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

1Care outpatient scheme - middlemen didahulukan?

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

 

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

i) collect funds from all working adults and employers

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

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

We foresee these problems may arise:

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

Modern docs

By Datuk Dr LEE YAN SAN

Sunday Star:  January 16, 2011

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Quality first, not quantity

By Dr MILTON LUM

Sunday Star, 09 Jan 2011

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

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

This principle is even more relevant today than in yesteryears.

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

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The situation in foreign medical schools is varied.

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

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

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

The issues and challenges that need to be addressed include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The issues and challenges that need to be addressed include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The issues and challenges that need to be addressed include:

● How many housemenship training hospitals does the country need?

● How many specialists are needed for housemenship training?

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

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

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

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

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

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

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

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

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

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

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

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

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

malaysiakini: Moratorium won't solve healthcare problems.... Dr Ong Hean Teik

Moratorium won't solve healthcare problems

Dr Ong Hean Teik
Dec 15, 2010
12:25pm

A moratorium on new medical courses in Malaysia will not solve the main problem faced by our healthcare system today, namely the large numbers of housemen with poor skills and questionable competencies.

Since these poorly trained doctors come from foreign as well as local institutions, stopping local medical intake does nothing to solve the issue.

What is needed now is a training system to improve the abilities of these young doctors, and even to weed out those who do not have the desire or competency to practice medicine.

Some may have hoped that registering a lot of housemen will ultimately solve three problems; fill vacancies in the Health Ministry, reduce healthcare costs by increasing doctor supplies and achieve a developed country status with a doctor-population ratio of 1: 400.

However, in our haste, we have registered poorly trained housemen, exposing them to a system that is not ready to cope with the numbers and their inability.

The call for action comes not from private doctors seeking to protect their rice-bowl; rather it is from dedicated senior government doctors who are worried about the future when these housemen take up increasingly responsible positions in public healthcare institutions.

Poorly trained doctors will be a burden to the Health Ministry, and may have to spend an increasing proportion of its budget on doctor salaries since such incompetent doctors will not be able to attract fee-paying patients who are very sensitive towards doctor competency.

No patient, no matter how poor, deserves an incompetent doctor, and no one, no matter how powerful can feel totally safe once incompetency creeps into the healthcare system.

We already have in place a system to train and assess our housemen. What is now needed is to formalise the system and have an end-of-housemanship examination.

Housemen must be transparently graded, with one-third coming from consultant's assessment, one-third from a theory paper and one-third coming from a practical examination.

After all, housemanship is only the beginning of a doctors' educational process. With many examinations still to go through, the houseman should not worry about a formal end-of-housemanship assessment. Those who do well should be rewarded with posting of their choice and entry to specialist training programs.

The majority should pass and proceed onto service as responsible medical officers. The really incompetent or disinterested ones should repeat their housemanship postings.

In the near future, the MMC must de-recognise poor-quality medical schools whether locally or abroad, without fear of political pressure.

The country cannot support 4000-6000 new doctors annually into the infinite future.

It should not be too difficult for the Ministry to calculate how many doctors are required annually, then seek to limit new medical registration to the calculated numbers.

Whatever the numbers, the aim must be to finally produce only capable, competent and dedicated doctors. Medical education, and the medical profession, should be for those interested in the art of healing, not those seeking financial rewards.

The public must try to understand that on this issue of having a competent medical workforce, doctors in both private practice and government service are speaking with one voice and truly have the interests of our community at heart.
Dr ONG HEAN TEIK is a cardiologist consultant in Penang

The Star: Delist poor quality med schools.... By LOH FOON FONG

Delist poor quality med schools

By LOH FOON FONG
foonfong@thestar.com.my

Thursday December 2, 2010

PETALING JAYA: The Malaysian Medical Association wants the Government to stop issuing licences to new medical schools and de-recognise existing ones which are of poor quality.

Its president Dr David Quek said stringent quality mechanisms should also be imposed on existing schools to ensure students are not short-changed.

“If medical schools do not have sufficient teachers or cannot offer adequate patient contact time, their student numbers should be reduced,” he said in an e-mail interview.

Recently, The Star reported that a high number of medical students graduating each year had crowded limited resources resulting in many housemen not having enough patients for adequate training with supervisors being overworked.

Sources also voiced concern that many graduates from lesser-known medical schools did not have adequate core knowledge to treat patients.

Dr Quek urged the Health Ministry to act quickly by sending “weak” new graduates for re-training.

In his blog on MMA News December 2010, he said there were 31,000 doctors and housemen and the Ministry wanted to reduce the doctor-population ratio by achieving 85,000 doctors for a projected 35 million population by 2020.

