The Ugly Physician, once again perhaps, a time to ponder…

"Our lives begin to end the day we become silent about things that matter." ~Martin Luther King, Jr.

“Health care professionals, lawyers, regulators and patients must rise above the long tradition of blame and denial and uncover together the systematic flaws in the U.S. health care system that lead to repeated errors. Rather than attempting to assuage guilt or outrage about errors by punishing, discounting, or self-flagellation, physicians need to look to preventing recurrence of errors.” ~ Lucian L. Leape, Author of To Err is Human: Building a Safer Health System, Institute of Medicine 1999 report.

It is saddening to read yet another scathing and cynical attack on the medical profession in a letter to the editor (NST 17 April, 2001).

The manifestly biased and unjustified allegations by the writer will undoubtedly raise the ire and requisite disgust of many a medical doctor.

It obviously begs the question that the writer must have been horribly aggrieved to feel so negatively and petulantly as he does toward the medical profession, and he deserves our sympathy.

It is truly sad because this implies that the writer has lost his trust of doctors. He views the medical profession with such suspicion and skepticism that he thoroughly confuses the issues of appropriate remuneration with his own values of what is construed in his own mind, as greed.

Just because a physician or surgeon earns more than a certain amount does not make him a criminal! Neither does this imply that he has to carry out surreptitiously illegal and unnecessary procedures to do so. Such allegations smack of envy, and envy does not become of anyone in this day and age of modern-day economics.

While one may have socialist aspirations and value systems, these should not be used to pontificate on one’s own version of righteousness, as to what is deemed appropriate and what is not. More importantly, this disparaging attitude is quite untenable and mischievously speculative.

Unsubstantiated remarks such as fee splitting, commissioning, performing unwarranted surgeries for financial gains, paints a rather contemptuous picture of the medical profession, particularly those in the private sector.

While some of these despicable practices might indeed be occurring, statements such as these should not be airily vented without adequate substantiation.

Just because one can imagine such terrible things happening does not mean that it is indeed taking place, especially when one is already quite noticeably paranoid.

If one has the proof and the evidence, I would strongly urge taking the most robust and appropriate legal action against the practitioner to help eradicate such practices, with haste.

However, one must remember that anyone accused of any wrongdoing deserves to be given due process of the law. Trial by media or mob lynching cannot be the approach to tackle these unspeakably unethical breaches of the medical profession.

Shouldn’t we be fair, or should we let our anger blindside our judgment so much that we adopt the slippery slope trampling of the rights of the accused, because we are so, so angry, so aggrieved?

Vengeance at all cost constitutes vigilantism and can be punishable when wrongly applied, despite the most righteously perceived justification. One simply cannot take the law into one’s hands, or failing that, character-assassinate another through libelous means.

Perhaps other avenues of grievance address and redress could be explored. Perhaps the medical profession could also make this easier for public scrutiny and audit of our records, without resorting to the adversarial medico-legal challenges, which is the approach available these days.

The public on the other hand should be more accommodating and less intimidating with their demands for blood and vengeance for their perceived suffering due to alleged medical negligence or errors.

Talking and working out with doctors, without naive expectations could form the basis of a better more trustworthy relationship, so that less anger and untoward grievances can be better avoided.

Patients should also learn to be less demanding and understand that health and medical care is not an exact science. It is at best a carefully constructed art of healing where the patient has to play a dependent yet rightful role, and the physician too his trained expertise. He must remember that sometimes errors or less than the best outcomes of medical treatment or procedures can and will occur through no fault caused by anyone.

Nevertheless, all these recurring themes attacking the medical profession angers and saddens me. Something is not quite right out there. There is too much misunderstanding, too much anger, too much hate. I cannot help but think that perhaps, there is just too much smoke to simply wish it all away, as if there was no underlying fire, to stoke it.

Could it be that we doctors have ourselves to blame for some of this malaise in our public’s perception of us?

As doctors it is a timely reminder for us to take up this recurring challenge to ensure that we are not repeatedly placed in such compromising positions where our actions can be called to question by either our patients or the press.

We should as best as possible remain above the fray of such actions and activities, which might be misconstrued as unethical or even downright illegal or criminal.

We must rise above ourselves in our professional services while earning our legitimate wages or fees. All dubious endeavours toward moneymaking concern or actions, which could insidiously breach the tenuous lines of propriety such as unjustified personal gain or enrichment at the expense of their patients or clients, should be scrupulously avoided.

Doctors’ connections or involvement with business-like concerns should be seen to be above board and not smack of conflicts of interest. The latter refers particularly to physician-owned or shared medical facilities or equipment such as pathological laboratories, MRIs, lithotriptors, catheterization laboratories, renal centres, nursing homes, etc.

Another tradition of medical education and option, which is surprisingly unpopular amongst the highly competitive atmosphere of secondary or tertiary care, involves specialists and sub-specialists.

This is the lost art of sharing resources and decision-making choices with fellow-colleagues through medical conferences and discussions. This is now almost nonexistent in most private healthcare facilities, where the interdisciplinary or departmental approach is frowned upon, and where solo practitioners reign supreme, often practicing at their wits’ end, within their narrowly circumscribed field or expertise.

While this might not be altogether bad—because there are some brilliant, highly skilled and most up-to-date specialists—case-sharing and information exchanges can always help hone one’s better development as a physician or surgeon. Bringing back the grand ward rounds might be for the better if we can be persuaded to welcome this enterprise into all private medical centres.

Because of fear of losing patients, there is now a tendency to precipitate actions and decisions. Part of the problem is the impatience or even contemptuous arrogance of our newly informed clients who hanker for quick instant results and treatment.

When such patients feel deprived of adequate or less-than-convincing explanations or are fearful from their limited knowledge of the pronounced diagnosis, they frequently panic and hunt around for immediate answers or possible clutches of redeeming straws.

Unfortunately they are then most gullible and vulnerable to the grandiloquent practitioner who can then promise them the world, often without due consideration as to the patient’s overall well being.

Nowadays, many a physician or surgeon would be only too happy (perhaps too human?) to oblige the demanding client for a quick perhaps less-than-correct surgery, or a less-than-optimum balance of therapeutic choice which might not stand the wisdom of time and longer term prognosis.

I have lost my fair share of patients whom I could not persuade that their conditions warrant more major surgeries, than the much preferred less invasive ones, sometimes to great disastrous consequence.

I can vividly recall one glaring example. A year ago, an otherwise fit 72-year old diabetic and hypertensive patient was referred to me for recurrent bouts of acute pulmonary edema.

He was subsequently discovered to have had diffuse triple-vessel coronary artery disease, and of course a poor left ventricular function. After a few months of stabilization, I referred him for coronary bypass surgery as this was in my considered opinion the best option for his long-term prognosis.

Naturally he and his family were disturbed that he should undergo such a major operation at such an age, and instead of seeing the cardiac surgeon, they self-referred him to another cardiologist, who promptly considered him a possible angioplasty candidate based on the patient’s desire for a lesser procedure.

He underwent multiple angioplasties and unfortunately for the patient, during the complex procedure, which crashed, he suffered a massive heart attack, hypotension and also a stroke.
The rueful son called me to relate what had happened and that his father was now on a ventilator, and the doctor had told them that there was not much else they could do. The son wondered if there was still some miraculous thing that I could offer by transferring him to the hospital where I practice!

Sadly I had to reiterate the bad news, which was that there was nothing else we could do, and he died at home a few days later.

Of course, most of us would hanker after a less invasive procedure, because we all want to recover more quickly without too much inconvenience or pain, but sometimes this is not the best-tried or evidence-based option.

Of course as well-trained and experienced practitioners, we might become too enthralled with our own superlative skills that we begin to imagine that we are god-like and that we can tackle all medical problems that are presented to us.

Doing all we technically are capable of doing, including heroic salvage procedures might sometimes be justifiable, but they must be well thought of, by weighing all aspects of our therapeutic decision.

We sometimes have a great difficulty in saying no, even when our lurking conscience tells us otherwise. We believe too much in our own talents and our expertise to pause and reflect on the right thing to do. We let our ego get the better of us, and our patient’s interest is not served the better for it.

I remembered one conversation I had with the late Professor TJ Danaraj. He had said that you could train a monkey to do anything including the most delicate surgery, but that that is not the point. It is making the right decision to do or not to do, to make a well-reasoned diagnosis, to choose a wiser therapeutic option that makes a better physician.

Rash fear-instilling opinions, which provoke the patient to make an ill-informed and ill-considered decision regarding their treatment options, should be avoided where necessary.

Re-consider the patient’s right to a second opinion or even a third, without the need to be fearful of losing face or the patient.

On the other hand, the referred patient for another opinion should also not be promptly hijacked from the poor first physician, by clever manipulation, implied connivance, one-upmanship or unethical self-promoting salesmanship.

But I believe the medical profession and doctors are made of sterner and better stuff—I believe too that there is that karma of life, which will come round, one way or the other. Surely as doctors we can do better for ourselves, and let the public judge us more kindly than they are wont to nowadays.

Let us give them reasons not to doubt us, and to trust us once again, and accord to us our rightful place in the health care paradigm as the respected provider and confidante. Are we so sure that we haven’t contributed to some of these ugly characterizations of our profession these days?

