Of Doctors' professional fees, and Rising Healthcare costs

Of Doctors' professional fees, and Rising Healthcare costs

By now most of you would have heard about the distorted Bernama abstracted report which has been  overblown out of proportion regarding doctors' fees.

Unfortunately the Bernama report has selectively picked on issues by the DG and taken the interview out of context from our May issue of the Berita MMA. Bernama has selectively left out my Presidential discussions on many issues including that of fees, medical schools and graduates glut, etc.

During the AGM in Melaka, the MMA also has brought to the attention of the Health Minister YB Dato' Sri Liow, some of these issues. The fees, if revised will be upwards and not down, as these have not been revised or changed since 2002!

The question of exorbitant fees is not true, but only a problem with a small proportion of some errant doctors (<5%) where the issue of unclear or ambiguous surgical procedures have been argued by insurers as too high, but in many instances are in line with the Private Healthcare Facilities and Services Act and regulations.

The fees in the regulations (2006) were adopted almost wholesale from the MMA schedule of fees of 2002! Some insurance companies refuse to accept additional charges for more complex procedures which lead to disagreements--these are what have been referred to the MOH. But we are still sorting out the disagreements.

The press have all gone to town regarding this so-called exorbitant fees and thinking that the revision is called for to reduce the fees. This is furthest from the truth.

Doctors on the other hand are all very upset that they have always been made to be the fall guy when hospital charges are concerned.

Specialist doctors are highly trained and experienced who have undergone long and arduous training at huge financial costs, effort and personal and family sacrifices. Medical college tuition fees are among the highest of all university courses, and the best brains are usually selected for this coveted professional training. Thus, this should be a factor to remember, parents expect this better 'reward' too, at some point in the future.

This does not make us mercenary, but as doctors, most of us believe that we should be paid our due remuneration which is fair and in tandem with other similarly educated and experienced professionals such as lawyers, accountants and engineers.

Importantly our wages and earning power must be similar to those of our neighbouring countries in purchasing parity value. But most of us do believe in social responsibility and are willing to sacrifice for some of our lesser endowed patients.

A comprehensive study of the income for doctors vis-a-vis other professionals will demonstrate that our fees have stagnated or have even come down in the last decade or so. We strongly urge that the press or the government to look into this study to dispel all the mistaken beliefs that doctors are unjustifiably profiteering from their patients

The MMA is working with the MOH to work out a more comprehensive fee schedule which will address all variants and variations in the many new and unaccounted for new specialised procedures and medical therapeutic charges, to lessen conflict with insurers.

The MMA believes that health insurance companies should worry less about doctors' fees and their insurance company unrealistic profits, but more with hospital charges which are totally unregulated. By antagonising doctors and patients with unreasonable denials and delays, as well as multiple 'pre-admission', 'interim' and 'discharge' forms and clarifications, these trails of paper work only take up too much precious time of busy doctors!! If only doctors can charge insurance companies for every document requested/demanded as per legal profession, we are sure these sorts of practices will be much simplified!

Below is a statement which I have prepared for another query from another newspaper:

Professional Fees—Revisions and Amendments on the way…

It is useful to remember that the latest schedule in the Regulations was based on our MMA rates first tabled in 2002! It is already 8 years old and the health insurance / third party payer companies are still fighting to reduce and limit our fees!

We are now embarking on refining the fees schedule, which has proven to be particularly contentious with third party payers and insurance companies. Although we have stated that we would prefer this fee schedule to be removed from the regulations, the Ministry has categorically rejected this suggestion.

Our 5^th Schedule (tendered to the MOH for consideration, since 2008) is unfortunately delayed due to concerns of costs inflation and disagreements with certain specialty societies, but we continue to urge that it be incorporated and updated soon, after some discrepancies have been ironed out. Doctors have been patiently waiting for this to be resolved soonest possible.

Greater detail in the itemizing of the schedule of fees would help remove misinterpretations and arguments as to the spirit of the fees chargeable by doctors. This aspect has been severely lacking in the adoption of our MMA schedule (of 2002) into the current PHCFS Regulations in 2006. This is what is mean by the DG of Health by comprehensive review of the fees for doctors--it is not to reduce the fees per se!

I am happy to note that the DG has agreed to extend our MMA initiative to revise this schedule by collectively gathering more input from all relevant societies and specialties. We hope to wrap this up before the end of the year.

