Essays

Medical Practice under Scrutiny: How much care is too much?

2011-12-17T21:14:00.000-08:00

Medical Practice under Scrutiny: How much care is too much?

By Dr David KL Quek, FRCP, FNHAM, FAsCC, FACC

NHAM Pulse, 2011 (December): 2-6

“Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.”

~ Susan Sontag[1]

The Illness Metaphor vs. Medicalisation

Susan Sontag’s introspection above encapsulates this very real if unsettling Manichean truism about illness and health in man. This was recently re-quoted in the frontispiece of Siddhartha Mukherjee’s 2010 book ‘The Emperor of all Maladies’ — a Pulitzer Prize-winning book about cancers and the heroic battles to conquer if not to deflect cancers’ dismal if inescapable trajectories and outcomes.[2]

The narrative on the history and advances of cardiovascular understanding and therapeutics would probably reflect a similar but perhaps with a more positive historiography.* But there has always been that tendency for physicians from time immemorial to over-extend our professional reach and our self-importance, as we insinuate ever deeper into society’s socio-economic web of life. With affairs of the heart, this is even more pronounced!

Sometimes, as physicians we tend to forget that illness is an innate part of man—we will always become ill at some points in our lives. Yet, most of us subconsciously embrace and expect its opposite—health—as a given. Perhaps we have let Medicine’s overarching narrative to reshape our societal psyche into embracing a pervasively systematic but false Nemesis.[3]

Eventually every one of us will die, sometimes suddenly, prematurely, but frequently enough from a drawn-out chronic ailment, which may be subtly quiescent (‘silent killer’) or which may visibly stress, depress, debilitate and occasionally dehumanize us. Illness and loss of health in humans and our patients are why we physicians are here in the first place—patients are our raison d’être.

Healthcare issues now encapsulate some 3 to 17% of mankind’s economic activity, depending on where you are in the globe.[4],[5] There is that growing conscious demand and push towards ‘good health’ and more accessible health care.[6] Health is regarded as an inherent component of life, and is rightfully demanded as a human right.[7] As physicians, we must serve as the natural guardians and advocates to ensure this, by making every possible effort to improve universal access and coverage for this increasingly out-of-reach ‘commodity’. At the same time we must remain conscientious that we do not create ‘health’ into an unreachable ideal, which can only bilk or disenfranchise the unquenchable demands and expectations of our willing but poorly informed patients at large.[3]

Yet, as we (as doctors) embark on our furious pace of modern medical practice, we embrace sometimes almost blindly all the advances that come our way, not wanting to be left behind in that unrelenting race to keep up with what are new and trendy, in the name of progress. We readily adopt and utilize whatever technological devices and drugs at our disposal, believing that most of these efforts would benefit or even cure our patients, sometimes at huge costs! But in the sum of all things, medicine does work—patients do benefit and perhaps arguably live longer and enjoy better quality of lives.[8]

Why? Because, as doctors we are trained to follow systematic if narrowly prescribed heuristics on how we approach illness, how we deal with it and how we treat it, piecemeal, one at a time. However, increasingly we have been reminded to look at each patient in as holistic a manner as possible—treat the whole patient, not the diagnosis, we say.

But because medical information is continually growing and evolving we also need to constantly keep abreast—hence, the exhortation to lifelong continuing medical education and learning. Knowledge growth also implies periodic shifting of the goalposts for what are recognized as normal or abnormal, sometimes akin to new wines in old bottles—blood pressure, blood glucose and cholesterol levels are now lowered for normal acceptable ranges.

This necessarily implies treating more patients to achieve lower and lower targets, because there have been growing research data that show that perhaps lower is better—lesser complications, better prognoses, better outcomes, perhaps longer survival, even better quality of life. But some detractors have decried such measures as examples of ‘medicalisation’ of health, calculated to exploit human vulnerabilities and anxieties.[9]

By looking at the patient as a whole, multiple risk profiles and factors also imply that we treat that patient with more therapies than was customary in the past. Most often this approach employs the easiest means—prescribing medications and pills—one on top of the other! This approach remains controversial and is not readily accepted by all. Lifestyle modification and counseling often take backseats in our therapeutic armamentarium because these are either too hard or time-consuming to carry out, too difficult to measure for results, or because they are inadequately reimbursed or not at all!

Risk Factors, Pre-disease & Injudicious Polypharmacy

Barbara Starfield et al., a pioneering advocate of primary care medicine has lamented:

“the progressive lowering of thresholds for ‘pre-disease’, particularly hypertension, serum cholesterol and blood sugar… (where) risk factors are increasingly considered as equivalent to disease… Encouraged by interests vested in selling more medications for ‘prevention’ and more medical devices for testing, the pressure for increasing ‘prevention’ in clinical care directed at individuals is inexorable – even though it is not well supported by evidence in populations of patients…” [10]

Alas, it is precisely this surge in preventive polypharmacy that has prompted so many pharmaceutical companies to aggressively target the medical community with the current deluge of blockbuster drugs in the hope to explicitly ameliorate the perceived harms of concomitant risk factors/illness, but covertly perhaps for greater profits as economic enterprises extraordinaire!

