Why measure clinic’s doors and floor?

I GRADUATED as a medical doctor in 1983, and have been running a specialist heart clinic since 1994.

I am keen to be an up-to-date, ethical doctor and have written letters and articles in Lancet, Journal of the American Medical Association, Singapore Medical Journal and British Medical Journal among others.

I regularly give educational talks to doctors and the public.

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Malaise in our public hospitals Pt 2

Malaise in our public hospitals Pt 2

Malaysiakini article by Ahmad Sobri | May 23, 08

The Narayana Hrudayalaya center is primarily the brain child of Devi Shetty who initially trained at Guys Hospital in London where Philip Deverall, a British pioneering and innovative paediatric heart surgeon was based. He has no formal postgraduate cardiac qualifications unlike most Indian cardiac surgeons. However, apart from the thousands of cases he has carried out, he has conducted hundreds of seminars, wrote innumerable papers, created many training programs and of course built and managed quite a few heart hospitals.

Devi Shetty is living proof that clinical and operative skills may not necessarily be congruent to academic qualifications, something our local MMC (Malaysian Medical Council) should wake up to. Dedication and commitment could be far more valuable factors. In fact in all likelihood; Devi Shetty might not even get a job if he applies for one at the MOH as his qualifications would have been deemed by our “elite” council members as “not recognised”

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Malaise in our public hospitals Pt 1

Malaise in our public hospitals Pt 1

Ahmad Sobri in Malaysiakini | May 22, 08

AHMAD SOBRI is a surgeon who has served in both the public and private sectors in Malaysia for 20 years. He is currently based in South England and his interests include resuscitative techniques including reanimation. His work also includes health policies, planning and finance.

When Dr Chua Soi Lek first came to office, he apparently called for a meeting of all senior officers and when asked about the priority of problems at the Ministry of Health, he reportedly was inundated with numerous comments about the dastardly troubles private hospitals had created and how they and their devious doctors were leeching the poor Malaysian public and something had to be done urgently.

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Prescription, dispensing, suffering (Pt 2)

Prescription, dispensing, suffering (Pt 2)

Product Of The System in Malaysiakini

Rules in any game should be fair and just and implemented on both parties.

  • If doctors are to be prohibited from dispensing,
  • shouldn’t pharmacists too be forbidden from diagnosing, examining, investigating and prescribing?
  • Yet this is exactly what takes place everyday in a typical pharmacy.

I have seen with my own eyes (not that I can see with someone else’s eyes anyway)

  • pharmacists giving a medical consultation,
  • performing a physical examination
  • and thereafter recommending medications to walk-in customers.

It is also not uncommon to find pharmacies collaborating with biochemical laboratories to conduct blood tests especially those in the form of seemingly value-for money ‘packages’. These would usually include a barrage of unnecessary tests comprising tumor markers, rheumatoid factor and thyroid function tests for an otherwise well and asymptomatic patient.

medical doctorsPharmacists intrude into the physicians’ territory when they begin to do all this and more. Doctors may occasionally make mistakes due to their supposedly inferior knowledge of drugs despite the fact that they are trained in clinical pharmacology.

In the same vein, pharmacists may have studied the basic features of disease entities and clinical biochemistry but they are nonetheless not of sufficient competency to diagnose, examine, investigate and treat patients. Pharmacists are not adequately trained to take a complete and thorough medical history or to recognise the subtle clinical signs so imperative in the art of differential diagnosis.

In more ways than one and increasingly so, pharmacists are overtaking the role of a clinical doctor. Patients have reported buying antibiotics and prescription drugs over the pharmacy counter without prior consultation with a physician.

If the MOH is sincere to reduce adverse pharmacological reactions due to supposedly inept medical doctors, then it should also clamp down on pharmacists playing doctor everyday in their pharmaceutical premises.

Patients will receive better healthcare services only when each team member abides by and operate within their jurisdiction.

The move to restrict doctors to prescribing only while conveniently ignoring the shortcomings and excesses among the pharmacy profession is biased and favors the pharmacists’ interests.