Let us listen once again to our hearts, to our soul within, which makes us choose to be the healer within, for as long as any medical doctor can remember.

Because, if we have forgotten how that feels, that wondrous feeling of being a healer, a doctor first, and that our patients are there because we have an obligation and a necessary connection to serve them with the best of our abilities (including helping them make the wisest and best medical and health choices), then it is perhaps time to quit being a doctor—to acknowledge that we have lost our vocation, and choose something else to profit by, lest we demean the profession by hanging in there with our growing warts and all…


(MMA News Editorial, July 2002)

Professionalism: Are We Made Of Better Stuff?

“The patient-physician relationship is at once constant and dynamic. Nearly a decade and a half ago, I described this interaction as a ‘covenant of caring - one individual with a need and the willingness to trust and another with knowledge and the desire to respond.’ Yet at the same time, this relationship must accommodate changing needs, perceptions, and expectations. Today, the patient-physician relationship is as much involved with advanced technology, innovative medical treatments, and high tech diagnostic tools as it is the delicate interaction of two human beings.” ~ Mike Magee, (Presented to the World Medical Association, on the occasion of the WHO Assembly Meeting, Geneva, Switzerland, May 13, 2002)

We live in very troubled times.

The science and technology of medicine appears to have outstripped our capacity to fully comprehend much less to contain its scope, reach and ultimate benefits for mankind.

Yet the art of medicine appears inflexibly tethered down by seemingly antiquarian concerns of traditional ethics and professional benevolence.

Since our accidental historical tryst with destiny, doctors have been propelled into the celebrated roles of saviours, salvaging heroes, curers and ameliorators of pain and suffering.

We have allowed ourselves to be persuaded that we have to continue our never-ending quest to alleviate or eradicate human suffering and postpone death—so much so that the general public has grown so accustomed to our seemingly relentless streams of healthcare advances and modern therapies. We all expect that someday every conceivable ailment will be conquered, simplistic as this may seem…

Doctors and scientists are therefore expected to doggedly pursue advances and improvements in medical or health-related diagnoses, investigations and therapies—in an inexorable yet spectacular search for the Holy Grail of immortality, and a complete dominion over ill-health—anything less would have been unthinkable.

Yet of late, many have come to realise that whilst all such advances are most welcomed, cost considerations and cost-efficiencies and benefits have to be factored in.

Runaway and unrestrained costs are not a sustainable option for modern society—because we simply cannot afford it for everybody. Besides, many of such new and costly tests or therapies are just too wasteful, and could have been inappropriately utilised. Some rationing and rationalization have to be considered.

Thus, in recent years, we have seen the advent of more rigid and well-tested clinical research, comparative studies and the development of evidence-based medicine.

Newer technologies and therapies have now to be tested against well-tried or previously accepted practices, before they can become accepted as mainstream medical practice.

Unfortunately, or fortunately, many of these stupendous advances have erupted so quickly, in surges and spurts, that they have simply overwhelmed the ability of the scientific and medical fraternity to quickly reconcile or to separate what’s considered still investigatory and/or what’s now acceptable practice…

In order not to be left out of the loop of advances, most physicians have jumped in with both feet, to quickly learn and adopt or adapt such technologies for the benefits of their patients, and perhaps also for their own personal enhancement or ego.

Importantly however, many of our patients appear to have benefited, and few have actually suffered ill-consequences as a result. In most instances, these advances helped create more demands and generate wider public acceptance.

With such well-publicised success, it is not surprising that our public expects and respects many if not most of our medical decisions.

True, intermittent reports of medical mishaps and errors have dampened our love-affair with modern medical practice, and skyrocketing health care costs have severely dented many an economy.

Yet, the system appears very much alive with no end in sight for more and more diagnostic and therapeutic developments and advancements—indeed despite the fact that they almost always encourage more cost, and further generate demand…

Into this scenario is thrown the physician, whose role has changed with the times. Primary care physicians while still the core of most healthcare systems, have of late faced the daunting tasks of gate-keeping and contending with patient-expected referrals for specialist or tertiary care.

With the model that we have however, everyone can seek specialist opinions and treatment directly.

This is perhaps the free-market option that we have adopted for years. In the past, when access was more limited and private or public tertiary healthcare centres more scarce, this could indeed be less of a problem.

However, these days, anyone who thinks he or she can afford it, would not hesitate to choose direct access to specialist care—whether this is medically necessary or cost-effective or otherwise.

Despite this, our private healthcare services constitute just about 30% of our total Malaysian healthcare services. Most Malaysians continue to patronize our ever-growing and modernizing public centres of excellence, which are increasingly well-equipped and whose specialist care is at par with the private sector, if not arguably better in some cases…

Most of the differences between the private and public sectors are perceptive and perhaps related to the degree of promptness, luxuriousness and individual-attentiveness of its ancillary services in the former.

This dichotomy has indeed served the Malaysian public well, with competitive pressures (on both sides) to provide better and better services to our more discerning patients. We are proud to say that nowadays, Malaysians enjoy a standard of healthcare second to none in the world, and yet at a relatively low cost, when compared even regionally.

However, the rapid development of our private health sector and the brisk expansion of our public tertiary care and services of late have provoked some disquiet that this might have led to indiscriminate uses of expensive resources, which could be put to better and more cost-effective use, for the betterment of a larger proportion of the public.

Cardiovascular services have become one of the most explosive in the world and indeed so too in Malaysia and the region. Its technological advances have also been one of the most intriguing and awe-inspiring.

What with Malaysia having the Number One killer in cardiovascular diseases for the past 3 decades, the growth in cardiological services has been mind-boggling. The advent of angioplasty, stents, coated stents, and other keyhole techniques have also added impetus towards the greater expansion of expertise and availability, in the past 10 years or so.

But this must also be seen in the context of an overall growth in every aspect of the medical-healthcare industry—including drugs, devices, tests and diagnostic and therapeutic amenities. Indeed there has been accompanying tremendous growth in pharmaceutical approaches to most medical ailments as well.

These days, besides surgical treatment and/or secondary prophylaxis, primary prevention has also been developed aggressively with promotion of the use of aspirin, statins and lately of some ACE-inhibitors.

Gone are the days when the cardiac patient once “bypassed” is pronounced “cured” by the cardiac surgeon, and then duly discharged with an aspirin a day, and nothing more… We now know that he or she has to be better managed for the longer good of the ultimate prognosis.

Still there are concerns that perhaps doctors and specialists have become too mercenary, and have lost their objectivity in choosing what’s best for their patients. While this is certainly not unheard of, it is nevertheless, a serious implication that every doctor should consider and ponder upon.

I have on innumerable occasions reminded our medical fraternity that we should always be firmly anchored on our inherent moral compass, and remind ourselves that we not lose our soul to our more venal desires.

There can be no denying that the lure of filthy lucre has become the catchphrase of modern society. And just like everybody else we physicians have become ensnared in the same tussle for an ever-enlarging piece of the materialist pie.

This can lead to promotion of subconscious or even deliberate pursuits of self-interests and possibly unfair monetary gain. Some and perhaps even everyone of us—at some point in time—might have been guilty of placing our own interests above that of our patients, when the overarching God of Mammon supervene our befogged conscience—long inured of amoral relativism.

Such conflicts of interests as well as potential moral hazards are becoming somewhat starker and are being voiced by the many ethically-challenged and concerned amongst us as well.

Increasingly, it is true that as physicians we can and do practice medicine which impinges upon the slippery slopes of ethical conundrums and contretemps.

However, this fine line of moral or ethical correctness must be judged within the context of society’s current realism and pragmatism. I have already cautioned against too much immersion into our senseless pursuit of material goods so much so that we lose our soul as human beings.

Yet, love it or hate it, since the collapse of communism and socialism, the sweeping triumphalism of free-market capitalism has become the predominant thought and philosophy of life---its universal reach being felt by even the staunchest of religious ascetics…

Thus it is hardly surprising that doctors—being lesser mortals than saints—have also become unwitting followers of this new creed of wanting more and more…

Therefore, it is perhaps timely once and again to review and renew our faith in life and goodness. It is good to reassess our priorities, our humanness vis-à-vis our fellow beings. It is also time to ponder upon our medical profession and what it truly means to practice as or belong to a “profession”.

Malaysian Healthcare Blues—We Need Newer Ideas, Better Personnel, not More Monuments…

“I regard the capacity of single-payer plans to ration effectively as a potential virtue. The need to ration care for the well insured is rapidly becoming inescapable in the face of an avalanche of new and costly technology. No system of rationing will be free of distortions, and a single-payer system may do the job well or poorly, depending on how it is organized and run. But creating politically sustainable institutions to ration health care sensibly and compassionately is one of the leading challenges that our nation cannot avoid and has yet to meet.” ~ Henry J. Aaron, Ph.D. Brookings Institute, Washington, DC 20036-2188 (NEJM 2003; 349:2461-2464)

Our National Health care system has been earmarked for change and modification for some time now.

There is some suggestion that it might even be considered for a more extensive revamp in the light of a planned move towards a Single Payer System, i.e. a National Healthcare Financing Authority and Scheme.