But the physician’s professional need and mandate to keep current and up-to-date also implies, that we become dependent on various modes of learning experiences and sharing. Clinical and scientific research relentlessly redefines our perception and belief systems about illness and health, so much so that we have sometimes delegated some of these learning encounters to affiliates and peripheral agencies. The danger is that, we might have been kept selectively informed by incomplete snippets of ongoing if premature data by the very same aggressive vendors of such cutting-edge advances and innovations—becoming unwitting agent provocateurs of their surreptitious influence and propaganda, i.e. we become too embroiled in possible conflicts of interest. [11]

Dr James Le Fanu warns that “doctors are not just doing more, but prescribing vastly more – an additional 300 million prescriptions a year, half as many again compared to just 10 years ago.” He went on to question the rationale of this modern shift in medical practice: “the merits of a coronary angioplasty in promptly relieving crippling chest pains of angina is self-evident, but the rationale for the majority of those 300 million extra prescriptions is very different.” He estimates that globally, annual pharmaceutical revenues have doubled from US$400 billion to US$800 billion (2.6 trillion Ringgit) over the past 10 years![12]

“This, then, is the Janus face of modern medicine, the most visible symbol of the power of science to banish disease for the benefit of all. But the distinction between the relative contributions of those technical innovations and the pharmaceutical industry to the spiraling costs of healthcare reveals, with great clarity, the origins and harmful consequences of medicalisation – and what indeed is required to control it.”

~ James Le Fanu

Perhaps we have become too indiscriminate, too undiscerning, and too gullible even. We appear to have become uncritical on what needs to be critiqued, to be critically analyzed and challenged. We have allowed possibly biased slants of information to imprint, even distort our impressionable minds too easily!

We must learn to acknowledge that we might have been somewhat less than judicious in deciding which are truly best for the patients in front of us! Perhaps we have become seduced by the glamour and the gloss of the pastiche of modern innovations—new drugs and devices, new techniques that titillate our sense of ‘beauty’ and wonder; and perhaps that patchwork assemblage of molding plausible theories into meaningful practices.

Perhaps, all these newfound concepts go on to strengthen our physician empowerment as society’s singular shamanic autocrats of medical knowledge. Perhaps, these constantly reconstructed patho-physiological models of consistency, of newly discovered molecules, gene-based proteomics, of mechanistic pathways, and biological systems endow upon us that sense of puissance, of control, of demigod status.

There can be no denying that sometimes we may have become enamoured with too much care, in doling out perhaps too many unwarranted tests and therapies, which could arguably satisfy our egotistical self and enrich us personally, certainly more so than our patients. We fail to be our patient’s best advocates, whose interests should really be our unwritten if expected ethical compass.

Patients’ Interests—First and Foremost

Have we failed in our duty to place our patients first and foremost, by possibly sacrificing their dignity, their interests, thereby undermining their safety and long-term health even? Have we fallen victim to our own entangled conflicts of interest, our moral hazard of being less than fully impartial, by unfairly tapping into the patient-doctor information asymmetry, or physician-industry ties and the last-gasp hopes and anguish of many of our less than educated or informed patients?[11]

Yet, perhaps this statement is too harsh as an indictment to our dilemma as specialist healthcare givers.

Let us return to practical considerations as we re-examine our roles as cardiovascular physicians. Increasingly we have been cast as unwitting but willing diagnostic as well as gate-keeping therapists all rolled into one. Some have even labeled us as unremitting purveyors of ever-newer medical devices: expensive drugs, balloons, stents, pacemakers, etc. Cardiac surgeons have rightfully questioned our objectivity, that we might have unfairly usurped our unique position to sequester all manner of revascularisation therapies, particularly emphasizing PCI to the detrimental exclusion of CABG.

Perhaps the increasing development and use of appropriateness and organizational care pathways, consensus cardiology-cardiothoracic team approach, of hybrid procedures and global budget or diagnostic-related groups (DRGs) remuneration models, can reduce the tendency for individual physician decision-making, which tends to bias the physician toward more costly or self-serving procedures.

Despite the availability of clinical care pathways and guidelines (CPGs), their variable interpretation also means differences in emphasis or practice. Many physicians disdain care pathways and CPGs as ‘cookie-cutter’ medicine, and interpret these loosely. They argue that a one-size-fits-all approach cannot apply to differing patient scenarios, best only known to the physician in charge.