“This goal of trying to achieve so many doctors in so short a time is happening way too fast and too soon,” he said, adding that the issue was not about doctors wanting to protect their ‘turf’, rather their concern over patient safety.

While there were complaints of a glut in some hospitals, in rural hospitals in Sabah, housemen were complaining of being overworked.

A houseman, who declined to be named, said rural hospitals suffered from a severe lack of doctors and housemen had to work round the clock to care for patients.

“We have to be ‘on-call’ continuously for a whole week and go without sleep on some nights,” he said in an e-mail.

A mother of a houseman based at Hospital Universiti Kebangsaan Malaysia in Cheras also complained that her daughter’s feet had swelled after having to stand for long hours every day.

Acknowledging that there was a severe shortage of doctors in certain hospitals, Dr Quek said the Health Ministry should work out a better distribution mechanism to overcome the problem.

NST: Editorial: In need of senior doctors

NST: Editorial: In need of senior doctors

2010/12/01

THE president of the Malaysian Medical Association has expressed doubts over the strategy of producing medical graduates as fast as possible to help address the shortage of doctors as it could lead to a "serious glut of doctors" and a "possible erosion of standards". Undoubtedly, the dramatic increase in the number of medical students and medical schools in the last decade --- from four 10 years ago to more than 20 today -- has posed challenges in terms of quality, staffing and infrastructure. 

 

However, just because fresh medical graduates are starting to tax the training hospitals -- more than 3,600 this year, and some 4,000 to 5,000 from next year -- it does not necessarily mean that we will face a serious oversupply problem. On the contrary, as we have just over 31,000 doctors and we need 85,000 in 10 years, it is more than likely that we will need every medical graduate that we can produce.
Certainly, as the sharp rise in numbers has resulted in a glut of housemen and the training hospitals are struggling to meet the demands of training the next generation of doctors, there is cause for concern. Needless to say, as housemanship is an essential component of medical training, it is vital to make sure that the interns get the necessary hands-on clinical experience and skills.

The problem seems to be insufficient senior doctors to train and supervise the new crop of housemen. As it is, the Health Ministry has pressed smaller hospitals into service, and is looking to hiring foreign specialists to help the training hospitals cope with the influx of fresh medical graduates. Just as we have looked outside the public medical faculties to address the doctor shortage, perhaps we should utilise settings beyond the government hospitals to help shoulder the training load.

As far as the dubious quality of the graduates from questionable foreign and local medical schools is concerned, as it is the task of the Malaysian Medical Council to regulate and review these institutions to make sure they measure up to the expected standards, there should be no question about any "dilemma" in carrying out its task. Either someone is good enough to be accepted into an accredited medical school, or he or she is not, and either an institution is fit to be recognised, or it is not.

That said, the challenge is not just to make more places available for more students as a solution to the doctor shortage, but also to make sure that this does not affect the quality of teaching and training that they receive.


Read more: In need of senior doctors http://www.nst.com.my/nst/articles/16med/Article/#ixzz16uTfFhKA

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

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

By LOH FOON FONG
newsdesk@thestar.com.my

Tuesday November 30, 2010

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

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

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

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

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

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

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

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

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

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

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

1Malaysia Clinics: Comments in Malaysian Medical Resources:

Dr Alan Teh's Comments in Malaysian Medical Resources:

1Malaysia Clinics

The recent introduction of the 1Malaysia clinics has more political connotations than a genuine attempt at providing quality healthcare to the poor. Clinics run by medical assistants with the minimal of equipment is to me a waste of public funds.

As a person who has worked for many years with medical assistants, I can attest to the fact that the government is toying with the health of the public in order to earn some political points.

The quality of medical assistants is suspect, from the selection of candidates to their training methods. Many of these medical assistants lack basic aptitude to practice medicine. Some are even poorly qualified. Training of medical assistants are different and hardly involves the rigours of medical schools. Their diagnostic ability is questionable.

Their role in the rural community is understandable but to allow this responsibility of managing clinics in the urban areas where doctors suffice, is tantamount to dereliction of duty by the policy makers.

Would any of our VIPs visit a medical assistant for even a simple ailment? Many would flock to ’specialists’ for the best available care. Why then are we toying with the health of the general public?

The reason of providing accessible healthcare to the urban poor is a misdirection. There are many clinics in the urban area, way too many actually. It might have been more prudent to implement schemes for the poor where their visits to the general practitioner is subsidised.

There are actually existing programmes in place via the Welfare Department to cater to these group of individuals where their healthcare is fully borne by the government. So what is the role of 1Malaysia clinics?

The name speaks for itself. Promoting a political agenda using tax payers money with total neglect of their wellbeing.