That this might be implemented soon is much anticipated, although the niceties and regulatory framework for such a potentially drastic exercise have yet to be fully revealed by the authorities that be.

Clearly the Health Ministry and the government of Malaysia will be finalizing the minutiae and will be rolling-out the scheme once the new Minister familiarize himself with the particulars of this long-awaited change.

In this regard we congratulate the new Minister of Health Datuk Dr Chua Soi Lek for his appointment into this hotbed of unending challenges, which has outlived many if not all of his predecessors. It will be good if the new Minster can approach this perennial quagmire with fresh eyes and ideas.

More important perhaps is the need for the Ministry of Health to re-appraise its priorities, as well as to formulate more consistently a definite Master Plan of where it wants the Malaysian Health Service to go in the coming decade or so.

Being a doctor himself, we hope the Minister can empathize with the healthcare providers especially physicians who have hitherto been emasculated from having too forceful a say, for fear of moral hazard and conflicts of interest.

Needless to say, we physicians believe that being an integral and inseparable part of the healthcare system, we should be the best qualified to understand the nitty-gritty problems and nuances of our profession and by that too the attendant problems of the healthcare and medical services.

The MMA of course stands ready to brief and assist in enlightening the Minister vis-à-vis these pressing problems.

The MMA has been instrumental in providing not merely lip service but also research and study plans concerning very many aspects of our healthcare services. Indeed we have been arguing for a higher standard of service for every Malaysian with the ultimate goal of global access of reasonable healthcare services for all without disparities caused by inability to pay or because of poor logistical or manpower support.

We have presented a comprehensive research document called “Health For All” (from the National Health Planning Committee of the MMA) to the government detailing these concepts of shared care and concerns. This committee is currently reviewing and updating another report to address newer more contemporary issues that we believe the government and the Ministry of Health can take due cognizance of.

We have argued for a shift towards a predominantly single payer system, because this is arguably the best mode of ensuring that every Malaysian be insured of getting every reasonable health care during acute illness, emergencies or catastrophic ailments, but at the same time respecting the constraints of a finite budget.

We have studied various other national systems of healthcare services and payment schemes, and have come to the conclusion that we must act soon before other forces of haphazard free-for-all managed care systems invade our tenuous state, and self-destruct whatever good the current system has allowed thus far.

We have also cautioned against an overloaded or third-party administrative structure which would in time consume too much of a chunk of the healthcare budget—ideally this should not account for more than 5 to 10%, so that more public monies from a mandatory contribution scheme, can be distributed more equitably to the people for their real health care needs.

While many envy the medical excellence and superlative care of the US model of healthcare, equally many consider this bloated behemoth to be untenable in the long run. The American model of managed competition or managed care-health maintenance systems have led to gross inefficiencies as well as to gross disparities of poor or no access (by some 43 million uninsured) to wanton wastage and spiraling runaway costs—upwards of 15% of the US gross domestic production.

In Malaysia we have been allocated just a paltry 3.8% (of the GDP: 2.2% public health allocation & 1.6% from private funding ) to play with—so it behooves us to be very cautious about adopting this very profligate model of excess and over-utilization of increasingly expensive services and medical technologies, and depriving an enlarging population of uninsured or uninsurable—i.e. the needy and indigent.

The Ministry of Health should seriously re-examine its expansion plans in its drive to convince the Malaysian public that it is doing everything possible to increase the quality of healthcare in the country.

We seem to have equated better healthcare services with building ever bigger and bigger facilities, at every town and urban centre. While this greater distribution is one way in which to expand our tertiary services—so that these can become more accessible to more of our citizens—we must also be equally concerned as to the quality of care of these services.

There is genuine concern that while we may have all these grandiose infrastructures in place (with more in the offing), we might still lack the requisite manpower, expertise or even simply the ancillary staff to support these services.

In the recent past decade or so, the Ministry of Health has been very aggressive at developing and constructing tertiary medical facilities at huge public costs, to cater to the needs and growing demands of our more discerning public.

That rapid phase of development has resulted in some very real access to expert but expensive healthcare services to many of the poorer segments of the population which would have been neglected by rationing just a decade or so ago.

To the government’s credit, many thousands of patients have benefited from such tertiary and sub-specialized care, so much so that Malaysians have prided themselves into believing that their health care system is now second to none and is at par with the very best in the world.

We therefore applaud the government for their foresight in pushing our Malaysian Healthcare services to the forefront of medical technology and expertise, so that some of our centres have now become singular referral sites even for some of our less developed neighbouring countries.

Medical tourism is now bandied about as a potential source of foreign exchange and income.
Conversely and ironically however, many of our own patients continue to be denied access to such services because of mechanisms which are beyond their control. Long delays or even cost-considerations have prevented unfettered access for some of these unfortunate people.

On the other hand previously untreatable and incurable diseases have become catchphrases for the newly-informed victims clamouring for some newfangled therapies which have yet to prove its ultimate benefits.

Clearly there are still areas where expert care is wanting or lacking and disparity between demand and supply exists. Better planning and greater training might provide an answer to this problem.

Because some of these catastrophic ailments can be extremely costly, there are presently insufficient mechanisms to allow everyone to equitably gain access to such care. Hopefully with a National Healthcare Financing Scheme this will become a thing of the past.

In the meantime, our Charity Health Fund has been assailed as being too niggardly and tardy at approving many requests for financial assistance to some of these costly but occasionally dubious medical therapies (which certain experts feel might simply be too prognostically dicey or not cost-effective to consider…) After all, we have only a very finite pool of resources and these public monies should be well-spent.

Nevertheless, our ever more demanding public now expects much more, perhaps more than we can adequately deliver or everyone and for every perceived ailment. They also expect faster more efficient delivery of services, as well as with better or even excellent results; and they are not too fearful to litigate or complain if less-than-expected outcomes occur.

Thus, although our healthcare services have expanded so rapidly, we have in many respects undermined our ability to sustain its continued excellence and productivity, and I believe its cost-efficiencies too. This is because we have let the development of our human resources and expertise to slide with inadequate planning and attention.

We have not in place a sufficiently well-structured training or apprenticeship scheme to continuously generate well-trained doctors, paramedics, nurse specialists, and properly accredited specialists, who can contribute with confidence and true expertise, for the sustained benefits of our people, and the public sector system.

In many respects, our training programmes have been haphazard and lack rigorous structure to ensure that our trainees once they graduate or pass out will be sufficiently well-versed with what are required of their operative skills and more importantly, of their so-called expert or ‘consultative’ decision-making and management proficiencies.

While we have been increasing our output of medical graduates in the past few years by encouraging the mushrooming of medical colleges (21, as of June 2008), we have failed to ensure that these graduates have been given the best quality medical education we can deliver.

We are adding some 1000-odd new doctors to the health service yearly, without too much concern as to the number or adequacy of their teachers or supervisors—indeed we stand accused of becoming another pariah state of medical graduate churners whose standards fall far short of international standards, if we continue along this murky path. The lack or withdrawal of reciprocity in recognition by foreign developed countries for our doctors is testimony to this sad fact…

We need a moratorium on the number of medical colleges as well as the number of medical undergraduates these colleges can undertake to teach or produce. Producing some 400 or so potential medical graduates from a single medical college demands more than a spirit of Can-Do-ism or a handful of teachers; there must be accountability that these doctors are well-taught too.

Every college must have adequate (rigorously specified) staff-to-student ratio—in every discipline so that the medical graduate it produces would not be of poor or suspect quality. More importantly this will ensure that the public will not be shortchanged or victimized in the longer term.

We must pay particular attention to this unruly development and nip this in the bud, before it is too late to intervene. Greed should not supersede the need for accountability when future lives of patients are at stake!

In this regard too, we urge the Ministry of Health (MOH) to encourage greater growth and development of its manpower and ancillary staff.

Doctors in the public services must be given more perks and given due recognition so as to attract them to stay longer and happier in service. One way is to provide proper and adequate training.

In order to do this, the Ministry needs to retain senior staff and experts so that these can be the much needed trainers and supervisors of the younger trainees. In this way the system will continually regenerate itself in terms of expert care and services.

The MOH has already allowed limited private practice for some specialists and other incentives for more allowances are now being given to service medical officers—these could be expanded further to make it not simply more work hours for more pay, but also more attractive and lucrative means, in other ways.

It is always a wonder to me how our neighbouring countries retain most of their experienced experts and specialists within the system, when we seem to fail here in Malaysia.

We have to seriously look at conditions of work and incentives to encourage more to stay in service as well as to provide some structured allowances for private practice, to these people in demand. Only then can we hope to stem their migration towards the seemingly greener pasture of the private sector.

Perhaps it is also time to allow those in the private sector to participate in the teaching of trainees or even to volunteer their services within the public sector. Such a radical step requires a paradigm shift but it is not impossible for the MOH to rethink this concept.

I believe that the MOH can do a lot more to develop the human resource strength of our public health sector, but this must be re-emphasized in a new model of understanding and planning at the very top.