Root problem is quality

A significant issue in Malaysian healthcare is that of the quality of our medical personnel. This includes doctors, dentists, nurses and pharmacists, therapists, amongst others. A substantial number of our doctors are locally-trained and educated. If current trends are extrapolated to the future, the number of local medical graduates is bound to rise exponentially alongside the unrestrained establishment of new medical schools.

The quality and competency of current and future medical graduates produced locally is an imperative point to consider. Competent doctors with a sound knowledge of pharmacology will go a long way in improving patient care and minimising incidence of adverse drug reactions. The very fact that the MOH resorts to the drastic step in prohibiting doctors from dispensing medications indicates that it must be aware of the high prevalence of drug-related clinical errors.

Much of patient safety revolves around the competency of Malaysian doctors in making the right diagnosis and prescribing the right medications. Retracting dispensing rights from clinicians therefore, will not solve the underlying problem. Our doctors might still be issuing the right medications but for the wrong diagnosis. In the end, a dispensing pharmacists will still end up supplying the patient with a medication of the right dosage, right frequency but for the wrong indication.

medical doctors in malaysia 120106Patient safety therefore begins with the production of competent medical graduates. The problem lies in the fact the same universities producing medical doctors are usually the same institutions producing pharmacists. It is really not surprising, since the basic sciences of both disciplines are quite similar. Therefore, if the doctors produced by our local institutions are apparently not up to par, can we expect the pharmacy graduates who learnt under the same teachers to be much better in their own right?

Among other remedial measures, my personal opinion is that the medical syllabus of our local universities is in desperate need for a radical review. There is a pressing need for a greater emphasis on basic and clinical pharmacology. At the same time, the excessive weightage accorded to para-clinical subjects like public health and behavioral medicine need to be trimmed down to its rightful size. Lastly, genuine meritocracy in terms of student intake, as opposed to ‘meritocracy in the Malaysian mould’, will drastically improve the final products of our local institutions.

MOH’s own backyard needs cleaning

Healthcare provision in Malaysia has undergone radical waves of change during the Chua Soi Lek era. The most sweeping changes seem to affect the private sector much more than anything else. The Private Healthcare Facilities and Services Act typifies MOH’s obsession with regulating private medical practice as though all doctors are under MOH’s ownership and leash.

An analyst new to Malaysian healthcare might be forgiven for having the impression that the Malaysian Ministry of Health is currently on a witch hunt in order to make private practice unappealing and unfeasible in order to reduce the number of government doctors resigning from the civil service.

Regardless of MOH’s genuine motives, it must be borne in mind that private healthcare facilities only serve an estimated twenty percent of the total patient load in the whole country. The major provider of affordable healthcare is still the Ministry of Health and probably always will be.

Targeting private healthcare providers therefore, will only create changes in a small portion of the population. Overhauling the public healthcare services conversely, will improve the lot of the remaining eighty percent of the population.

medicine health pills and tablets and capsulesAt present, the healthcare services provided by the Malaysian Ministry of Health are admittedly among the most accessible in the world. The quality of MOH’s services however, leaves much to be desired. Instead of conceiving ways and means to make the private sector increasingly unappealing to the frustrated government doctor, the MOH needs to plug the brain drain by making the ministry a more rewarding organisation to work in.

The MOH needs to clean up its own messy backyard first before encroaching into the private practitioners’.

The prescribing-dispensing issue should hardly be MOH’s priority at the moment. I can effortlessly think of a list of issues for the MOH to tackle apart from retracting the right of clinicians to dispense drugs.

Private laboratories are conducting endless unnecessary tests upon patients and usually at high financial cost despite their so-called ‘attractive’ packages. In the process, patients are parting with their hard-earned money for investigations that bring little benefit to their overall well- being.

Mildly ‘abnormal’ results with little clinical significance result in undue anxiety to patients. More often than not, such tests will result in further unnecessary investigations. The MOH needs to regulate the activities of these increasingly brazen and devious laboratories.