Nurses Association-NST: 1MALAYSIA CLINICS: Lift our nurses' standards

1MALAYSIA CLINICS: Lift our nurses' standards
DATIN HATIJAH YUSOF, Honorary General Secretary, Malaysian Nurses Association letters@nst.com.my 2010/01/15

I REFER to the letter "Rethink 1Malaysia clinic move" by the Malaysian Medical Association (MMA) (NST, Dec 25). The Malaysian Nurses Association (MNA) supports Prime Minister Datuk Seri Najib Razak's choice of registered nurses (RNs) and medical assistants -- now known as assistant medical officers (AMOs) -- to run 1Malaysia clinics.

These clinics are to offer treatment for common illnesses, attend to minor ailments, and do follow-up treatment for well-controlled diabetes, hypertension and asthma, which RNs and AMOs have been doing for decades in rural and urban areas.

The public should be aware that RNs and AMOs have been the main providers of primary healthcare. There are simply not enough medical officers to provide healthcare to millions of Malaysians.

The MMA has expressed concern over the quality of medical care at 1Malaysia clinics. Nurses have been providing healthcare for decades, particularly in maternal and child healthcare.

They are all well-qualified public health nurses who have undergone a year's training in midwifery and another year in public health, apart from their three-year training as nurses.

These nurses have five years of education and training and several years of experience before they take the public health course. Since 1996, nurses have not only been providing healthcare to mothers and children but also to the elderly, children with special needs, women and adolescents. We also provide mental healthcare.

As a doctorate candidate (PhD), I did field observation of RNs and AMOs in six states on their roles in early 2000.

It was obvious that RNs and AMOs were the main healthcare providers in all these clinics. While the nurses are champions in maternal and child healthcare, health education, prevention and promotion, the AMOs treat the general outpatients.

In most of the clinics, AMOs saw 90 to 100 per cent of the patients. The MMA can easily check such data at any health clinic. There are far too many patients for one or two doctors to cope without the help of these AMOs.

A morbidity survey of community health then and retrospective data of six months collected from each clinic showed that the diseases they sought treatment for were just common illnesses.

It is unbecoming of the MMA to run down nurses by saying that allowing nurses and AMOs to run
1Malaysia clinics would place "the standard of these clinics at the level of Third World countries".

The MMA is ignorant of the fact that in developed countries such as the USA, Canada, the UK and Australia, community clinics are run by nurses independently.

These nurses are known as "nurse practitioners" who are advanced-practice nurses with master's degree education or degree nurses with specialisation.

Is the MMA aware that we have several RNs who are PhD holders and that many have a master's degree? We have also quite a number with degrees and specific specialisation.

We also wish to inform that we are advocating that all RN training should now be at tertiary level. We want to be under the "professional group", not in the "supportive group".

We feel that diploma-level training is no longer suitable for RNs. Nursing colleges here should offer degree courses instead.

To give quality care, the MNA has recognised four areas of basic nursing competencies that RNs should possess.

These are problem-solving, knowledge-based practice, clinical competence, and accountability and ethical practice.

In the area of clinical practice, nurses should have clinical skills in physical assessment to detect medical abnormalities, skills in auscultation, palpation and percussion, just like the AMOs who have this special training.

Even though nurses lack clinical skills, experienced nurses would have no problem running a 1Malaysia clinic.

On the MMA's remark that we have sufficient doctors and that "2,000 to 3,000 new doctors are returning to our shores annually", I would like to ask: where are they?

The truth is, medical officers have to work very hard to meet patient care demand and are frequently on call due to a shortage of medical officers. They work straight on for 34 hours, which is inhuman.
Also, apparently MOs are not keen to work in semi-urban or rural areas.

We predict that there will never be enough MOs in the Health Ministry as it is a hard life and less lucrative than working in the private sector or setting up private practice.

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

When Prime Minister Najib Razak announced in the Budget 2010, the setting up of 50 1Malaysia clinics in urban areas, the MMA was dumbfounded and perplexed.

That these clinics be set up at all, is perhaps a good exercise in public relations for our Prime Minister, who must have genuinely felt the need to offer some much needed goodwill to the urban folks, especially the poor and the marginalised.

However, what is more disturbing is the plan to have these clinics run by medical assistants and/or nurses, which in effect places the standard of these clinics at the level of third world countries, where there is a real scarcity of fully-registered physicians. It is certainly a major step backwards for a progressive nation such as Malaysia, which aspires to be fully developed by 2020, just 10 years away.

