMA article continues with an attempt to estimate the income of physicians relative to other members of Babylonian society. Laborers at the time of Hammurabi earned eight shekels of silver a year. Admittedly, the standard of living for laborers may have been low. Earning one and a quarter times the annual wages of a workman for a single operation, however, seems “fairly satisfactory,” in the restrained wording of 1910.
This seems to indicate, the article concludes, that “four thousand years ago the medical profession was highly esteemed and rewarded.” If the editors of JAMA could have seen 100 years into the future, I wonder what they’d say about the esteem and remuneration of physicians today.
Jan Henderson is a historian of medicine who blogs at The Health Culture.
Joint Meeting of AFPM, MMA, Qualitas & PCDOM on Primary Care Concerns
Objectives:
To form a united working group which coordinates, collates and raises critical viewpoints of primary care medical practitioners, to provide timely responses to challenges and threats which may arise from time to time.
Members comprise of representatives from the various primary health care medical practitioner societies and groups, i.e. MMA, AFPM, PPSMMA, Qualitas, PCDOM, FPMFAM
Report on the Inaugural Working Group Meeting on 29.10.09, held at the Academy of Family Physicians of Malaysia Office, at Academy Building, Jalan Pahang
In attendance:
Dr. Frank Tan Eng Huat, AFPM
Dr. Sudha Nanthan, AFPM
Dr. Noor Azizah Tahir, AFPM
Dr. David Quek, MMA
Dato Dr. Tharmaseelan, MMA
Dato Dr. Mohan Singh, PPSMMA
Dato Dr. Noorul Ameen, Qualitas
Dr. Molly Cheah, PCDOM
The discussions covered many aspects of the impacts where the family medicine doctors / GPs are affected by new developments, such as:
MSQH trying to impose the credentialing and quality-assessment of GP clinics
-Possibility of charging a fee for auditing our medical clinics
-two weekly statistics returns that is imposed on the administration of the clinics
-regulatory mechanisms that will further burden us
-possibility of MSQH lobbying to regulate through new initiatives through the Cabinet or EPU, or through subtle imposition of standards requirements before GP clinics are afforded panel status or even eventual reimbursement schemes, health care insurance restructuring
-enforcement surveys being carried out by paid surveyors/officers, perhaps similar to the processes of Fomema, or Unit Amalan of KKM
-We want to manage our own Quality Assurance.
-Accreditation should be voluntary, and should not encumber or discriminate against those without such quality assessments.
2. Setting up of feeder clinics and primary care clinics by many tertiary Private Hospitals
3. MOH opening up more primary care clinics, such as 1Malaysia clinics manned by MAs
Our Aim: to discuss proactive methods to try and prevent these developments from taking place without safeguards and to lessen the impacts of such possible oversight processes from overwhelming our medical practices.
The minutes below detail the discussions of the group:
Opening Remarks
Dr. Frank Tan Eng Huat, President of AFPM called the meeting to order at 3.30 pm. In his opening address the President mentioned about the worrying trend where primary care centres were being opened by private hospitals, by Wellness Laboratories and even by the ministry of health.
He welcomed all present. Dr. Frank then requested the members to introduce themselves. The AFPM President then asked the members of the various groups to have an open discussion on the various issues highlighted.
Matters Discussed
MSQH Concerns
There were lively open discussions and debating by all the members. Dr. Sudha requested each member of the group to please look into the future with a new vision and as a team. He said that there were some common grievances that we are facing now. Each of these must be addressed and brought up. The main issues were in the agenda. The new ones brought up today can be brought up later or at the next meeting.
Dr Sudha gave a run down of the role of MSQH all these years and the role of MMA and MMA’s contribution of RM100,000. He said that the DG supported MSQH since 2007 but later came to know of the work done by the Academy through its subsidiary QIP. Subsequently, the DG has been supporting AFPM’s QIP and has advised that all primary care groups work together.
Dr Sudha said that he was directed by the Chairman of AFPM, Dato Thuraiappah to get the primary care groups together to have a meeting. Dr Sudha was further supported in this endeavour by Dr David Quek when he brought it up at the MMA Council meeting. That is how all the members are here today.
PPSMMA Perspective
Dato Dr Mohan then mentioned that he had the gathered various documents of the deals that MMA had made with MSQH. He said that the direction that the working partnership had taken was different now compared with what was envisioned. The threat of parliamentary support for MSQH would mean that further regulations would be imposed upon GPs and considering that hospitals were spending a fortune for the MSQH accreditation, the same could be imposed upon us.