Potentially lethal procedures

Medical assistants trained and produced by the MOH’s own grounds are running loose and roaming into territories that are far beyond their expertise. It is not uncommon to find patients who were on long-term follow up under a medical assistant for supposedly minor ailments like refractory gastritis and chronic sorethroat.

A few patients with such symptoms turned up having advanced cancer of the stomach and esophagus instead. The medical assistants – who for years were treating them with antacids and multiple courses of antibiotics – failed to notice the warning signs and red flags of an occult malignancy.

They were not trained in the art of diagnosis and clinical examination but were performing the tasks and duties of a doctor. There is no doubt that the role of the medical assistant is indispensable in the MOH. Just as a surgeon would not interfere with the role of an oncologist, medical assistants too must be aware of the limits of their expertise. MOH will do well to remember the case of the medical assistant caught running a fully-fledged surgical clinic in Shah Alam in late 2006.

refugees in malaysia 130207 medicalAdulterated drugs with genuine risks of lethal effects are paddled openly at roadside stalls and night markets. They are extremely popular among folks from all strata of society who rarely admit to the use of such toxins to their physicians. It is possible and highly probable that many unexplained deaths taking place each day are in some way related to the rampant use of such preparations.

Non-medical personnel are performing risky and potentially lethal procedures daily without the fear of being nabbed by the authorities. These are mostly aesthetic procedures. Mole removals, botulinum toxin injections and even blepharoplasty are carried out brazenly by unskilled personnel and usually in the least sterile conditions.

It makes a mockery of the plastic surgeon’s years of training but above all, proves that the MOH is indeed barking up the wrong tree in its obsession to retract the dispensing privileges of medical practitioners.

Get priorities right

In summary, a patient’s health is affected by many factors – a doctor’s aptitude is merely one step in a torrent of events. The health seeking behavior of patients play an imperative role in the final outcome of one’s own health.

Most harm to patients can only occur as a result of unidentified minor errors in the management flowchart of a patient. If allowed to accumulate, such errors converge as a snowball that threatens the long term outcome of an ill person.

There are a multitude of other clinical errors apart from prescribing and dispensing, some of which are not at all committed by trained medical staff. The MOH must get its priorities right by first overhauling an increasingly overloaded public healthcare service.

Lastly, the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison.


 

PRODUCT OF THE SYSTEM is the pseudonym of a doctor in government service.

Masters of malaise everywhere

Masters of malaise everywhere

Sorry folks, this kind of discrimination could be seen everywhere. But it is still manageable and not too bad here. In Burma, I was the top student in my class in every subject in every year. And I got first in the written examination for the post-grad entrance examination for all the Medical Universities, conducted by Ministry of Health, Directorate of Medical Education.

But I was rejected or failed at the interviews and when the Director of Medical Education openly remarked that he had no choice but to fail me because I am an Indian, I left Burma. (We are not allowed to sit the foreign exams at that time.)

Although I passed the Part 1 Membership exam from UK, HELD IN Singapore, I was denied further training in UK, Singapore and Malaysia because I am holding a Burmese Passport and not the official candidate sent by Myanmar Military Government. Only after working for many years in Malaysia, I was allowed the training but need to enlist in the Masters programme first.

Read this article/letter by Jason Gilbert in Malaysiakini_

It is that time of the year again, when application results for the local masters for medicine programme is announced. Places in these programmes are limited due to the resources required to run such a course in the local setting.

This is usually not the problem, as most are content with the fact that places are limited, and there is a competition for it. What’s unbecoming is the time and again issues of candidates who are selected for this programme by some whim and fancy, or by being some VIP children.

What is the message being sent out here? Work hard for the government and do your best, but only don’t hope to progress as there are others who take the shortcut method into the system.

Eligibility of the masters entrance denotes that candidates should be in good standing, and has completed government medical service by the time of entry into the programme. Also, ones has to declare one’s interest in the many specialties of medicine, and taken steps towards it by publishing in the appropriate discipline, or attempting courses or exams which are related to the said course.

