Malaysiakini: Euthanise medical advertising now.... by SM Mohamed Idris

Euthanise medical advertising now

SM Mohamed Idris
Oct 6, 10
6:10pm

We have said it before, and we have to say it again - the government has no rationale at all for allowing the medical profession and their institutions, whether general or specialist clinics or private medical centres, to advertise.

We see absolutely no sense in Health Minister Liow Tiong Lai's statement on Sept 24 that the liberalisation of the guidelines under the Medicines (Advertisement and Sale) Act 1956 had been done 'because medical tourism was a growing sector'.

All this because the government has targeted to increase the number of 'medical tourists' by 20 percent from last year's figure of 336,000? And why didn't the government engage with civil society before approving the revised Advertising Guidelines for Healthcare Facilities and Services way back in July?

Convince us, please. Can we ever believe that members of the medical profession would be 'cautious and professional' when advertising their services following the government's decision to liberalise the provisions under the law?

We have raised this question several times before, and we must repeat it because neither the authorities nor the medical profession have responded truthfully: with patient load and services at private healthcare facilities increasing due to the aggressive promotion of services, charges for treatment will go up.

This means that the private sector will also have increased needs for medical staff and will move to attract those from government hospitals – which are in no position to match the remunerations offered.

Remember that for many years, despite the Health Ministry's pledge to ensure efficient enforcement to ensure that all parties 'keep within the prescribed ethical guidelines for advertising' there still were numerous occasions of advertisers flouting the law. And this was before this new development!

Today, in Europe and the US, it is no longer the 'medical profession'. It is the 'medical industry', a mafia involving private hospitals, pharmaceutical drug giants and medical equipment manufacturers that are taking the lead, influencing the authorities and freely advertising on the print and electronic media, even in the Yellow Pages.

In the US, the Advanced Medical Technology Association (Amta), which represents medical device makers, released a new set of guidelines that its members have voluntarily taken up to make advertising more comprehensible to the public.

Over and above the regulations enforced by the US Food and Drug Administration (FDA), which is highly influenced by the American pharmaceutical industry, Amta is praying that 'endorsements by celebrities are acceptable as long as the ads are truthful and clearly state when actors are being used'. 

Thankfully, it added, the regulations are 'voluntary and not enforceable by the FDA'.

Just take advertising directed to consumers on television or over the Internet on what well- equipped hospitals in the US can offer: It was worth an estimated US$193 million in 2007, according to a consulting firm, TNS Media Intelligence.

Also, consider what Philip Parker said in the Journal of Marketing Research way back in 1995: 'Most forms of advertising rely on 'information asymmetry', the idea that the party doing the marketing knows more about the product and how to sell it than the consumer'.

Information asymmetries result in higher profits for advertisers. They know more, and the consumer, less. When the product is chewing gum, the imbalance is usually no big deal. But with something as crucial as healthcare – where the opportunities for information asymmetries happen to be much greater – all sorts of problems crop up.

Advertising empowers only the medical profession and the drug companies. Once patients get fixated on trying a certain medicine, chances are they'll either pressure their doctor for a prescription or find another doctor who will supply it. Medical advertising will only hit people when they're ill and most vulnerable to the lure of a quick fix.

People will always buy from pharmacies, whether they want vitamins, tonics, remedies to help or cure indigestion, and even painkillers. All these are freely advertised. And they need not queue up to see the doctor, and pay more for the doctor's fees. So, please tell us, will advertising by the medical profession help? Or cost the common man more, since the advertising cost will be worked into the fee payable by the patient?

There are many other unethical practices that are bound to increase as medical personnel pay more attention to the profit-making potential of healthcare.

Healthcare must not be treated as a business. CAP wishes to reiterate our call to the Ministry of Health: Halt the practice of encouraging medical tourism and address the shortfalls that are ailing our present healthcare system. The needs of Malaysians must be the priority.

The writer is president, Consumers Association of Penang.

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.

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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...

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

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Dr David KL Quek
President, MMA

Doctors must be Vigilant when dealing with unexplained Custodial Deaths

Any custodial death must always be considered circumspect and should invite close and meticulous scrutiny as to the possibility of foul play.

The custodial death of Kugan Ananthan therefore, is very worrying and needs full explanation and disclosure to the satisfaction of all fair-minded Malaysians. That this is one highly publicised case among the many other custodial deaths (1,535 from 2003 to 2007!) in recent history of our Malaysian police detention centres, must alert us to the possibility of a sustained if tacit condonement of such practices by the highest echelon of our police or even government authorities. See Dr RS McCoy's article " Kugan's death a reminder of systemic weaknesses".