The Health Ministry must continue to raise the momentum of growth of the healthcare sector, by demanding a higher piece of the GDP pie—even a rise from 3% to 5% might be sufficient to boost the morale of our healthcare services. The W.H.O. recommends an allocation of at least 8% of the GDP for comprehensive healthcare services. We need to train our nurses, our technicians, our radiographers and other ancillary staff much better, and we must pay them well too, in order to keep them happy in service.

However, although we must continue to modernize and upgrade our hospital and medical facilities, we must be prudent in ensuring that we do not go overboard in profligate expansion just for the sake of doing so. It is mind-boggling to note that most of our new hospital complexes currently being built are now costing hundreds of millions a piece!!

On top of that, the turn-key project model that is employed these days has to be reined in, and better audited. Why? Because these inevitably make the construction and development costs much more than what it should be—and all at public tax-payers’ expenses.

Medical equipment and amenities are also being purchased without due diligence as to its utilization potential or its real-life usefulness at all! For instance, should we continue to build huge unwieldy hospital complexes and superfluous medical facilities at every conceivable locale, or should it consider smaller but more accessible, better-managed but patient-friendly medical centres, clinics and amenities, which are not only more cost-efficient but also more productive and less wasteful in terms of resources (both human and material).

Other examples: do we need multiple robotic surgical facilities in remote areas of the country, expensive imaging technologies (e.g. PET machines, MRIs, etc) where their indications or utilization are suspect?

Worse, what about staffing these facilities with already-scarce experts remaining a perennial problem? Would not such expenses be better employed training and developing medical personnel and expertise?

These are some of the urgent areas for the Minister and the Ministry of Health to consider. Our Public Health Sector needs urgent and better human resource management, development and retention.

The Private Sector should also be ready to assist in a more cohesive seamless integration of services so that all our patients can benefit, by having more choices.

Smart partnerships as repeatedly advocated by the DG of Health should be made a reality by taking bold steps to address these real personnel issues, and not just creating ostentatious monoliths.

The MMA stands ready for a continuing dialogue with the MOH to ensure the realization of the best healthcare service money can buy for Malaysians.

“There are always a lot of people so afraid of rocking the boat that they stop rowing. We can never get ahead that way.” – Harry S. Truman (1884-1972) 33rd U.S. President

“Our lives begin to end the day we become silent about things that matter.” ~ Martin Luther King, Jr.

(MMA News Editorial, March 2004, updated June 2008)

Modern Day Medicine Men: Hypocrites or Hippocratic?

“If medicine were simply a matter of prescribing drugs and wielding scalpels, then monkeys—or at least robots—might make adequate doctors. It's the human bit, as in most enterprises, that makes medicine tricky, fascinating, and difficult.” ~ Dr Richard Smith, Editor, BMJ June, 2004

“Humans must always be the subjects of rights, must be ends, never mere means, never objects of commercialization and industrialization in economics, politics and media, in research institutes, and industrial corporations. No one stands ‘above good and evil’ – no human being, no social class, no influential interest group, no cartel, no police apparatus, no army, and no state. On the contrary: Possessed of reason and conscience, every human is obliged to behave in a genuinely human fashion, to do good and avoid evil!” ~ Hans Küng – Karl-Josef Kuschel (Eds.), A Global Ethic. The Declaration of the Parliament of the World’s Religions (SCM Press, London / Continuum, New York 1993).

“Come One! Come All! Come and get this fantastic Snake Oil! It’ll cure anything, indeed everything!”

So cried the snake oil medicine men of yesteryears, and indeed similar clichés resonate these days, cloaked under newfangled technologies, fringe pseudo-scientific claims and cleverly camouflaged advertising gimmicks—straight to the consumer—bypassing the meddlesome medical fraternity and ethical do-gooders, or so it seems.

Healthcare services and products are an increasingly attractive sector for the market economy to penetrate and so many are now targeting these as test grounds for making a quick buck.

Direct marketing and multi-level marketing (MLM) of healthcare consumer products such as supplements, vitamins, herbs, and even dubious alternative “medicine” gimmicks are making strong inroads in Malaysia, enticing and embroiling not just the gullible and the less educated, but so too, many literate New-Aged people who are confused as to what is true science from what is pseudo-scientific nonsense.

Homeopathic, complementary (traditional) and naturopathic claims are supplanting scientific (allopathic) medical thinking and vying for public credibility as well as for consumers who are becoming simply too bewildered to know whether these are truly useful, beneficial or otherwise. Which should be the better proven or indeed the rational choice is becoming harder to fathom for the ordinary man in the street.

To make matters worse, many newspapers and newsmagazines from the well-established to the local vernacular press have been blatantly offering devious advertorial messages, which imply that many unfounded alternative therapies are sound and reasonable.

The Star, in particular, is quite notorious in its avant-garde action for promoting alternative therapies and supplements—it regularly devotes tens of pages to so-called “health information” which are frequently inappropriate and often misleading, but which pander to public voracity for quick and simplistic cures, contemporary if unconventional ideas.

Worse, in its attempt to appear fair, it also intersperses medical and health facts amidst these pages of highly ambiguous and contentious information. This lends undue credibility to poorly justified “alternative therapies” and totally confuses the unsophisticated reader.

Of course, there is that unqualified disclaimer being attached to all such missives, as if these could then exculpate their guilt in promoting such a retrogressive step for humankind. But then, there is that almighty advertising dollar to contend with…

Since these subliminal ‘factoids’ have appeared in the press or the media, then they must have some elements of truth in them, so the thinking goes. Sadly, such is the din of the current state of affairs that scientific truths are becoming drowned out and are being displaced by these bogus and downright magical thinking!

This is no small matter because Malaysians spend some 3 times more on alternative healthcare products than on actual allopathic health products or medicines—the latter of which include such expensive medicines as for HIV/AIDS, cancer or heart problems!

Malaysians, it seems, prefer to self-medicate and view such unassuming supplementary “medicines” and herbs, etc. as sufficiently “harmless” to combat whatever possible ill-health that may be forthcoming—“no harm-lah, just for health promotion only; besides they are all safe for my body, no side-effects like western medicines which are all poisons!”

Sadly when such phony claims prove to be neither beneficial nor to do anything beyond the placebo feel-good effect, they are dismissively shrugged off as acceptable—“just preventive only, sure cannot guarantee no health problem in the future”.

Contrastingly, they are less generous when it comes to western medicine, where they expect cures every single time, and are disproportionately worried about adverse effects—“my kidneys, my liver, will they be damaged?”

Yet with herbs, roots, and other so-called natural products, they are willing to accept their safety wholesale, without checking on their authenticity, purity or better yet their purported benefits—seemingly believing in simplistic anecdotal stories as living proofs.

Into this mindset, we are thrust the onus of explaining the more esoteric science of modern medicine which appear outside the realm of antiquated but deep-seated system beliefs such as humours, qi, angin, even charms, pukau, etc. Doctors have also to compete with sinsehs, bomohs, dukuns, Ayurvedic doctors, Qi Gong masters, and the occasional itinerant snake-oil medicine men.

Lately, more enterprising homeopathic and naturopathic advocates have been stridently proclaiming their expertise through paid advertorial pages, and promoting health supplements and natural therapies without the threat of ethical misconduct that doctors would be subject to.

Lopsided as this may seem, modern medicine would still have to maintain an air of sophisticated distance if for no other reason than to be prudent and not to be drawn into a war of ideas, which might have to be fought on unequal terms and widely-divergent playing fields. Or perhaps scientific medicine is simply too superior…

Of course, this does not imply that we would have been guaranteed adequate or fair hearing if we had chosen to be more vocal about truly scientific concepts.

Notwithstanding this, most mass media are ever willing to be more objective, and are often looking out for authoritative and scientific expositions, from doctors and scientists alike. The trouble is that there are not enough of us willing to devote our time and effort to correcting or informing the public about what’s new, current and yet factual.

Nevertheless, we can do better and should be more proactive in debunking falsehoods when they occur, so that we have at least tried to put the record straight.

So we have here an underlying crisis of confidence in the system of healthcare and medical practice, which would take time and a lot of concerted effort to correct or improve.

Then, we face another very damaging challenge from within our healthcare affiliates. Instead of complementing our work as health care providers, retail pharmacists and pathology laboratories have increasingly become our direct competitors for patient access.

This asymmetrical problem arose because doctors in Malaysia are still tasked with the dispensing of medications instead of just prescribing. And there is simply inadequate policing of the pathology laboratories without a Medical Pathology Bill with teeth!

There are valid issues behind the arguments for and against this practice of doctor dispensing rights. However, it will remain unresolved until we have sufficient retail pharmacists willing to be posted throughout the entire country including rural locales; and doctors feel comfortable that they can earn their fair remuneration of professional fees, which in time our patients feel duty-bound to reimburse.

Hence, we are seeing a new breed of retail pharmacists who have become embolden to challenge the mystique and realm of the medical practitioner. Unscrupulous advertising and blatant canvassing for patients, with billboard claims of cheaper treatment for coughs and colds, free blood tests and BP testing are enticement gimmicks now increasingly prevalent.

Many a retail pharmacist blatantly sell prescription medicines (with discounts, and other offers) without prescription orders from doctors, and some even change the medications to those available at their stores (often generics of unsure quality or parallel imports), with no reference to the doctor concerned—in other words they are behaving as if they are medical practitioners—except that they are unlicensed and untrained.