Perhaps a permanent committee to revise these reimbursement guidelines and fee schedule amendments can be set up for annual review, so that these will be more timely as Ministerial regulatory directives, which do not need Cabinet or Legal clearance.

This is the method of revision practiced by more advanced countries such as Australia, the USA and even in neighbouring Indonesia, which would be fairer to all stakeholders. More regular revisions also allow insurers to estimate premium revisions more accurately, and thus decrease the hassle of inflationary worries.

Rising healthcare costs: not just professional fees but more so hospital charges

Contrary to the recent public announcement of the DG about “exorbitant” charges, the amendments being sought is to help streamline the fee structure so that ambiguities can be avoided or lessened.

The MMA does not believe that the professional fees are excessive, although there might have been isolated minority (<5%) of black sheep among the profession, who do engage in such ambiguous practices of unbundling of fees.

Some of the reasons, which have been offered are that the current fee schedule does not address rising complexity, after hours consideration, and even duration of complex procedures and direct specialist input or required presence, and extremely high medical negligence insurance premiums.

This new exercise will be to better refine  the charges so that there will be less denial of claims by insurers, or excessive charges by doctors.

In all likelihood the fee restructuring will lead to timely increase in fees, in tandem with the inflation over the years. Remember that this has been frozen since 2002!

What we urge the MOH to consider is to look into hospital fees and charges which are thus far unregulated and which is the uncontrolled bulk of the cost escalation in many private medical centres.

The MMA feels that the entry of big business corporations into the healthcare sector has been instrumental in pushing these costs increases and this has been unfairly blamed on the doctors’ fees, which are already pegged and limited by schedule.

We understand that recent corporations such as Khazanah, KPJ groups (they collectively own more than 90% of all major private hospitals in the country) are placing the performance burden of huge profit margins of some 20 to 30% on non-medical CEOs, thus leading to a variety of extraneous miscellaneous charges. This unfortunately is the unfettered role of the free market economy which is adopted by the country.

It is useful to remember that in the past, when medical doctors own and manage these centres, the profit margins rarely exceed 6 to 10%.

Thus industry-driven and profit-orientated business entities are the direct cause of the recent ballooning of costs for tertiary healthcare.

Furthermore the rising demand for luxury care and 5-star services and amenities also add to competition to provide all and sundry, in terms of expensive state-of-the-art CT scanners, MRI scanners, laser machines, etc. which have a low shelf-life but high maintenance and running costs.

It is said that in the Klang Valley we have more CT scanners, Catheterisation laboratories, and MRI scanners than the whole of Australia! This is the case of ‘kiasu’ attitude, which can lead to patient/doctor/administrator demand or pressure for overutilization of services because it is there to be used! 

Another cause is the rising medical indemnity premiums, which have grown by some 8 to 12% year or year. For obstetric and neurosurgical practices, the premiums are now more than RM 50,000 per year! There may need to be a way for doctors to factor in this charge, as already happening in parts of the USA, where a portion of the medical protection fee is levied on each procedure or patient.

We sincerely hope you will shed a true perspective on the real situation of private healthcare costs in the country. It is important to remember that all the government's health care budget is exclusively utilised for public sector healthcare needs with almost nil for the private sector.

As significant taxpayers, the MMA believes that special matching grants should also be given to the private sector doctors, esp. those who do not belong to large corporations to enhance their capacity, continuing professional development, clinical information systems, and the later possible integration of care with the public sector in due course.

Dr David Quek

President, MMA

Malay Mail: MMA affirms standard of local medical students

MMA affirms standard of local medical students

President rebuts declining quality claim by Indonesian university

Pearl Lee

Malay Mail, Wednesday, September 2nd, 2009 07:24:00

THE REMARKS are clearly gratuitous, provocative and uncalled for. This is the response of the Malaysian Medical Association (MMA) over remarks made by an Indonesian university that Malaysian medical students in that varsity are not up to the mark.

MMA president Dr David Quek said the poor quality of students had nothing to do with their country of origin but if the entry admission criteria is low, one can expect less-than-stellar quality students to apply for such colleges.

“That is why there are concerns as to some of these so-called paper or diploma mills, which are notoriously driven by tuition fees and foreign exchange earnings.

“Some of these medical schools even have international student sections, conducted in English, for export only,” Dr Quek said.