No matter the circumstances of detention, every prisoner or detainee must be accorded his/her human right to be treated justly. He or she must be presumed innocent until proven otherwise in an independently constituted and respected court of law.

Because history is replete with such cynical and abhorrent cases of torture leading to custodial deaths under various authorities, it must always behoove doctors that they owe it to humanity to expose these heinous acts so that we can help prevent their continued recurrence.

It is useful to remember that despite the furore of recriminations against the Abu Ghraib and Quantanamo detention centres, the number of custodial deaths following the Afghanistan and Iraq wars, from 2001, did not reach such numbers as have been acknowledged by our own police force. (See Steve Inskeep "The Question of Torture")

Timely reminders to physicians have been shown to alert them to the dangers and possibilities of slipping down the slippery slope of expediency and collusion with authorities in such repugnant but illegal activities involving torture to extract information or forced confessions.

There can be no clearer mandate than that expounded by the World Medical Association (WMA). In its 1975 Declaration of Tokyo, which describes guidelines Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment, the first article states explicitly that:

"The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife."

Therefore, it must always be in the forefront of any physician or forensic pathologist's mindset that he or she must exert his/her full medical professionalism to the best of his/her knowledge and experience, without fear or favour. Of course, this is not to say that many or most doctors willingly adopt such timorous or subservient attitudes just to be on the 'right' side of the law.

It is generally recognised that in authoritarian or autocratic states, physicians can find themselves in very difficult circumstances of having to consider their own personal or family's safety and self-interests. There may be genuine fear of repercussions, harassment or threats which can and indeed had occasionally been shown to intimidate physicians who had conscientiously written medical reports which are opposed to the expectations of certain authorities.

Notwithstanding these possibilities of threats, the physician must undertake to serve out his function and duty, without falling victim to such fear and intimidation. Every physician who acts righteously will always have the strongest and most vocal and concerted support of all his fellow physicians the world over! The WMA and the MMA together with other human rights proponents including the UNHCHR (United Nations Office of the High Commissioner for Human Rights) will always stand with the physician—i.e. he or she is not alone.

Thus, being physicians, there can be no compromise: we must abide by our rigid codes of professionalism and medical ethics to put such personal interests aside in favour of our patients, and in the case of the deceased, our unbending duty to determine the forensic truth as to the cause or causes.

When anyone dies, especially unexpectedly, the cause of death must be ascertained with reasonable certainty, so that there is closure and acceptance from their loved ones and society. Forensic pathology's dictum is that it must serve as the ultimate arbiter to provide the concluding proof of science of the final truth, the final diagnosis... (See Role of pathologists in human rights abuses)

In fact, one should endeavour to go overboard to prove that no criminal action had led to the unexplained death of anyone under detention. To be too ready to attribute to natural causes when there had been overt signs which cannot be explained, can lead to accusations of collusion to obstruct the explication of the truth.

Most importantly, doctors must not allow themselves to be persuaded or intimidated by the authorities to facilitate favourable but inaccurate reports, just to placate the illegal actions of the police or military or any other persons who had so callously disregarded their responsibilities as purported guardians of law enforcement in any country.

It is understandable that clinical role conflicts between duty to the state and to the patient sometimes arise. However, there is no compromise as to where our physician duties lie: i.e. our patient's welfare must take all precedence, and "undivided commitment to patients is the sole guidepost for clinicians who face conflicting expectations." For the physician the importance of clinical fidelity is of the highest moral and ethical standpoint which should and must not be compromised. (see M. Gregg Bloche "Clinical Loyalties and the social purposes of Medicine", JAMA. 1999;281:268-274)

Attempts to subvert the truth or to cover up illegal acts are not only unethical and unprofessional but also lends such actions to possible criminal prosecution as colluding to condone torture and abetting homicide.

The World Medical Association will support, and has encouraged the international community, including all national Medical Associations and fellow physicians to support, the physician and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

As physicians we will all stand with the doctor under threat—the world community is watching and will support earnestly the clinical rectitude of any doctor so implicated, if or when he or she acted in an ethically correct manner.

However, the converse is not true, we cannot and will not support any physician who choose to act to condone or cover-up any police action or actions which are cruel, inhuman or degrading, especially when this leads to death.

Unfortunately in this country, there is no mechanism to quickly look into or investigate such suggestions of medical misconduct, if indeed that is the case of the custodial death of Kugan Ananthan. As our Medical Act now stands, we still need an official complainant for us to initiate proceedings against any medical practitioner, and this will still take some time to be fairly and fully completed, even if given expedited pace in the public interests.