However, each year the university takes in candidates under the Slai/Slab scheme, which pinches the available places from going to truly deserving candidates who have served the country. These usually consists of JPA deserters, who refuse to come home and serve the 10-year bond, and apply the easy way out. These are the truly ungrateful lot. Why should they be given this opportunity, and deprive a genuine candidate?

If we go into the depth of the Slai/Slab debacle, we’ll be here till the cows come home. No time for that. Let’s talk about the KKM candidature itself. Even here selection of candidate is not transparent. It has always been a grey area.

The health minister and the ministry’s DG lament day in and out about the shortage of doctors but to what effect? There is no remedial action. Good genuine doctors are lost from the KKM fold due to frustration of being slighted and treated unfairly in the masters application. What is your answer to that??

Doctor BS for example, is a candidate who has served the government for the last six years. He had applied for masters in surgery unsuccessfully. The year before last, he had not passed the entrance exams, which in itself was a smokescreen (previous undergraduates from the university which was organising that exam were informed before hand of the questions). This year however, he had passed his entrance exams and went ahead to the interview.

Dr BS has two years experience in general surgery, and another two years in sub-specialised surgery. Completed his Part 1 and Part 2 membership exams with the Royal College of Surgeons in UK. All his paperwork is in order (by no means an easy task going by the standards set by KKM and the staff who ‘makan gaji buta’), his SKTs (Sasaran Kerja Tahunan – a form of dubious assessment in government service) are well over the required 86% for three consecutive years. Yet he was denied entry into the masters program.

In his place the university has accepted far inferior candidates. So, people like Dr BS, are left with no option but to quit service, after being frustrated for years. Here is a candidate who is true to the name, a bona-fide postgraduate candidate and yet again, has been let to slip through the nets of dubious selection criteria.

Well done KKM and the universities. Shame on you.

 

 

Health minister making doctors ill

  Health minister making doctors ill

Dr Raj Kumar Maharajah in Malaysiakini | Apr 2, 08 4:15pm

I am a doctor practicing in a clinic in the outskirts. I was totally taken aback when I read the media reports wherein the DG of Health was reported to have said that doctors will eventually be relieved from their right to dispense medication at their clinic. This is another unpopular move by the DG of Health who also happens to be the president of the Malaysian Medical Council.

Indeed, there was a lot of rumbling and grumbling on the ground almost immediately and many were not pleased by this statement by the DG. I think sooner or later the DG aims that doctors should be out of jobs.

There will come a day when medical laboratory technologists will say that they can run blood and urinary tests and are capable of inferring results so there is no need for the doctors to infer the results. Then the radiographers will say they can do X-rays and scans and therefore patients who need an X -ray or scan may just walk in to their ‘clinics’.

As it is the health ministry is trying to phase out doctors from hospital administration. Now we have paramedics who have reached the stage of deputy directors of government hospitals. Soon computers may be able to diagnose diseases and there you go – the mission and vision of the health ministry will have been achieved.

The right to dispense is the right of the doctors and that’s why we read pharmacology in medical school and journals/CMEs now. No one can say that a doctor doesn’t know much about drug interactions, drug reactions and adverse reactions. Only fools will believe that. If a patient is supposed to get a prescription from a doctor and goes to the nearby pharmacy, what guarantee is it that the medicine is being dispensed by a qualified pharmacist and not a helper in the pharmacy?

We all know that you only get to see the pharmacist in any pharmacy if you request to see one. All other transactions are done by helpers with no medical back ground whatsoever at the counters. You mean to say these helpers are better than a doctor in a clinic who gives personalised treatment to his patients ?

I also found out that doctors in Taiwan and Korea went on a strike for three days despite government warnings. When there were demonstrations last year in Malaysia, the government was quick to belittle the organisers by saying that ‘this is not our culture’.

Well, Health Minister Liow Tiong Lai, the dispensing of medicines at clinics in Malaysia has been a Malaysian culture ever since time can remember and this system has worked very well in the Malaysian scenario. Kindly do NOT change this workabale, time-tested Malaysian culture.