Malay Mail had on Friday published an article quoting the vice-rector of Diponegoro University, Dr Muhammad Nur, that the varsity had stopped accepting Malaysian students because their standard was low.

Dr Muhammad said that the freeze on Malaysian students was not only for the 2009 – 2010 academic year but would stay until such a time when they could get better quality students from Malaysia. He said that over the years the university had noticed the decline in the quality of Malaysian students who go there for degree courses and the university cannot afford to lower its teaching standards.

At present, there are only four Malaysian students in that university — two sponsored by the Malaysian government.

Dr Quek refuted Dr Muhammad’s claims that Malaysia’s standard was lower. He said the educational standards was high enough that many qualified students have to compete for entry into top medical schools.

“Many are disappointed at being rejected despite full scores or 4.0 GPA results. Thus, many resort to overseas medical schools to pursue their dreams and ambitions to become doctors,” Dr Quek said,

“As for medical students, we are opposed to our students simply going abroad to just any country to obtain a medical degree, because of cheaper costs or easy or low entry criteria.”

Dr Quek said that students should only go to varsities recognised by the Malaysian Medical Council (MMC), which provides governance on the required minimum standards of medical schools the world over, after careful periodic review of their curriculum, their teaching staff to student ratio and their clinical teaching programme.

“In fact, because of such quality concerns, the MMC recognises less than 10 medical colleges from Indonesia, and we have had concerns about their standards over time.

“It is therefore ridiculous to turn around and accuse us of poor standard medical students. If they are not good enough, then as is anywhere else in the world, don’t graduate them!

“There will be good students, exceptionally brilliant students and bad ones. The medical school must stick to its standards and pass only those which it thinks are fit to practice as doctors the world over.”

This is the benchmark all Malaysian medical colleges practice. Each medical school must ensure that it passes only sufficiently competent doctors, and fail those who are not up to the mark.

Asked to comment on whether the standard of our doctors was lower compared with Indonesians, Dr Quek said that it would be unfair to compare standards, as there was no criteria acceptable to all.

“Doctors are usually of acceptable standards the world over, but there are bound to be variations in quality and performance. I don’t think anyone has come up with any standard ranking for medical doctors.”

Malaysia has been ranked one of the top five medical tourism destinations around the world and if this is the case, he said, it was clear that our standards of healthcare cannot be that bad.

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Diponegro not on approved list
NAJIAH NAJIB [1]

Malay Mail, Friday, September 4th, 2009 09:54:00

AFTER all the brouhaha over supposed poor quality Malaysian students complained about by Diponegoro University in Semarang, Indonesia, it turns out that the varsity is no longer on the approved list of Malaysian education authorities.

Speaking to Malay Mail, Higher Education Ministry director-general Prof Datuk Radin Umar said the Malaysian authorities in medical education — namely the ministry and the Malaysian Medical Council (MMC) — had to drop Diponegoro after it failed to comply with the guidelines and requirements set by MMC.

“As far as I’m concerned, there is no issue at all in terms of the claims made by Diponegoro University that our medical students there are of low quality.

“Malaysian students who want to study medicine overseas have to obtain a ‘No Objection Certificate’ (NOC) from the ministry first. This documentation would certify that a student has met the minimum requirements needed for him or her to enrol in a university that is recognised by the ministry to have good standards.”

Radin said the problem arises when students — who are unable to obtain a NOC from the ministry due to insufficient qualification — seek out agents and apply for entry into overseas varsities through them.

“We don’t have any jurisdiction over the agents because they are not our local agents. Education agents are people from a particular overseas university because they want to promote their institution to our students.”

Some of these universities or colleges were not recognised as being among the top educational institutions in
their country, and several are known to be driven more by tuition fees and foreign exchange earnings.

“It is through such agents that some overseas universities are able to get lower quality students from Malaysia. The onus is not on us, the onus is on the university for accepting such students, like in the case of Diponegoro University,” said Radin.

He said Diponegoro was dropped from the ministry’s partner university list because of some concerns involving their curriculum.

It is learnt that the MMC has specified three core requirements before the ministry could engage a particular overseas university as a partner for medical studies.

Firstly, the university needs to promote studentcentred learning. Secondly, the ministry needs to ensure that the university is able to conduct an integration of different teaching systems in their curriculum (eg. to educate students in such a way that they are able to understand and relate their learnings to real-life situations effectively).