Nevertheless, in the light of such widespread publicity, the Malaysian Medical Council will have to be very wary not to be seen to be colored or prejudiced by public opinion, but to be as fair and just to all parties concerned, with only its necessarily circumscribed focus on what is deemed medical professional conduct or misconduct.

Thus, it is premature and unfair to expect instantaneous conviction and/or to pass judgement as to whichever aspersions of misconduct that has been cast on the first pathologist in the light of conflicting reports from a second. Differences of opinions alone cannot be the basis of professional misconduct, unless it can be proven beyond reasonable doubt that the physician concerned had unethically colluded with the law-breakers to cover-up such a dastardly act as torture and finally the unexpected death of a prisoner under detention.

For the unfortunate case of Kugan Ananthan, we will have to let the courts decide on the exact nature of his untimely death, and let all fair-minded people determine the merits or demerits of the two conflicting post-mortem reports. Dissatisfaction with whichever report or action by any medical practitioner can only be reported and lodged with the Ministry of Health and the Malaysian Medical Council, and let due process take its rightful if tardy action.

For whatever it is worth, this unfortunate but highly-publicised custodial death has put on notice that the police or any authority for that matter, cannot expect a free ride to do as it pleases with impunity.

Our rakyat demands that this cannot be allowed to recur, and that we all expect retribution or answers on those who so callously take another's life, under the guise of duty of law enforcement. The dignity of our Malaysian citizen must not be brushed aside so coldheartedly any more.

I'd like to end by paraphrasing M. Gregg Bloche's concluding remarks, that "by making a strong stand for clinical fidelity, ethical medicine in Malaysia can reanimate its sense of purpose and promote those facets of professional autonomy likely to contribute to the common good. In so doing, physicians might also contribute modestly to reducing the insecurity and incivility that appears to be escalating in Malaysia, fed by repeated collective experiences of breach of faith."

Our rakyat demands and deserves more, our rights have been awakened! Physicians must stand unequivocally on the side of progress of human rights and an unshakable and respected medical professionalism. Our authorities and police force should aspire to do the same.

A slightly abbreviated version appears in malaysiakini on 11 March 2009, Physicians must be more vigilant

WMA-INSEAD Leadership Course-Caring, Ethics & Science

This week marks another chapter of my learning experience.

Together with 3 other Malaysians, I enrolled in and was selected to participate in the one-week INSEAD Leadership Development course in Fontainebleau, France. This intensive course is sponsored and put together by the World Medical Association (WMA) in its efforts to produce and train a core group of physician leaders as part of its ongoing Caring Physicians of the World Initiative, first mooted by its past-president Prof. Yank D. Coble Jr.

I must admit that I am curiously grateful, somewhat excited and charged-up at having such a chance to join Europe's foremost and most illustrious graduate and executive business school. I have always believed that continuing education through whichever means, is one's necessary life-long learning process which should never cease.

But to learn how to be an effective spokesperson and advocate for health care issues, to re-energize one's medical professionalism and perhaps to enhance my individual capacity on how to better influence and shape health policy makers, is a challenge that I find hard to resist.

This course is also meant to help us interact more cogently with decision makers and national political leaders. There are also ingenious exercises on team building which would help foster greater unity of purpose and cohesion with our own medical colleagues. Media and public speaking training is also incorporated into this course, which provided great if sometimes obscure insights as to how we can each become better and more effective as leaders who can and must perform well.

During his tenure as President of the WMA (2004-5), Dr Coble edited and produced a book aptly titled "Caring Physicians of the World" where in his introduction, he quotes:

"The most important thing is caring, so do it first,
for the caring physician best inspires hope and trust."
~ Sir William Osler (1849-1919)

In this beautifully produced book, the publication of which was sponsored by Pfizer Inc., one of the 65 doctors (from 58 nations) so honoured included one Sister Lucia Yu from Korea.

Following specialisation in obstetrics and gynecology in Korea, Lucia Yu did post-graduate training in the USA, converted to Catholicism and became a religious nun. Then for more than 20 years, she worked as a missionary doctor in Kenya lookng after African patients with malaria and tuberculosis--much in the footsteps of the famed Dr. Albert Schweitzer. Currently she is back in Korea where she runs a clinic for the poor and indigent.

Malaysian doctors are also honoured in having Dr Thamboo Devaraj, 84-year old Penang-based clinical oncologist-physician, featured. Datuk Dr Devaraj is also a past-president of the MMA (1983), chair of the ethics committee (1985-2000) and elected Malaysian Medical Council member for many years. He is honoured for his relentless pursuit of palliative care and advocacy for cancer patients, when he helped establish Cancerlink Foundation and the National Cancer Society of Malaysia. He is also the founding chairman of Malaysian Hospice Council in 2001. We salute such great men and women of humility and caring, and these should serve as standard bearers of our now much maligned and dispirited profession.