Of course, this is not true of every pharmacist out there, and that these might only be a minority. However, those few who totally disregard this professional breach, continue to flout the regulations with impunity because we appear powerless to police their actions, through the inadequacy of our pharmacy surveillance and implementation units. As a result, some of our doctors are feeling the looming effects of such unfair competition.

Doctors feel frustrated that they are unable to offer cheaper prices on medicines as this would bite into their cost of running a medical practice, with rentals, incidentals and personnel to take care of.

We are also aware that pharmacies are able to offer differential discounts and then pad their earnings from sales of other supplements and other consumables where the profit margins are better.

So what do the poor out-competed doctors do? Although a very small minority, some have taken the easiest ways out—selling medical certificates, cough mixtures to drug dependents, hiring unqualified medical assistants, etc.

They too are resorting to pushing consumables, supplements, vitamins and even MLM products under the guise of healthcare use. Indeed it has been strongly suggested that within their clinic premises, some medical practitioners are profiting much more from such commercial enterprises than from practising medicine per se!

Many doctors are ‘diamond’ and very senior level dealers of MLM products which are health-related but largely unfounded in actual science.

While we cannot deny the medical practitioner his or her right to be involved in business, there is an extremely thin line of moral uncertainty where he or she can practice such an enterprise.

Furthermore, it could be construed that this breaches our ethical code of using uncalled-for enticement and market practices to attract patients, or using our professional position, premises and undue influence in society to enhance our financial gain with questionable commercial undertakings quite outside the ambit of medical practice.

These are contestable ethical conundrums which we can and should do without, because they can lead to accusations of serious professional impropriety and ethical misconduct. Yet there are many younger physicians out there who increasingly feel that we have become too rigid and old-fashioned, too much bogged down to our past glories and ethical millstone.

Are we too sanctimonious and out of touch with the modern market economy?

Are we all hypocrites since we are all human and hanker after the same pleasures, the same conveniences, the profit and the good life?

Should we allow our superimposed altruistic self to supersede our post-modern culture—where man is suppose to surpass himself, to attain a Nietzschean superman status?

So what can medical practitioners do in such a state of heightened competition for more attention from the consumer out there?

How indeed should we stay relevant and needed, and yet be practising within the ethical boundaries of our medical profession?

It is true that we are, by and large, still much respected as honorable professionals, but there is no denying that we are losing our grip with the public’s trust and dependence on us.

Still, is becoming more commercially-orientated the answer? Or are we beating about a lost cause in this new era of market-driven economy?

As increasingly astute consumers, our patients are constantly bombarded with indiscriminate and baffling information from diverse sources all purporting to enhance their health and well-being.

Thus, patients are inexorably thrust into seeking alternative ways to empower themselves with decisions about their own health care needs.

The mass media can of course help to alleviate the situation by being more selective in their portrayal of all such sundry health information, as incontrovertible scientifically-proven facts.

A watchdog committee should vet what constitute ethical and scientific medicine or healthcare, and clearly delineate those that are fringe or borderline alternative therapies or complementary practices into a separate well-demarcated section.

We must separate the wheat from the chaff, if the mass media strongly considers alternative therapies as must-publish entities because of public or commercial demand—but they should state this so as clearly as possible.

Pharmacists should be constantly reminded, educated and re-orientated to stick to their own ethical boundaries. They should use their training to educate their patients with sincerity and assist the medical practitioners for the betterment of the patients and consumers.

Supplements should be labeled as such and not be given undue emphasis or weight to enhance their unproven value or benefits, just for the sake of monetary gain.

Family doctors must practice restrain and high resolve to steer clear of unprincipled or ambiguous actions which can breach their code of ethics.

Specialists must refrain from offering too much service—over-prescribing, performing unnecessary surgeries or investigations or over-utilization just for the sake of profit. They should also refrain from overstating their expertise, or over-performing their limits or skills.

Informed consents should be more rigorously employed so that our patients are better prepared and educated as to risks and benefits—more sensible and satisfactory expectations can then be made—with fewer need for dispute resolutions and unhappy consequences.

Grandiloquent promises should be avoided as these breed unrealistic expectations and demand for unnecessary, costly and futile management strategies and cost-inefficient catastrophic surgeries.

Unfortunately, fighting for the soul of our patients’ thinking and trust is an ego-shrinking game in this new era of easy and ubiquitous knowledge largesse.

As doctors we must learn to acknowledge that we no longer have the sole control of such health-related information. But we can channel our paternalistic energies and informed training into authoritatively educating our patients out there so that they can make correct and more rational choices. Still, this is where serious divergences in approach occur.

With commercial pressures and money-making enterprises beckoning in the tempting horizons, many are adopting increasingly dubious practices to regain the ‘personal’ touch and connection with our consumers.

This is where some physicians have begun indulging in integrating untried and untested alternative therapies to gain wider patient acceptance.

While properly trained acupuncturists can now be considered part of integrative medical practice, other quasi- and pseudo-medical quack practices should be scrupulously avoided and shunned.

Sadly instead, we are seeing more and more clinic practices incorporating seriously doubtful therapies such as chelation therapy, ozone therapy, rejuvenation therapy, iridology, aroma therapy, hydrotherapy, cleansing therapy using colonic washouts, beautification boutiques and salons, etc.

What happened to our rigorous medical training that we should have become so easily beguiled with superficial beliefs in the ‘occult’, the ‘magic’ and the quackery of fringe practices which have no bases whatsoever in science or scientific thinking?

Why have some of us become so credulous or as gullible as some of the lesser initiated in scientific literacy or medical or healthcare education?

Is it the whimsical wish to distinguish ourselves for a niche market, is the commercial lure for lucre so strong, or is it simply a wish to be different?

But surely, in my mind, such practices cannot ever be construed to be smarter or more reliable than the orthodoxy of medical science currently at stake.

Either we accept medicine as an evidence-based evolving science or we can decide to leave this science and join the pseudo-science—but abdicate we must—we cannot fuse these two disparate systems, and jeopardize our medical fraternity and professionalism.

Quackery combined with some aspects of medical science only demeans our professionalism, and shortchange our scientific approach to life and living.

We can only be deceiving ourselves by selling our soul to the darkness of ignorance and remitting our minds to the forces of anti-science, perhaps just for some erstwhile 30 pieces of silver…

Conversely, this is also where as per our medical professionalism, we can show that we are better than we should be—and regain our patients’ eroding trust in us.

While it is true that nowadays more than ever, the medical profession is pressured to become an integral part of the business world, one that is market-driven and which adapts to consumerist demands and expectations; it is also true that we have to be very mindful as to our professional calling.

It is true that the motto “if you can’t beat them, join them” runs deep and is increasingly permeating our medical circle. It is also true that in trying to determine our rightful place in today’s society, doctors have become torn between the ethical confines of the Hippocratic Oath and their drive to be successful individuals traipsing among the maze-fields of widely-disparate economic activities.

Some conservatives among us are righteously adamant that the medical profession remains totally detached from commercialism, and that it should not become another trade enterprise subject to the vicissitudes of supply and demand, with its various proclivities to mercantile aspirations and buyer-seller, provider-consumer mindsets.

They maintain that we remain the noble profession which has persisted since time immemorial, with the highest of ethical standards, which should not become tainted by venal interests and scurrilous profit-orientated motives.

I believe we must actively remind ourselves that such questionable actions must be consciously eschewed, and we should not become drawn into their tantalizing tentacles of self- or financial interests.

Not only that, we must also shield ourselves from the encircling vultures of market-economic interest groups, etc. which are constantly bombarding us with seductive attractions, allurements and temptations to slide down the slippery slope of commercialism.

Again and again, we may be tempted to unwittingly slip into ethical transgressions which become with time, more inchoate and less conscientising. Ultimately these can become entrained into acceptable if morally ambiguous behaviour.

Yet we must uncompromisingly remind ourselves that we are medical professionals first and foremost, with a moral imperative to consider our patients as our raison d’être.

We must therefore set our ethical standards purposefully and exceptionally high to constantly kindle the embers of our moral rectitude and probity, without which we stand to fall deeper and deeper into the hubris of uncertainty and moral conundrums and depravity.

One of the problems of modernity is that we have been exposed to the relentless onslaught of technological and economic progress which has generated a callous climate of demand creation and amoral craving for more and more—a consumerist mindset which is inexorable and insatiable.

We are forced into a struggle of Faustian proportions, with less than certain anchors for which to judge what is proper and right. I do not believe we are as yet doomed to a Mephistophelean future.

In his 1993 Ethics lecture to the American College of Surgeons, Dr Leffal reminded medical doctors that “high ethical principles represent the grace notes of our profession and involve not so much intellectual rigor but a disciplined spirit. Ethics represents not just what we do or what we say but what we are… What is important in our practice is something the Romans called ‘gravitas’—moral and temperamental weight—that binds us in an ethical way to our patients.”

Edmund Pellegrino, a noted medical ethicist, defines ethics as the science of human conduct and that medical ethics refers to the whole medical arena—including care of the sick, prevention of illness, and cultivation of health for individuals and society.