The Malaysian Medical Association (MMA) is gravely concerned that such a major shift in policy with regards public sector healthcare should be so implemented without sufficient input and discourse with stakeholders, such as the medical practitioners and perhaps even with officials of the Ministry of Health. It has been suggested that some health officials were also taken aback by this announcement, but they have been made to implement this as a directive, come January 2010. (I stand to be corrected on this fact.) It appears that this plan was brought about by fiat, rather than by persuasive rationale or long-term planning.

Firstly, let us reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also always concerned about our patients, i.e. the rakyat out there, who are our reason to exist, our raison d’être.

We welcome the government’s concern about our rakyat’s health needs. We also recognize that for many urban poor, their only recourse to health care is that offered by the overcrowded and understaffed MOH outpatient clinics. That there have been much queuing and long waiting times is notorious and wasteful in terms of productivity. Certainly we should do better.

We also know that new health ministry directives have been employed to try to shorten waiting times to less than 30 minutes; this has been included as part of the KPI/KRA so proudly announced by the government. Perhaps because of this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution has prompted this new approach.

But we also urge the government to recognize that throughout the country, in urban areas, there are already in place many GP clinics, some only a few doors away from each other in almost every urban block of shop-houses or complexes.

There is a severe glut of GPs in urban areas, where in the Klang Valley, Penang, Johor Bahru, Melaka, Ipoh and other major towns. In all these townships and cities, the ratio of doctor to population is around 1 in 400, more than the WHO recommendation of 1 in 600.

While some GPs have been very successful, the great majority is simply ekeing out a meagre and mediocre living, many GPs are seeing less than 20 patients per day and so are under-utilised. This is grossly unproductive and wasteful when seen in the context of the long arduous training and huge expense required for producing any one doctor, whether locally or abroad.

Our problem is learning how to manage the distribution of the doctor-patient function better and more efficiently. It is with this in mind that for several years now, the MMA and the Ministry of Health have been seeking a better public-private partnership in shaping a better health care system for the country.

Unfortunately because of the differential system of fee and/or payment mechanisms, this is proving rather tricky to bring about a cohesive transferable system. Thus, there has even been growing talks about integrating the public-private sector for primary care medical services. This will hopefully seamlessly integrate the use of almost all GPs into a primary care network where the public can register and seek treatment at either public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will undoubtedly be the way forward.

Of course quite a few discrepancies need to be addressed, e.g. differing expectations, possibly standards of every aspect of care, variable amenities available, level of support staff, etc. But these can be worked out, and we are establishing common areas of standardisation, which will then ensure that the public can be assured of and experience as high a standard of health care as possible.

So, in this context, the hurried establishment of the new 1Malaysia Clinics appear irrational and un-called for. If the government feels genuinely that these have to be carried out regardless of the medical profession protestations, then the minimum that it should do, is to ensure that these clinics are duly manned by registered medical doctors, fully in charge of all aspects of the clinics. This standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is quite unbecoming to offer a lesser level of care to those citizens just because they cannot afford to pay to see a doctor. Employing medical assistants and nurses to do a doctor’s job is called task-shifting, which is employed mainly in third world countries where there is severe shortage of doctors. To do so in this country would be a major step backwards and in our MMA’s view, shameful and unnecessary.

Do we have enough doctors? Of course we do. It is just the mal-distribution and poor logistics, which need to be addressed. Recently, more than 2,500 new doctors joined the public service as house officers. It is understood that many of these are under-deployed in the various departments of the government hospitals.

Due to the mushrooming of so many medical schools (23 as of this year) in the country, and medical graduates returning from abroad, we will continue to have some 2,000 to 3,000 new doctors returning to our shores annually!

We can certainly tap into this growing number of doctors to help make our public service clinics more efficient. At the very least the public will be better served by some recognized registered medical doctor, although they may just have probationary medical licence—the fact remains that they have had sufficient training and learning. Medical officers, registrars and specialist, (who can also be deployed to enrich the public sector healthcare service, if need be), can supervise these younger doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.

Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or deregistered!

Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.

Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.

There should not be one law for some and another for others, even if approved by the government or the MOH.

Two wrongs do not make a right.

The MMA believes that setting up 1Malaysia Clinics in urban locales is wasteful, redundant and shortchanging the rakyat. Utilising the already many GP clinics would be the better way forward. 

Furthermore, manning these clinics by other than registered medical doctors is also wrong and undermines the health care service, which leads to a possibly poorer standard of care, which can lead to many uncharted medico-legal problems.

We urge a rethink about this project, and for the MOH to seriously look into the implications of this poorly advised move.

The MMA will strive to work together earnestly with the MOH to help raise the level of healthcare for Malaysians, but not by compromising on the standard of care, or of shortchanging the uninformed rakyat.

Dr David KL Quek, President MMA