Dr. Yank Coble is President-Emeritus of the American College of Physicians, the American Medical Association, and the American College of Endocrinology. Currently he heads the Center for Global Health and Medical Diplomacy as Director, and is truly a distinguished physician par excellence, with an unflagging passion for medical advocacy, professional standards and ethics. He underlines the 'Caring-Ethics-Science' paradigm of modern medicine which should underpin our medical practice, where we place our patients' interests first and foremost.

He is a tireless crusader for the professional well-being and honour of doctors, believing that the medical profession is still well worth its while, and that doctors must re-ignite their passion and enthusiasm for their chosen vocation. He reminds us not to become too disheartened and dumbed down due to the current changing climate of patient empowerment, eroding trust for doctors, medicolegal challenges and deterioration in professional autonomy.

In his introduction to our Leadership course, Dr. Coble emphasised that we must try and reinforce the concept that health care costs are not merely budgetary 'expenses', and that these should be regarded as long-term 'investments', with extremely worthwhile returns. In focusing on our patients, who have much retained their ongoing trust in physicians, we can and have reduced disease, despair, disability and premature deaths. He gave some research data which estimated the return of investment (for health care expenditure over the past few decades) of some 57 trillion dollars (USD)!

He cautioned against the uncontrolled entry of money and commercial interests into the health care sector, which had rendered the previously cared-for 'patient' into a cold disinterested 'consumer'. He represents perhaps the old school of what is still good and reminiscently evocative of what it means to be a physician--a healer and mender of ill-health and broken bodies, a socially-mindful campaigner for public good and justice.

Perhaps there is still hope yet for all aspiring and even jaded ('burnt-out') physicians that even as our roles have changed and seemingly diluted from its power status and paternalistic past, we have stalwarts and exemplary doctors who continue to champion our profession so stoutly and fervently. All we are called upon to do, is to remember our caring nature, our vocation which should always place our patients at the forefront of our work, our vision and mission...

"The health of the people is really the foundation upon which all their happiness and all their powers as a state depend." ~ Benjamin Disraeli (1804-1881)

By focusing on the patient, his/her rights and responsibilities, and on the value of modern medicine (economic cost-effectiveness), Dr Coble hopes to restore enthusiasm and optimism in the field of medicine among medical professionals. He urges that physicians should engage in more inclusive and advocative medical and social leadership, which when based on caring, ethics and science, can help our patients "die young, as late as possible".

As physician leaders, perhaps we can help make a difference. No matter how small the impact, we may yet make the practice of modern medicine that much more meaningful and rewarding...

"Knowing is not enough
we must apply;
Willing is not enough
we must do!"
~ Goethe

The ethics and folly of indiscriminate ‘sms’s and e-mails…

“When learning about life and people, make no more assumptions than are absolutely necessary. Ask and observe.” ~ William of Ockham (c. 1285-1349), Philosopher

“Words are chameleons which reflect the color of their environment.” ~ Learned Hand (1872-1961), Jurist

"We are entering a period of human history that may provide an answer to the question of whether it is better to be smart than stupid." ~ Noam Chomsky, author, philosopher, social scientist

One recent MMC hearing involved a complaint against a doctor for sexual harassment—as a result of several sexually suggestive ‘sms’s received by a subordinate female worker at a medical centre.

The complaint was apparently brought up by the medical centre’s chief medical officer who had earlier had a personal fallout with that particular doctor, and when this complaint arose from a subordinate worker, he took prompt action by complaining that the doctor was in breach of his professional conduct. Erstwhile friends thus, ended up becoming uncompromising foes…

The involved doctor admitted his actions but explained that he was merely being ‘friendly’ with several of his co-workers and occasionally, when he received some of these saucy jokes would re-forward these to others for ‘fun’. He pleaded that he did so with no intention to sexually accost or embarrass anyone. He also claimed to have a good working relationship with the lady concerned.

Fortunately, because there were no other sexual overtures associated with this miscalculated action, and after much deliberation, the case was dismissed by the MMC as unproven.

The doctor was advised that he should be very careful of indiscriminate sending of sms’s and emails in this day and age.

Certainly he should refrain from assuming that every friend or acquaintance would understand his bawdy pranks just for ‘laughs’! There are simply too many interpretations and possible misuse and misconceptions that can arise.