Qualitas Input
Dato Noorul Ameen gave a description of the workings of MSQH and he said that they were already in the process of setting up a pilot project based on a good assessment tool. He said that AFPM was represented by the various members at MSQH before, but a strong enough voice was not heard from them.
Dato Noorul was against the idea of further regulations forced upon GPs.
He also said that he was disappointed with AFPM and MMA for their lack of appropriate actions when called upon to be more involved or vocal, in the past.
MMA’s perspectives
Dr David Quek then joined in, and commented on the lack of serious, concerted and quality participation by the GP sector. This was echoed by Dr Norazizah and also Dato Dr Tharma. He also said that GPs hardly attended GP meetings, MMA AGMs, other seminars like the H1N1 etc. Their participation in PPSMMA is also very selected and insufficient in numbers to give more impact.
Our GP groups also appear to be weak in coming forwards with detailed working papers or research which can help influence national health policy matters. He contrasted our weaknesses compared with that of the UK where the GPs’ strength is phenomenal and their input into the NHS enormous and substantive.
Declining GP remuneration
Dato Noorul, Dr Norazizah and Dr Molly Cheah then discussed on the declining and poor remunerations of the GPs and the cost of locums which especially of late, had gone up further because of MOH initiatives. Everybody then decided that one of the issues to be discussed at the next meeting would be stressing on need for a better and more reasonable GP remuneration.
The past actions and relatively passive responses by MMA and AFPM were discussed at length and eventually it was agreed that the new working group would in future work together, have regular meetings and be more pro-active in their stance.
PCDOM, Membership issues
Dr Molly Cheah came up with the role of PCDOM, its computer medical information systems, and the lack of participation by fellow colleagues. This may be discussed at the next meeting.
Dr David Quek reminded Dr Cheah that membership numbers are also important for GP groups to impact on any important issues which are raised. He asked if PCDOM can share its membership numbers, so that whatever is raised by its leadership can then have greater weight and influence.
Dr Quek admitted that even the MMA has membership issues which are declining in proportion to the rising number of registered doctors in the country—we are now only about 32% of all the 25000+ registered doctors, but still the largest representative group for doctors.
Accreditation issues should not be regulated
Dato Noorul then suggested that we must first of all address the threat of the Accreditation of Primary Care being brought up to parliament which means that it could become an act and there fore another regulatory mechanism enforced upon the GPs. He suggested that we must first of all act upon that.
He said that following that, we can all work together, and suggested that with the MMA and Dr David taking the lead in tackling the various grievances, perhaps we can then implement the quality assurance programmes through the AFPM, we can bring in the rest of our working group to tackle the problems facing us.
Dato Mohan strongly supported and reinforced that the accreditation process should not be allowed to be tabled at parliament by MSQH.
Dato Dr Tharma then summarised the issues discussed
a. Press / Media campaigns – to stop further regulations that could be enforced upon us through mandatory accreditation. Accreditation should be a voluntary process.
b. Identifying ourselves as a new working group that coordinates all the different challenges and threats that we face.
c. Discussion on these issues should be an on-going process.
d. Primary Care Doctors should have a recognised GP group like the SCHOMOS to discuss the various issues faced by GPs. PPSMMA will encourage GPs to work with MMA in full force to help realise our objectives more effectively and collectively.
e. This working group will meet again next month. A Thursday at about 5.30 pm was suggested. The discussions will be based upon an agenda that will be drawn up.
f. As part of the agenda:
- The Strengths/ Weaknesses of each component of our working group will be outlined and addressed
- A New Vision and objectives will be the thrust.
- All GP groups and primary care doctors will be indentified.
- All members of the working group were advised to contribute towards the agenda.
Other matters:
The next meeting by this group (name to be decided) would be hosted at the MMA House, The discussions will be based upon an agenda that will be drawn up. The course of action on the various issues will be decided there.
Action Points
The members of the group were requested to give the ideas and comments on the various points to be discussed. Dr Quek asked Dr Norazizah to come up with some ideas to encourage GPs to take an active part in matters affecting them. He also requested Dato Dr Noorul Ameen to come up with a paper on costs comparing primary care managed by GPs to that managed by the government and the effect opening of primary care centres will have on the economy.
Meeting with DG Health
Dr Sudha then mentioned that the AFPM had set up a meeting with the DG of Health on the 4th of November at 12 pm. He said that representatives from each group was ideal. Dato Mohan could come, Dr Norazizah will try and Dr Molly Cheah will come. Dr Noorul will send a representative. Academy will be represented by the EXCO.