The university must also conduct at least 120 hours of clinical practice for students.

“Despite the issues, Malaysia and Indonesia are maintaining good ties in the medical education industry. Many of our local doctors today were trained in Indonesia during the 1970s.

“Back then, their standard of medical education was undoubtedly higher, having been in the business longer. Although we may have surpassed them on some grounds such as infrastructure and facilities in our medical universities, they are still considered as our ‘Big Brother’ in medical education.

“It is crucial for the two countries to be respectful of each other.”

Last week, Malay Mail quoted Diponegoro University vice-rector Dr Muhammad Nur as stating that the varsity had stopped accepting Malaysian students because their standards were low.

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MMA's Full Statement below:

28 August 2009

PRESS COMMENTS

ON

STANDARD OF MEDICAL STUDENTS

___________________________________________________________________

1. The Vice Rector of Indonesia’s Diponegoro University (UNDIP), Dr Muhammad Nur claimed that Malaysian medical students in the university are not up to the mark. He claimed that our student is of poor quality and they are no longer accepting our students until a time where they (Malaysian students) can show some improvement?

What does MMA have to say with regards to these allegations? The MMA has a category for student membership, and would like to seek your views on these claims.

I think his remarks are clearly gratuitous, provocative and uncalled for.

Poor quality students have nothing to do with the country of origin. If the entry admission criteria are low and easy, then one can expect less than stellar quality students who apply to join such colleges.

That is why there is concern as to some of these so-called paper or diploma mills, which are notoriously driven by tuition fees, foreign exchange earnings, etc. Some of these medical schools even have international student sections, being taught in English, for export only!

In Malaysia, we are very sure that our standards are so high that so many qualified students have to vie so competitively for entry into our top medical schools. Many are disappointed for their rejection despite full scores or 4.0 GPA results. Thus, many resort to overseas medical schools to pursue their dreams and ambitions to become doctors.

As for medical students, we are opposed to our students simply going abroad to just any country to obtain a medical degree, because of cheaper costs or easy or low entry criteria.

Every student must keep in mind that they only go to those which are recognised by the Malaysian Medical Council, which provides governance as to the required minimum standards of medical schools the world over, after careful periodic review of their curriculum, their teaching staff-student ratio and the clinical teaching programme. As such we do not simply recognise any medical school overseas.

In fact because of such quality concerns, the MMC recognises less than 10 medical colleges from Indonesia, and we have had concerns over their standards over time. It is therefore ridiculous to turn around and accuse us of poor standards of medical students—if they are not good enough, then clearly as is anywhere else in the world, don’t graduate them!

There will be good students, exceptionally brilliant students and bad ones, the medical school must stick to its standards and pass only those which it thinks fit to practices as doctors the world over. This is the benchmark where all Malaysian medical colleges practice.

Therefore, the final results of the medical graduate is the most important outcome—not all top students make the good doctors, and some would even fail to make the grade due to some reason or other.

However, each medical school must ensure that it passes only safe and sufficiently competent doctors, and fail those who are not up to the mark! Entry into medical school as is any other degree cannot be a guarantee for a diploma!. Thus, the MMA does not wish to enter into the debate as to who are better or otherwise.

2. How many student members does the MMA have presently? Are they mostly local or foreign university based students? By any changes are there any members from the above mentioned university (past or present)?

Currently we have about 2,533 student members in the MMA. The largest number of student members is from Kursk State Medical University followed by Melaka Manipal Medical College.

3. Generally are the standards of our doctors or even students (to your knowledge) vastly lower compared to the Indonesians? What is our ranking worldwide?

It would be unfair to compare standards, as there are no criteria which will be acceptable to all. Doctors are usually of acceptable standards the world over, but there is bound to be variation in quality and performance. I don’t think any one has made any standard ranking for medical doctors.

Malaysia has been ranked as one of the top 5 medical tourism destinations around the world. If this is the case, then clearly our standard of health care cannot be that bad.

Furthermore, most of our medical tourists are actually from Indonesia, which therefore, begs the question as to who some of these Indonesian patients trust more, their home country health system, or Malaysia’s. I think it is fair to say that not many Malaysians would opt to go to Indonesia for more expert health care treatment.

However, I have many good physician friends from Indonesia, who are excellent doctors with great quality and are truly experts in their own right, just as we have here in Malaysia or even Singapore. It is just that the consistency of healthcare in some of our neighbouring countries may be less than expected for all its citizens.