The doctor was touched and deeply grateful for having been given the benefit of the doubt, and admitted to having had many sleepless nights based on this painful ordeal.

The case above illustrates the point that we do not always predictably know people, no matter how well we believe them to be our acquaintances or friends. It also underlines the fact that unthinking actions can lead on to many possible outcomes, some of which (especially unpleasant ones!) can occasionally redound on us when we least expect them!

Unbeknown to many of us, there is always that possibility that someone somewhere out there may wrongly misinterpret or may feel slighted by some of these injudicious actions. These unguarded misunderstandings can put the unsuspecting but imprudent doctor at risk of complaints which can not only sully his/her reputation, but may also put his/her career and professional work at severe risk of ethical breach or misconduct.

Besides, the agony and stress of having to undergo an MMC inquiry is a very trying and angst-laden experience—sometimes this might even severely undermine one’s sense of personal justice or self-belief.

Thus one has to be very circumspect when it comes to delivering or passing on messages or emails, which can lend themselves to different interpretations and possible misconstrued meanings.

In this era of easy and nearly free distribution of information, it is often convenient and unthinkingly dismissive to pass along forwarded mails, stories, gossips, even downright libellous juicy stories, with nary a thought of possible consequences.

Oftentimes, we do not care or bother to check with the authenticity or veracity, as long as these seem innocuous enough as fleeting titillating snippets to us.

We may not even consider the person or persons vilified or caricaturised by some such ‘stories’. And so we continue to forward along automaton-like, akin to many an unsolicited chain mail… and the circulation expands like waves in a pond, until possibly these bounce back to the person or persons themselves, when offence can then be taken!

It is said that these days, the world is so interconnected that it only needs 6 degrees of separation/communication, to find someone who might know or is related to an ‘utter’ stranger to begin with. So it is invariably easier for what goes around, to come around full circle!

Thus, never underestimate the power of mass circulation, particularly when these are of salacious nature, when even the most pious and religious among us might find the risqué distraction hard to brush aside or circumvent…

So, it is better to be wary and thoughtful. Perhaps it is good practice to always think twice before clicking on the send or forward button of either the pc or the mobile phone. When there’s any remote possibility of misapprehension, then desist from doing so, and stop there.

With the omnipresent swarms of messages circulating in the hyperspace of the airwaves and world wide web, one or a few distractions less won’t really matter. And unless something is really worth it, or carries a higher or more mood-elevating message, it might be good to simply withhold one’s eagerness to join in the all-pervasive torrent of the internet’s or telecommunication’s ‘white’ noise!

Remember Mother Teresa’s exhortations: “Kind words can be short and easy to speak, but their echoes are truly endless.” The converse is of course also true; inappropriate words may be callously expressed but can have endless reverberations and consequences!

Indiscriminate messaging with racy content overtones may be less innocuous than you think, and these can come back to haunt you, should anyone complain. In this regard, it is even more important not to embroil your patients or their relatives who might find offence if these were to be misunderstood or if there are unrequited attentions sought.

In our frequent connections with patients and their kin, it is not inconceivable that some may have crossed purposes, and occasional personal attractions may be sparked. No matter the temptations or the opportunity, the asymmetric relationship that empowers the physician an edge cannot be an equal or fair one. Thus, this kind of relationship is greatly frowned upon by ethical authorities from time immemorial.

Emotional or sexual involvement with patients or their immediate relatives are usually considered professionally unethical, and these have been well articulated in our Code of Professional Conduct and Good Medical Practice guidelines.

This becomes even harder to defend when unsolicited harassment or misconstrued attention is complained about when relationships go sour! So as physicians we have to be very mindful, and must stridently try to remove ourselves from such possible entanglements, even at its earliest outset. Don’t allow such seeds of possible misbehaviour to germinate, which can lead to professional suicide…

For those thumb-happy messaging fanatics out there, think before you blink… Forwarded messages and emails are not as harmless as you imagine. And sexual innuendoes and racy items are best avoided from needlessly propagating unchallenged in the airwaves…

“No aspect of healthcare should be considered outside the realm of ethics because all areas entail value choices that ultimately affect the well being of individuals. An ethical decision-making process ensures transparency to stakeholders. Not everyone will be pleased with the outcome, but they can be reassured that every effort was made to achieve a morally responsible solution.

"When an organization engages its decision-making process with this sort of ethical framework, it demonstrates integrity, strengthens its identity, becomes a place where people will want to work, and is embraced by the community.

"In short, ethics enables accountability, dignity and justice.”
~ Rev. Michael D. Place, President and CEO, Catholic Health Association of the United States, St. Louis.