He advocates strongly that ethics as a discipline with its own content and method can be taught. He believes that ethics encompass certain but concrete human judgments in various situations where actions have to be taken, in spite of all the multifarious uncertainties and inexactitudes that are integral to clinical medicine.

To inculcate medical ethics, several objectives are realizable; these include: (1) teaching the skills of ethical analysis essential to making medical moral choices, (2) raising sensitivities to ethical issues in everyday clinical practice, (3) enhancing critical reflection on one's personal values and obligations as a physician, and (4) identifying the substantive ethical assumptions underlying clinical decisions.

Pellegrino believes that medical ethics can be reconstructed and must be based on the “one irreducible foundation of all clinical medicine—the relationship between the one who is ill and the one who professes to help and heal.” This article is written to highlight these objectives and to remind us that medical ethics stringently applied as they have been are still relevant today.

True, these days the ethical issues confronting the medical profession have become more numerous, tenuous, and amorphous—often defying or obscuring ethically correct or black-and-white answers. Some of the pat answers to many a searing ethical question seems to lack the moral symmetry that fairness demands.

Nevertheless we must choose to remain steadfast in our devotion to higher ideals and principles if we are to give our patients the best care that is their just due. We must steer clear from our own personal or financial interests and possible gain, which can corrupt our souls surreptitiously.

Since its founding in 1987, the Josephson Institute (in America) has advocated that civil society be built upon a foundation of 10 consensual ethical values: honesty, integrity, respect, caring, fairness, promise-keeping, pursuit of excellence, civic duty, accountability, and loyalty.

It is perhaps timely to remind ourselves of what these ten values mean to each and every one of us, individually. We cannot and should not pick and choose, when and where or how and what, but we should encompass all these into a rational whole—an entity which is above the human weaknesses of expediency, complacency, compromise or hypocrisy.

What then, is our charge as doctors? It is simply thus: to cure when possible, to relieve pain and suffering always, and above all to do no harm, to our patients in particular, and to society in general.

Sometimes we fail in our charge, but when we fail and if we fail, we must always fail while trying. Yet pragmatism dictates that some prioritizing of our finite and personal resources must be undertaken if we are to help the greatest number of patients.

By tempering our egotistical impulse with practical lessons in life, guided by our professional moral compass, we can then pursue our medical lives with the decent strength of a saint, and keep our business portion of our lives scrupulously away from ethically ambiguous commercial activities. If in doubt, it is always safer but much harder, to say ‘NO’.

Our continued professionalism depends on this moral anchor to which all medical practitioners are beholden. We should not waver in our adherence to the modern Hippocratic Oath, which binds all medical practitioners and this we must strenuously swear to uphold.

We must choose to be more Hippocratic in spite of all our baser tensions working against our better instincts.

“We must show … patients our sensitivity and compassion. We hear so much about death with dignity but we must also realize that there is a need for life with dignity. And dignity for our patients must be preserved. Without the moral compass of our duty and obligation to our patients, we can be hurled quickly into the abyss of inappropriate behavior. Ethical lessons loom large here. Certainly attention to caring, truthfulness, and the concept of the good of the patient come more sharply into focus. Generally, telling the truth with hope, compassion, and sensitivity seems the best course to follow in these circumstances.” ~ Dr. LaSalle D. Leffal, Jr., American College of Surgeons Philosophy and Ethics Lecturer, 1993. Medical Ethics in Today's Society.

(MMA News Editorial, October 2005)

The ‘P’ words

“The words ‘health’ and wholeness’ come from the same root—old Saxon and early English words like hool, heil, and hail (as in ‘hale and hearty’) meaning ‘unwounded, entire, sound’. These concepts in turn echo the ancient idea that health is a form of bodily and mental integrity, in which nothing is missing or amiss: a balance, as the ancients had it, between the wet, cold, hot and dry ‘humours’.” ~ AC Grayling, The Meaning of Things, Applying Philosophy to Life; 2001, Pheonix Paperback, Orion Books Ltd, London, p171.

“The meaning of things lies not in things themselves, but in our attitudes to them.” ~Antoine de Saint-Exupery.

“The means by which we live have outdistanced the ends for which we live. Our scientific power has outrun our spiritual power. We have guided missiles and misguided men.” ~ Martin Luther King, Jr. (U.S. clergyman and civil rights leader, 1929-1968)

In November 2000, Dr I Hedley Piper wrote a paper in the Annals of the Royal College of Surgeons of England, where he discussed clinical governance, the profession, the ‘p’ words and responsibility.

That timely reflection came about in the aftermath of the Bristol scandal, where at one regional heart centre, pediatric cardiac surgical mortalities were found to be abnormally high, and that there were systematic lapses in oversight which led to these excess deaths.

Following this scandal, public confidence in the British health care services took a nose-dive, with politicians and authorities all scrambling to try and stanch the frenzied hemorrhage of public outcry and media criticism.

This became one of the lowest points in the history of the National Health Service in the United Kingdom, and seriously undermined the previously hallowed prestige of the General Medical Council—the regulatory authority for professional conduct and practice of doctors in the UK.

Following this there was another public uproar when a Dutch-born pathologist was found to have kept several hundreds of patho-anatomical specimens (body parts), some in his own home, which the current public felt breached the sanctity of proper doctor-patient relationship.

Fueled by an already hostile media, the public was influenced to believe that such unauthorized retention and irreverent treatment of body parts (without permission or stated authority) was an affront to the dead and their loved ones.

Notwithstanding the medical reasons why these body parts had been retained (for pathological analyses, pathology or anatomy museums or otherwise), many felt that these eviscerated bodies had been defiled and were incomplete when returned to their relatives for interment.

This scandal clearly showed the changing climate of public opinion and their diminishing acceptance of all that the medical profession had been dishing out all these years.

The public even in stoical UK has become more discerning, more demanding, more questioning and importantly more empowered and knowledgeable—no longer are they willing to be passive recipients for the historical paternalism of doctors.

Like the rest of the modern world, patients worldwide are gaining a new embolden voice to be heard, and they are not afraid to say so, even to demand for more disclosure and transparency.

The hitherto opaque, esoteric and jargon-laden medical profession is slowly but surely becoming unraveled. Indeed the last ten years following the explosion of the internet, have witnessed the unprecedented equalization and equilibration of the knowledge economy—empowering almost everyone, from the poorest to the wealthiest, from the simple-minded to the more informed, indeed from all walks of life.

We are no longer sole keepers of the healthcare monopoly, nor are we the sole purveyors of healing salves and panaceas. We are no longer hoisted on the pedestals as the heir-descendents of Asclepius, whose exclusive rights to all that are health- or medically-related, are guaranteed.

We now share the podium with disparate systems of beliefs and alternative approaches which range from organic naturopathy to traditional herbalism to New-Age pseudoscience.

Our Hippocratic mandate has been repeatedly punctured and many now believe that its tenets have become irreparably emasculated to continue as a reliable guide and beacon for the modern-day medical practitioner. And it would seem that we are not averse to taking lives as well, condoning torture, and turning blind-eyes to medical errors, mishaps or even professional misconduct by fellow practitioners…

The other major scandal that shocked the world was the ghastly murders perpetrated by Dr Harold Shipman, a seemingly benign-looking soft-spoken general practitioner, who was convicted for 15 murders but thought to have murdered some hundreds of his patients.

Whether he committed these mass murders for monetary gain, or for some obscure motives which we simply cannot fathom, we will never know.

Shipman carried his taciturn motives with him to his grave—he committed suicide in his prison cell some time ago. Perhaps he was inherently evil, or was a covert sociopath, but perhaps he simply got away with it for so long because he just could, with the powers of life and death that every medical practitioner carries in his hands…

Among those who have now to answer to the General Medical Council are some of his compatriots in the district where he had worked—fellow doctors, coroners who had co-signed many of Shipman’s death certificates without sufficient scrutiny, for failing to suspect that there might have been foul play—perhaps negligently so, by failing to report these out-of-character deaths and dying.

This new action has now been decried by some, as overblown knee-jerk reaction of the GMC to placate public wrath at its earlier inaction.

Many are asking if medical doctors are now duty bound to be their brothers’ keepers. Rivalry and professional jealousy aside, it is recognised that most doctors are reservedly indifferent to their compatriots’ performance as doctors, believing that once a doctor has graduated, he or she must be sufficiently capable of making the right decisions in every aspect of their medical vocation.

Most of us would like to believe that because every patient is individually distinct, then the physician-in-charge should have the best knowledge to treat and manage that person.

Most of us would still hesitate to second-guess our colleagues, although increasingly because of intense competition these days, many are blatantly or covertly undermining the credibility and skills of their rivals—an unhealthy development which borders on ethical misconduct.

However, we would be very hard pressed to formally disagree with, much less challenge a possibly errant practitioner, unless some very egregious deed has occurred as a result of willful or negligent action.

We baulk at having to testify against our peers or even to offer a contrary opinion or to cast blame or aspersion whether this was deserved or otherwise. Most of us have to be coerced or subpoenaed to report in an adversarial manner. Perhaps this approach is simply too late and may be too co-conspiratorial.