4. Are there certain standards set by the MMA with regards to (new) doctors when accepting them as members?

We have certain criteria for membership in our Association. Following are the categories of membership and its criteria.

All doctors in good standing with the Malaysian Medical Council will be accepted as members of the association when they apply to join and pay the necessary fees. We cannot discriminate about standards which are arbitrary and unnecessary.

The regulatory body which is the Malaysian Medical Council will be the authority which exercises this right to determine the standards and the quality of care and professionalism expected of every doctor who practice in the country.

Honorary Membership

The Association may confer Honorary Membership on those persons who, whether or not registered in the Medical Register, have done exceptional work in the fields of Medicine and allied sciences or have rendered meritorious event in the cause of Medicine and associated sciences or to this Association.

Life Membership

Life Membership of the Association shall be open to Ordinary Members who in place of annual subscriptions to the association, shall have contributed to the Capital of the MMA Special Savings (Life Investment) Fund established by the Association, an amount determined by the Annual General Meeting from time to time. The annual income, generated by investment of the Accumulated Capital contributions of each member to the Fund shall be irrevocably assigned in perpetuity by the contributor to the Council of the Association to disburse as it deems fit.

Ordinary Membership

Ordinary membership shall be open to every medical practitioner whether registered or provisionally registered or conditionally registered in the Register kept by the Registrar of Medical Practitioner and those terms shall have the meaning assigned to them be the Medical Registration Ordinance currently in force.

Overseas Membership

Overseas Membership shall be open to a registered medical practitioner who is a Malaysian citizen and whose permanent residence is outside Malaysia.

Associate Membership

Associate Membership shall be open to para Medical Personnel who being qualified in their respective profession legally practice in Malaysia.

Student Membership

Student Membership shall be open to registered medical student who are citizens of Malaysia and who are undergraduates in any medical schools, provided that no local Universities or Universities College student shall be admitted as a member without the prior written approval of the Vice – Chancellor concerned.

Exempt Membership

Exempt Membership shall be open to medical practitioners who have been Ordinary Members in good standing of at least 20 years and have attained the age of 65 years.

Dr David KL Quek, President, MMA

Moments of Madness…

"A disciplined conscience is a man's best friend. It may not be his most amiable, but it is his most faithful monitor." ~Henry Ward Beecher (U.S. clergyman, 1813-1887)

"The shortest and surest way to live with honor in the world, is to be in reality what we would appear to be; all human virtues increase and strengthen themselves by the practice and experience of them." ~ Socrates (Greek philosopher, 470-399 B.C.E.)

[Some 2 years ago, I wrote an editorial on moments of madness following the infamous head-butting by football superstar Zidane, which had been coined a 'Zizou' Moment. I think it is good to review the principles of that message today...]

Possibly 2 billion people viewed the World Cup finals early Monday morning (10 July, 2006, in Malaysia) riveted by perhaps the most memorable incident of the entire month-long orgy of soccer extravaganza. French football maestro ‘Zizou’ Zidane head-butted Italian agent provocateur Marco Materazzi in what must count as the most inexplicably perplexing act of the tournament.

Notwithstanding whatever the provocation, that loss of control, that one moment of madness must forever be etched in the psyche of Zidane, as one final act of regret, which has blemished the demigod-like status of perhaps the most remarkable playmaker of soccer the world has ever known over the past twenty years.

What happens when one finally snaps may never be totally explained, nor can we ever hope to finally comprehend how or why it had taken place. Volumes have now been written about this indelible incident, and I do not wish to add to psychoanalyzing the whys and the wherefores.

This ‘Zizou’ moment however has been dissected and interpreted in several ways. One most recurring theme is that of justifiable violence/retaliation, taking the law into one’s own hands when provoked, when criminal acts or even insulting verbal or physical gestures are directed against us, when we feel that our honour has been tarnished.

It harks back to faintly-remembered times when lawlessness abounds and we the helpless wretched citizens cannot depend on the authorities or law enforcement agencies to deter or to take action against these perpetrators of wrong-doing. Thus, this wrought-up sense of unquenched frustration and blinding anger had swung many toward some form of vigilantism or justifiable retribution, which seems to have become more acceptable, but which in every civil society we have always resoundingly frowned upon.