The guardians of healthcare in this country are the doctors and not with the minister, the DG, the pharmacists, the MLTs, the radiographers or anyone else. The body that represents us is the Malaysian Medical Association and NOT the Malaysian Medical Council.

Any change in policy should be done in consultation with the doctors and not by force by the Minister or the DG as in the case of the Private Health Act which was bulldozed past us last year

Repeal draconian private healthcare Act

Repeal draconian private healthcare Act

ZARIM KAMARUL’s letter in the Star Online_

I REFER to Dr John Teo’s letter, “Act unfair to doctors” (The Star, March 28).

The PHFSA (Private Healthcare and Facilities Act) was created in 1993 at the urging of consumer associations as they claimed they often handled complaints from the public on poor services provided by private hospitals and clinics.

But they were told that the Health Ministry’s hands were tied.

This is untrue.

The Medical Act 1971 is very clear, especially in trying to apprehend bogus doctors.

Doctors wanting to practise in Malaysia must have graduated from a recognised university, must have registration with the Malaysian Medical Council and must posses a valid Annual Practicing Certificate.

Anyone not complying is a fraudulent or unlicensed doctor and is liable for a fine or jail term of two years or more.

The Medical Act 1971 is in itself comprehensive.

But what was absent was enforcement.

One of the bizarre edicts of the new law was that it applied only to private doctors but not to government ones.

Among others, private practitioners will need to work in specified clinic conditions, pay a suspicious registration fee of RM1,500 and buy medical equipment they may never use.

The Act was passed in parliament despite the objections by MMA presidents.

The recent elections have shown that the Government must pay attention if unfair laws are proposed or are being promulgated.

This country must not exchange democracy for the rule of little Napoleans as the de facto method of governance in the civil service.

The PHFSA must be repealed.

ZARIM KAMARUL,
Shah Alam.

Act unfair to doctors

DR JOHN TEO’s letter in Star Online

AS our Prime Minister announced his new Cabinet and as the unprecedented general election results unfolded before our eyes, what was clear to all Malaysians, regardless of race, gender, religion and profession, was that our destiny and objectives are the same. That is: equality, fairness and the ability to share and prosper together as one race in this great nation of ours. 

One of the very important tasks ahead for the new Health Minister and the Cabinet to look at is the Private Healthcare Facilities and Services Act 1998 which came into force last year amid an outcry by private doctors throughout the country. 

With the usual government modus operandi of implementation of similar regulations like the introduction of Fomema to monitor foreign workers’ health and the proposed E-kesihatan to monitor transport workers’ health which was later scrapped, the stakeholders i.e. the private doctors and even patients do not play any major part in its formation.  

The threat of a RM300,000 fine for not registering is enough to send all private doctors scurrying for the registration forms. The concession was that the authorities will not use the Act without due care and disregard to the private practitioners and that its main objective is to weed out bogus doctors and unqualified practitioners. 

It is now necessary to ask why is a fully qualified doctor from a local university with a valid annual practising certificate that qualifies him to practise professionally in this country as in the case of Dr Basmullah Yusom languishing in jail because of the PFHSA?  

His only crime is of course failing to register his clinic as he is planning to move to another locality soon. 

I speak for myself, but I also believe that I speak for a big majority of private doctors in this country, that the PFHSA should be repealed. 

Most doctors, whether in government service or the private sector, have only one main objective in mind and that is only their patients’ welfare and health first and foremost. 

I am not suggesting that errant doctors or practices should not be regulated. But there are many Acts in place already to do that and the fact remains that the PFHSA has too many regulations that can be yielded and enforced in so many forms that many doctors are objecting too. 

In all fairness, the PFHSA should also be renamed and revamped as the Facilities and Health Services Act without the word “private” as I believe that the same high standards should be demanded for all health facilities and services, be it private or government, as all Malaysians are equal under the law in this great nation of ours. 

It is the fervent wish and hope of many doctors that this great injustice called the PFHSA is corrected swiftly and effectively by the new Cabinet in this dawn of a new era in Malaysian history. 

DR JOHN TEO,
Kota Kinabalu.