Hence, many among the medico-legal community have long accused medical practitioners of being too complicit in perpetuating a tightly-spun shroud of professional silence, to purposefully deny society’s probing into our purported frequent mishaps and our not-inconsequential errors.

In a recent essay on “patient-centred professionalism” in the Medical Journal of Australia, Dr Donald H. Irvine (past-president of the GMC, UK) lamented the fact that the public inquiry into the Bristol affair demonstrated that “doctors’ collective attitudes to audit, teamwork, whistle-blowing, consent to treatment and complaints about poor practice…,” were conspicuously at fault.

We have been found wanting as well as too inward-looking, too reactive like the recoiling leaves of the mimosa plant—we simply close-up and cover-up when exposed to perceived threats.

In short, doctors tend to be terribly myopic with regards their faults and misdoings as well as those of their counterparts! Collectively we have elected to be very reluctant to find fault or whistle-blow any errors which might be the result of professional incompetence or grievous errors.

We choose to proffer excuses and turning a blind eye, perhaps because many of us are conscious of the fact that we may ourselves fall prey to this mishap, some time, some place…

The inexactitude of medical science and the uncertainty of some outcomes still defy our best efforts—and doctors are very poor acceptors of failure. Yet we know deep down that some of these could be prevented, avoided or simply shouldn’t have happened—we are just not comfortable attributing blame to particular practitioners.

We are also aware that some treatment choices shouldn’t be done, yet we remain forgiving that perhaps the difference in opinion, in styles, in approach, was justifiable…

These are the grey areas of medical practice which occur day in, day out. Some of us anguish over this, and are consumed by angst of insecurity, anger and feelings of being shortchanged, misunderstood and injustice. But we remain aloof and suffer in tongue-tied silence.

Yet indeed, this must surely be one recurring theme that all of us must revisit every now and then, to keep alive that already tenuous linkage with our professional calling, and our ethical moorings.

Do we indeed have the right to remain reticent when obvious wrongdoings take place within our sight and experience?

We now have reports of medical practitioners colluding with prisoner abuse in the Abu Ghraib scandal in Iraq. These are military doctors who have chosen to ignore the abuses of clear-cut torture and inhumane treatment of the detainees in war-torn Iraq, Afghanistan and elsewhere.

Our duties and responsibilities as medical doctors have become suborned to military authority, political expediencies and/or personal emotions of indifference, hatred or vengeance.

Some of us have become lesser mortals, by becoming too human (and therefore subject to our inherent foibles, our baser instincts), too remote from our underlying ethical bearing.

We have failed to remain true to our vocation—we have failed in our professional duty, indeed our professional dictate to heal, to alleviate suffering, to comfort and always to avoid harm at all cost…

Some of us may even have become complicit in engaging or tolerating torture which by any civilized world accounts must be a serious breach of any ethical framework—much worse if these take place within the ambit of our medical profession.

It is under these circumstances that the GMC has now enunciated more clearly some of the expected concepts of good medical practice, which every medical professional are enjoined to embrace. These must now include the following:

• Make the care of your patient your first concern
• Respect patients’ dignity and privacy
• Give patients information in a way they can understand
• Keep your professional knowledge and skills up to date
• Recognise the limits of your professional competence
• Be honest and trustworthy
• Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise.

The ’p’ words? Some of these are: patient, physician, probity, patience, prescription, prerogative, privilege, power, pay, and professionalism.

Let us renew our faith in our profession, by giving some thoughts to the ‘p’ words, and see how each of these mean to us individually as doctors.

Let’s renew our commitment to professionalism as the highest order of our vocation.


(MMA News Editorial, September 2004)

Prudently Paranoid—Can We Trust Ourselves to do the Right Things?

“Rules of conduct, whatever they may be, are not sufficient to produce good results unless the ends sought are good.” ~ Bertrand Russell (English mathematician and philosopher, 1872-1970)

“Morality cannot be legislated, but behavior can be regulated. Judicial decrees may not change the heart, but they can restrain the heartless.” ~ Martin Luther King, Jr. (U.S. clergyman and civil rights leader, 1929-1968)

The recently concluded Deepa-Raya holidays once again showcased one of our worst Malaysian traits—our blatant disrespect for the traffic regulations and our mindless disregard for human lives and limbs.

We callously slip into our now very well-renowned baser instincts: ignoring red lights, flouting speed limits, queue-cutting, overloading, insistent me-first aggression and road-rage.

We lapse into a voodoo-like mindset and drive like obsessed maniacs not just with outrageous speed but with wanton recklessness, as well.

Behind the wheel, we seem to lose all sense of proportion and put on an animal-like persona of the possessed, and magically believe that we are indestructible, nay, immortal.

Worse, we are totally oblivious to any other driver, passenger, pedestrian or person who may chance to share that erstwhile but tragic serendipity out there—haplessly placing him or her in harm’s way.

So much so that the police and the government have instituted shamefully harsh traffic ops which purportedly are designed to change our aggressive attitude, and curb our thoughtless disregard for human life and limb.

Yet despite these measures, deaths and serious crippling injuries continue to mount, albeit at a slower rate this year than the previous year.

It appears that we as Malaysians cannot be trusted to do the right thing. While many (perhaps the majority) still drive with care and sensitivity to others—a sizeable ‘others’ seem not to respect the rules, the laws, the lives, the sanctity and rights of other fellow road users. And so the accidents, the injuries and the death toll mount with horrendous consequences for their victims and their loved ones—maimed and/or scarred forever.

Extended public holidays leave me with a sense of quiet exasperation and heart-aching foreboding, particularly when my family and I decide to rough it out by staying put in good old KL.

We decided to leave those who are prepared for the tedium and rush for home-coming to do their needful duties, but we are not joining them this time round.

Normally I would have enjoyed the quieter hours of R and R, with nary a responsibility for the day-to-day drudge of clinic work—I would just have to follow-through with my hospital inpatients and emergencies…

I would have time enough to do some catch up on my reading, perhaps some writing, perhaps the much needed mental reassessment of my hurried life thus far.

My wife calls this my mid-life crisis—and perhaps she is right. Next year I will hit the proverbial half-century, woe behold the thought! But like they say, it’s not the age that counts, but the mind. I do feel nearly always anchored at a far younger age—perhaps in the mid-thirties, frozen in time and space anatomically, physiologically, and hopefully mentally, while maturing with wisdom, patience and tolerance (ahem!). While the world continues to turn and move along, regardless…

Yet, it appears that our horizons continue to shift and change relentlessly—particularly our health care scenario and the medical profession that I had adopted as a vocation some 25 years ago.

Increasingly, the health care landscape has become unrecognizable: from passive patient-paternalistic physician knows best mindset to technologically-enhanced, mechanically-manipulated, industry-pharmaceutical-driven health maintenance.

Perhaps more worrying from the standpoint of public health policy, is the gradual but ever-widening scope for encompassing more and more health-related issues into the public domain of health care and their labeling as disease entities.

The implications are of course huge—because once labeled as disease, these new ailments would require higher and higher health budgets and expenditure.

This disturbing trend has been viewed with much wariness and circumspection. It has also been termed by some as the medicalisation (or worse the commercialisation) of health, a dubious if less-than-reputable label.

Under this category would include: the menopause, the ageing male, baldness, and some say even sexual dysfunction including declining libido, female sexual arousal disorder and erectile dysfunction.

While good for business in their expansion in scope, we may be creating a new passion for hypochondria among our population out there. This is may be why so many amongst us have involved themselves with health maintenance schemes such as supplements, multivitamins and other gray areas of complementary health products such as growth hormone, androgens, DHEA, etc. Perhaps the Dorian Gray legacy has come home to roost with the medical fraternity which has lost its bearings and are running out of ethical business to tackle…
We have still to contend with new incurable diseases which have become pandemic such as the HIV/AIDS, and incurable others such as age-related malignancies, and we are still grappling with ancient ailments such as TB, malaria, hemorrhagic fevers and other infections.

Newly emerging viral infections have also stunned our recent complacency, when we begin to encroach into the animal-human boundaries of interaction and sanctuaries.

Our own Nipah epidemic, the bird flu and SARS seriously undermined our sense of personal safety, when they descended upon us with such a vengeance that practically quarantined entire geographical regions (the size of continents even!). We cannot yet escape the feeling that more challenges are in store for us, just lurking in the nooks and crannies of hitherto undisturbed undergrowth of animal-plant kingdoms.

Zoonotic transmission to humans will remain a serious if inevitable possibility. And we must continue to be vigilant, innovative and enterprising. Yet perhaps we might want to do more and take more care not to disturb the equanimity of our fragile ecosystem—by respecting and recognizing the limits of our ruthless development and unsustainable greed at the expense of nature.

Ironically however, mankind’s proclivity for self-destruction means that behind the clandestine walls of secret military intelligence, powers that be are still developing and holding huge caches of biological weapons, which could prove to be the end of us all, once these are intentionally or unintentionally deployed!

Viruses and bacteria have always been the most ancient and indestructible of life-forms—simple yet complex, miniscule yet parasitic, but most importantly they possess that innate trait of undiminished capacity to mutate, adapt, infect and propagate through the ages.