Personally, I am of the opinion that physical violence and reprisal is never justifiable and that this can only amplify tensions toward an escalating gratuitous and senseless denouement, where innocents become embroiled and are hurt or slaughtered without rhyme or reason.

Consider the rising violence and tension in Israel, Palestine and Lebanon, and the potential for wider conflict in the Middle-East. Truly, as had been so well expostulated by Mahatma Gandhi decades ago, “An eye for an eye would make the whole world blind”!

I want however, to address here the more common moments of madness, the careless thoughtless actions which we sometimes act out, unthinking yet irreparable and irretrievable: small oftentimes silly acts which thankfully do not cast huge imprints or sequelae which can change, cripple or endanger someone else...

Most, if not all, are miniscule in their impact and are forgotten almost as quickly as they are committed—perhaps our ‘venial’ sins, our little ‘white lies’.

Sometimes however, these little acts become inured and acceptable, when they are repeated often enough to become subterranean habits or subconscious patterns of behaviour, which harden the insensate and Dr Hyde-like aspect of our other selves.

As doctors however, these may have been inadvertently but unprofessionally negligent, dangerous or even lethal to our charges, our patients, but we have become just too anaesthetized to recognize their gravity, their presence even.

Yet in rare instances some or even just one of these may have implications, which can be life-changing, life-defining or even catastrophic. Pleading in hindsight, with simplistic statements that we were just being human and had been pushed to the edge of our tolerance and control unfortunately, does not make this any better or justify its severity or gravity.

Consider some of these common instances of shame, these moments of weakness, of madness even:

• taking unfair advantage of our gullible but frightened patients by suggesting urgent but unnecessary tests or therapies;
• preferential referring to our doctor friends or hospitals who promise some kind of kickback;
• dishing out supplements because our patients urge or apprise us about their preference for alternative medicines;
• deceiving or defrauding our patients by inducing them to take part in some financial deals because of our special doctor-patient relationships;
• submitting to our baser self by engaging in sexual liaisons with our patients or their partners;
• choosing a convenient career path to become high-level drug-pushers by indiscriminate selling of hypnotics, sedatives, cough mixtures to drug addicts;
• selling medical certificates for a quick buck;
  
• becoming serial abortionists because there’s money to be made; etc…

We would all be remiss if we do not animadvert on such acts, which are growing more common nowadays.

Are these baser instincts simply trivial moments of madness? I beg to disagree, but no, these are not momentary lapses of conscience or behavior, they are consistent patterns of ethical breaches, which should be loudly denounced. They are definitely not conduct becoming of a medical professional.

Are they occurring more frequently than we have recognized? Sadly, perhaps so. Are they simply the work of a tiny segment of our fraternity? We certainly hope so, that these are the fringe numbers which bring shame to the profession and are unfortunately tarnishing our good name with their very thick brush strokes of professional delinquency.

Nevertheless, there are other possible moments of weakness that rarely can afflict the medical doctor. These uncommon out-of-character and enigmatic errors are often one-off, but may sometimes be extremely serious and egregious, and then become ethical challenges, which have to be scrutinized.

These are moments sometimes squeezed and secreted out due to tremendous pressures of internal conflict. Pertaining to these, we must be very resolute in our self-restraint and be extremely mindful so as to maintain our innate sense of proportion, our professional ethics.

There is unfortunately for us as doctors, very little hope of retraction or turning back, once these actions are set in motion or are enacted out to the full, and we would have to face all the attendant consequences and possible sanctions.

But this is one human dimension which doctors could perhaps be better understood from the public and the governing/regulatory authority perspectives.

Because of our lofty position in society—our innate and traditional trustworthiness which the public has endowed upon us—we are often placed in an unreal pedestal of pre-eminence, which may not always be in our best interests (and certainly not in our patients’ either!), and which are often too high and haughty for us to sustain continually as fallible human beings.

It is true that as doctors we welcome even relish such respectability. Sometimes we deceive themselves that we indeed deserve such supercilious placements and snobbishly surround ourselves with such arrogance that we fail to see our humanness, our human frailty and our foibles.

But any thinking person, much more so because we are doctors, will concede that we are all imperfect and will make mistakes; that medicine is altogether more of an art (with more uncertainties than we can imagine) than an exact science that we would want it to be—whatever evidence-bases there may be to embrace and ratify.

We doctors have differing standards of practice, experience and perceptions, largely because of the multitudinous medical colleges and training that we individually have passed through. We are also of disparate personalities, which range from the benignly empathetic Dr Marcus Welby-type to the arrogantly cocksure Dr Christian Barnard-type.

We range from the placid, contemplative doctor to the brash, trigger-happy knife-wielding surgeon or catheter-brandishing interventionist, willing to try out any medical procedures or therapies whether they are experimental or just because they are simply possible.

Let the devil in the details look after themselves, benefits or harms are immaterial and does not immediately concern us in the near term… Our patients become our playground, our artistic canvas to create and display some of our audacious skills and derring-do prowess… Some of our patients may fare poorly, but some may also do superbly well, often in spite of us and our actions, or our lack of it.

Some newfangled techniques have actually been discovered from just this type of intrepid cutting-edge experimentation and hit-and-miss try-outs. But at what costs? At this current point in time when more and more documentation and accountability is expected of the medical profession, what would be acceptable and what not?

How do we draw the line on what is ethical and what may be professionally dubious or even reckless endangerment?

We must each and every one of us, contemplate and decide for ourselves, periodically and conscientiously that what we profess as medical therapy are indeed in the best interests of our patients—our raison d’être for our existence.

Our pecuniary, entrepreneurial or other self-enhancing interests must always be subservient to this singular precept, and we must make that especial effort to keep this alive and as an overarching conscience to contain our potential excesses.

How best can we help avoid or contain our moments of weakness, or madness? Simple, and yet perhaps the hardest to implement… review our code of professional conduct frequently, be mindful of our Medical Act at all times, and keep our medical professionalism at our highest level of conscientiousness always. Be what our medical training has always taught us to do—the right stuff!

Let us strive to forever be known as healers par excellence, and not be remembered for lesser baser misconduct or acts unbecoming. Let us always tame our recurrently straining moments of madness, and retain our moral anchor always.


[MMA Editorial, June 2006; Vol. 36 (6):pg7-8]

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

Healing is a painful experience: Mum's home, post-CABG

Most of us doctors take it for granted that humans can and should heal rather quickly. At least we expect the human body to recover as physiology dictates, and as science predicts--logically and systematically, minus the emotional and psychological underpinnings...

As doctors, we have always had to maintain that detached feel when approaching our patients, no matter how close and comfortable some of them may have become after years of intimate encounter and trust. We empathise as deeply as we can, but try to remain as dispassionate and as objective as possible.

Although a paternalistic approach of the doctor-patient relationship has been frowned upon of late, there is some truth that a slight top-down relationship can help establish a better patient outcome in some therapeutic exercises. Of course, we have to ensure that every patient should be appropriately and sufficiently informed to the best of his/her ability to understand.

We try and maintain a professional distance and authority so that the doctor-patient relationship can be put on a better and surer footing. Many patients still accept the prerogative and trained wisdom of physicians to do the right and proper thing, i.e. to bring about a healing process.

Most times we try and project a professionalism which because of our training and expertise, we can then exude that confidence that the patient and his/her relatives can trust and believe in.

In many instances, this slightly asymmetric relationship can help build a stronger physician authority which then makes informed consent and certain medical decisions easier to arrive at. But this is not to say that, we should bully our patients into making hasty decisions for which they have cause to regret later on.

Nevertheless, this has made many of us doctors into sometimes too distant and aloof partners, from the point of view of our patients' suffering. And because of this we can be rather brusque and sometimes downright tetchy when our patients appear to be slow in accepting our recommendations; and when they do, they appear to be slow or fearful from wanting to ambulate or move/exercise too quickly especially after an operation.

We are all brought up with the belief that the quicker the efforts to return to normal activity (within reason and capacity), the more rapid and complete the recuperation process would be. And so we make it our religious duty to impose stringent rehabilitative commands that our patients do as we tell them to, so that they can improve the way we expect them to do so.

Yet very often, many of us forget that there is a body and soul out there, trying to cope with a sanctioned 'assault' on a part or parts of the body, which may be more extensively and exquisitely injured than we think.

But for most of us, even as doctors we are spared the real-life experience of the actual pain and suffering, that some of our patients go through. It is said quite correctly that we can never feel enough unless we actually experience exactly or more of the same...

It is difficult to imagine how the human body recovers, and at rather wondrous and fantastical speed at that. It has been a long while now, but recently, I have been personally privy to just such an experience.