Perhaps they have always outlived all other extinctions from whence life began on Earth some three and a half billion years ago. Perhaps a new era of earth life will emerge devoid of humans, once we self-destruct…

Can we not allow ourselves then to fall back on less synthetic cures and panaceas?

Hence the return of organic and natural health salves and concoctions—we hope to avoid the use of the ‘poisons’ of new…

Yet unscientific as these may be, their word-of-mouth salesmanship continues to attract and beguile not just the uninitiated and illiterate, but many among the educated as well.

Doctors themselves are spellbound by either their touted benefits or their profit-potential…
Yet, we have to contend with ever-escalating patient empowerment, and socially-demanded health care scrutiny and audits for evidence-based practice.

The authorities and the media do not help much, and neither do our peers who are too busy eking out a living or too embroiled in new schemes for engaging a susceptible public.
But do we really care? Does it really matter? Who does the audits for benefits anyway?

Adjacent pharmacies, alternative healers and neighbouring sinsehs, homeopaths, naturopaths are thriving and our medical practice continues to face stiff competition.

But the business has to go on, some money has to be made one way or the other, better from someone who is well-versed about the benefits, the dangers or the potential harms or their lack thereof… Why bother at all?

Because so many of our patients have been reconsidering their own health options of late, which increasingly factor in alternative therapies and self-medicating, despite their many imponderables and question marks.

There is that growing distrust for all things science in this post-modern world, where the artificiality of life has become too much associated with perceived adverse outcomes, too out-of-touch with the senses, emotions and feelings.

Out-worldliness and new-found spirituality has remolded an ever-widening circle of new people (young and old) who want to make more sense of their own individual world and self-worth. They will not just tolerate the senseless cold reality out there.

Yet the fear of the unknown, and of ill health in our context, makes them adopt measures which are not totally in sync with their purported aspirations.

We all want to be as healthy as possible, and not suffer the consequences of ageing and other catastrophic ailments. So, many are willing to adopt dubious if totally useless supplements or alternative therapies which are if not harmful at least cater to their peace of mind that they are doing something positive for themselves.

Sadly quacks and charlatans, and indeed snake-oil purveyors have re-emerged as an amorphous group to challenge modern scientific health care.

To make matters worse, some of our own medically-trained doctors are immersing themselves into such contentious and poorly tested or unproved alternative or complementary therapies, many of which are based on bunkum and pseudoscientific gibberish.

It is a sad testimony of the fact that we as medical professionals are too diverse by nature, and too opinionated that we ourselves cannot be taught or guided to think along scientific principles.

Some of us are obviously willing to try the fringes of mainstream medicine and engage in wishful magical and senseless experimentation on our teeming clients out there.

We all worry about side effects and untoward consequences of new drugs, or of any medicine for that matter. Unfortunately such dreaded news have sporadically erected their ugly heads of disastrous public relations for the pharmaceutical and medical industry and which must unfortunately embroil us as doctors and health care providers!

The recent recalls of Lipobay and Vioxx have been particularly troubling and will remain sore points for us medical doctors to encourage long-term use of prophylactic medicines for chronic illness such as heart disease, hypertension and diabetes.

While it is true that hundreds of other drugs have been used for decades with great salvage of lives and improvement of survival and quality of life, all these become diminished in the harsh spotlight of such medicines being withdrawn due to harmful effects. “First, do no harm…”

Yet the medical establishment and some innovative physicians are now trying on newer and newer technologies in our quest to do the impossible—to cure and treat all and every illness and try achieve immortality, so to speak, for ourselves and for our patients or potential patients.

Many new research and studies are now testing new cures which add only marginally incremental benefits in the long-run, but in the name of progress we allow ourselves to be charmed by the munificence and beneficence of these types of ultra-modern care.

Polypharmacy has become the watch word for all cardiologists of which I am also guilty of—being in touch with the most current management guidelines and my peers, dictate that multiple drug regimens will enable my heart patients to live longer and more productive lives, but at costs which are so far only confined to dollars and cents.

Dare I venture to say that they will live longer and better? Based on our current information, this answer is still thankfully in the affirmative.

Less certain outcomes pertain to more aggressive interventions to correct the mechanical aspects of coronary artery disease.

With cardiac surgeons competing with the cardiologists for a bigger share of the limited pie, there is less than solid ground with which to objectively decide the “best choices” for the individual patient. It has now boiled down to patient’s preferred choice, and physician influence…

Often quicker results, shorter term gains and micro-surgical techniques will attract more adherents, despite more uncertain longer term results.

Then more recently, we have been encouraging more and more formerly normal (and by all purposes, “hearty and hale”) people to learn more and more about their health status and to try discover that potentially lurking ailment beneath the veneer of health.

Screening medical examinations have developed and grown staggeringly and has become expensive but profitable enterprises, although misguided when we factor in cost-effectiveness and possible harms.

From the humble beginnings which utilize the annual physical examination, simple blood screening tests, chest radiographs, rest ECGs, then to stress ECGs, gastrointestinal endoscopies, we have now progressed in certain urban locales to multiple-detector CT scanning.

Health scan or heart scan (or heart/health scam for the more cynical) are now being touted to make that unprecedented leap of faith to discover the miniscule chance that something might be wrong within the human anatomy.

Such mass CT health screening as these has never been endorsed by authorities world wide, but these days, they have been offered by enterprising medical groups (including doctors and business-partners) the world over.

The United States FDA in its statement recently noted that public health agencies and national medical and professional societies including the American College of Radiology, the American College of Cardiology / American Heart Association, the American Association of Physicists in Medicine, the Health Physics Society and the Agency for Healthcare Research and Quality's U.S. Preventive Services Task Force - do not recommend CT screening.

For heart scanning, the attraction is the purported simplicity and rapidity of the test and the captivating beauty of its photographic imagery of the heart and its vessels, as well as the 3-D rendering of the viscera in deceptive color-painted glory. Its not inconsiderable radiation exposure however, should be carefully considered.

Annual screening with a heart scan would expose any person to a radiation dose equivalent to more than 3.3 years of background radiation from cosmic and solar rays, or equivalent to having some 500 chest x-rays. A whole body scan would expose a person to an equivalent of more than 1000 chest x-rays of ionizing radiation (source: US FDA, 2004).

The potential dangers from such ionizing radiation cannot as yet be estimated. However, if annual whole body scanning examinations such as these are carried out, then the potential health hazards could be huge in the long term.

And there is that inescapable danger of self-referral which has dogged the medical profession since time immemorial.

In a recent Sept. 15 editorial titled “Who Owns Images of the Heart?” Dr. Alfred A. Bove, editor-in-chief of CardioSource for the American College of Cardiology (ACC) (an online journal and web page), noted that turf wars have broken out between the radiologists and cardiologists.

He noted that radiologists have voiced concerns in The New York Times, that imaging cost has become too high because this was driven by physicians’ self-referral patterns, particularly those of cardiologists.

According to Levin and others from Jefferson University Medical School, noninvasive diagnostic imaging rose 71% from 1993 to 2001, with cardiologists’ share of those Medicare dollars increasing almost twice as rapidly as that of radiologists. More important, payments to cardiologists in offices and private imaging centers grew at a rate of 240%.

Dr Bove however disputes the radiologists’ concern about self-referral claiming that this would be unlikely to occur as the ACC develops appropriateness criteria for utilization of imaging procedures.

However, Dr Levin (a radiologist) said it's ridiculous to believe that self-referral problems will disappear if cardiologists set guidelines for scanning. “That's a joke. They order scans for everyone who walks in the door,” he said.

Has medicine become too hot to handle? Should we in Malaysia engage in such obviously commercial enterprises? Clearly we cannot stem the onslaught of progress and we are seeing that glimmer of “cannot-beat them, join them” medical commercialism in Malaysia.

Can we regulate ourselves and our instinct to self-refer and if so, can we be objective that we are doing so for the public good?

Of course we all hate to lose out on new advances, new technology, but let’s not go overboard with too much enthusiasm as to lose our noble soul.

Consider too, a few years down the road when every medical establishment will get their own scanners and new technology, what then?

And where do we stand as doctors, as impartial healthcare providers whose main interest should be to provide for the patients’ interests, whilst not forgetting the public welfare?

Let’s not throw away the ethics baby with the bath water.

Let’s maintain our sense of proportion, and help preserve our trust in ourselves and the public’s trust in us.

Let’s keep some prudent paranoia about our basic instincts to see if we can still hold on to the candle in the dark.

Let’s contemplate our mission, our ethical moorings and search for that deep-seated flame of medical professionalism that must still be burning inside.

Perhaps dinosaurs like some of us who continually sing such an outdated song, are destined to become extinct.

But let’s see if we can preserve our professionalism for that little bit longer… and ask if we can be trusted to do the right thing, not in every instance, but at least we should try, and if we do fail, we do so by trying…

“I wake up tired, or more exactly without any appetite for life. My will to live diminishes as I get older, Did I ever have a great lust for life? I’m not sure, but I certainly used to have more energy. And expectations too. And you live so long as you have something to expect. It’s Saturday. I have time to dream and grieve.” ~ Ivan Klima, in No Saints or Angels, Granta Books, UK, 2001, p1.