My mum underwent coronary bypass surgery exactly 3 weeks ago at the age of nearly 77 years. That she has come out with flying colours is testimony to her tenacity and iron will to live. At this elderly age it was already a very difficult decision to make to undergo such a major surgery. As children (and worse as a doctor!), we were all very aware of the inherent unknowns associated with bypass surgery at such an age--the risks to the brain, the kidneys, the limbs, the lungs, etc...

But thank God, she not only survived it, she had a couple of complications to boot, which piled up the tension for us, as we waited with bated breath, the unfolding of her pulse-raising untoward events (significant pleural effusion requiring a midnight chest tube insertion, and re-suturing of her thigh wounds from excessive haematoma formation), en route to her final discharge from the hospital.

Here, I must acknowledge and thank the dedicated doctors and nursing staff of Pantai Medical Centre, Bangsar, KL, who had to work tirelessly and under such stress (of looking after a rather anxious and truculent colleague's mother!).

Dr. Arunachalam and Datuk Dr. Zainal Abidin Hamid (cardiac surgeon and cardiologist extraordinaire, respectively, whom I have known and worked with for some 20 years since HKL-days!), Dr. Sylvian Dass, anaesthesiologist and friend, who painstakingly ensured that her anaesthesia and sedation was just spot on, and second surgeon, Dr. Syed Mohd Adeeb, for superlative support. I know that midnight calls are tough on any doctor, but your timely and urgent interventions certainly helped smooth the way of my mother's road to recovery!

The ICU staff and ward staff of D2 were simply fabulous and attentive, despite the ceaseless distressful demands of the very ill patients under their charge. Words alone cannot express my family's gratitude for a job well-done and all the singular care you have all so selflessly extended to my mother. Thanks a million!

Having said this, I now turn to the recovery phase, which I am now fully aware can be very trying and hugely difficult for many a patient! My mother certainly tried to do as she has been 'commanded'--deep breathing exercises, arm and leg exercises, ambulation attempts, self-attempts at personal hygiene, etc.

But every one of these is especially harrowing and painful--the sternotomy site remains bone-crunchingly sore (aggravated by every breath and cough!), and the leg wounds from the venous graft harvesting, are deep cuts which continue to lacerate with each movement! And yet, we urge and exhort that these be carried out repeatedly, to supersede the pain threshold, all in the name of good rehabilitation!

That my mum has always had a higher than usual pain threshold previously, only makes me now comprehend the exquisite pain levels that she has to undergo doggedly, in her resolute will to recover as quickly as possible so as not to burden us her children, any longer than necessary!

But it is also nice to see that within a couple of weeks, her surgical scars at least outwardly has healed so finely, with only intermittent scabs to belie the healing wound; and her haematomas and extensive bruising are now receding... Her breathing still needs more consistent work, and she has to gain her confidence that her many wounds will not dehisce or open up, that her post-op exhaustion, asthenia and mood swings need to be overcome...

Most importantly, her fainting spells and chest tightness which had accompanied her earlier disease and quite incapacitated her, appear to have become things of the past, i.e. her bypass grafts must be functioning well, thank goodness! From now on, it should be all smoothly downhill; but it has been an excruciating experience, which hopefully will be replaced by fonder memories of being well and active again.

From a personal perspective, I have learnt that as doctors, we have to feel and experience more intimately, so that we can understand the legitimate fears and pain of our patients when we recommend surgery or therapeutic procedures, which may be more than has been bargained for.

Importantly, we have to always consider the back-up support of family members, who play an extraordinary role in helping physically and emotionally our more dependent and older patients recuperate. My dad, sisters and brothers, wife and children, nieces and nephews have contributed immensely towards making mum feel good again.

Also, it has renewed an uncommon bond amongst us, which has strengthened our extended family relationship and dynamics so much better--something which would have been impossible, without this crisis. Simply because, we have each of us so many personal things to do, we're too busy with our own lives, despite the fact that we still gather and meet for a few days every year.

But we often fail to connect purposefully for something more ethereal and familial, which many consider as marginal and insufficiently important--that especial relationship which telescopes the time capsules of our historically crossed paths as brothers and sisters, and parents.

I am glad we all had some fond and occasionally tacky reminiscences, singular memories that can perhaps one day fill a book of experiences for our future generations...