By the very nature of PCI being conceptually ‘simpler’ and less invasive, cardiologists have cornered the market so to speak, so much so that our patients appear to prefer our services, although the actual long-term results may be inferior to the initially more disabling bypass surgery.

Most cardiologists these days appear to have become singularly coronary artery disease (CAD) experts, but not much more, sadly. Almost every young aspirant in cardiology wishes to be that interventionist, that doer who can heal, with that magical balloon and stent. It appears that to do more, rather than simply counsel and advice might be more effective—at least, it seems that way. It has been well described that an injection (even if of sham medicine), surgery or any intervention gives greater effects or is perceived of as being more efficacious than some simple pill.[13]

So could it be that we have become too conditioned into believing that all the percutaneous interventions that we have performed on our patients, are but that ersatz veneer of favourable placebo effects, instead of true outcome-evidenced benefits? Hence, could this misconception lead to some of us becoming perhaps a little too reluctant to relinquish control of that patient in need, to someone else (e.g. cardiac surgeon, or heart failure expert) more capable, more adequately, or more appropriately trained than ourselves?

Consider the recent findings of the extended follow-up OAT cohort that showed that delayed routine revascularization during the subacute phase, gave no greater benefit. Long-term clinical events were not reduced after routine PCI in stable patients with a totally occluded infarct-related artery, if there was no severe inducible ischemia.[14]

It is also important to note that performing such PCI in the non-ACS setting, for patients who are symptom-free (silent ischemic heart disease, SIHD) just because of some ECG or imaging changes during stress testing would not be associated with survival benefits or even lessening of potential CV events. For most scenarios of angiographic stenoses (other than significant LMS and/or proximal LAD disease) the recommendations are Class IIB or even III.[15]

PCI versus medical therapy in stable CAD can be summarized as follows:[ 15]

• PCI reduces the incidence of angina

• PCI has not been demonstrated to improve survival in stable patients[16]

• PCI may increase the short-term risk of MI[16]^,[17]

• PCI does not lower the long-term risk of MI[18]

We should learn to re-examine our clinical objectivity and soberly address such issues of potential moral hazard for the ultimate benefit of our patients. Our therapeutic decisions should neither be because of our overwhelming paternalistic influence, nor to our subconscious desire to profit personally.

The ACCF/AHA/SCAI guidelines also strongly recommend that every PCI program should operate a quality improvement program that routinely: [15]

a) reviews quality and outcomes of the entire program;

b) reviews results of individual operators;

c) includes risk adjustment;

d) provides peer review of difficult or complicated cases, and

e) performs random case reviews.

They recommend too that every PCI program should participate in a regional or national PCI registry for the purpose of benchmarking its outcomes against current national norms. Perhaps this is the sort of benchmarking that every cardiologist and heart centre must adopt, as we embark on our journey to make our own ACS and PCI Registries more comprehensive and complete.

Medical Screening Dilemmas

The U.S. Preventive Services Task Force has in recent reports pose yet more dilemmas in the way of our clinical practice.[19] The simple rest ECG and the more routinely performed stress ECG of annual medical check-ups, so much a part of cardiology practice, are now considered too indiscriminately over-utilized.

For the symptom-free person, the benefits of these tests appear to have been inadequately studied. Whatever few studies available apparently showed no major benefit for the population at large. The taskforce warns instead of the potential harms of consequential downstream therapies or decision pathways such as more angiography, bleeding complications, radiation exposure, and contrast allergy or nephropathy; more statin use and its possible adverse effects!

This conclusion was somewhat surprising because the pooled evidence actually says otherwise: “Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1). Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG). No study estimated harms from subsequent testing or interventions, although rates of angiography after exercise ECG ranged from 0.6% to 2.9%.”

The main message appears to be quoted from 2 previous studies which state that “a small proportion (<1%) of patients have revascularization with coronary artery bypass graft surgery or a percutaneous coronary intervention after screening exercise ECG, despite the risks of these interventions and their lack of benefits in asymptomatic persons.” [20]^,[21]

So what are we to do, stop screening of symptom-free patients, and perhaps only judiciously target those who need further evaluation based on complaints and not necessarily for global risk assessment? The recent accompanying editorial addresses this conundrum, but did not offer specific solutions, except to urge for more research.[22]

Should we then not perform electrocardiography at all in asymptomatic adults? Apparently so. Chou and others of the Task Force argue that because of this persistent lack of evidence, clinicians should not incorporate screening with resting or exercise electrocardiography into their practices except in the context of clinical trials! This sadly sounds counterintuitive to most of us physicians and cardiologists!

The more plausible American Academy of Family Physicians recommends the following for the asymptomatic patient, that:

“Exercise stress testing may provide valuable prognostic information in asymptomatic men older than 45 years who have risk factors. The higher the number of risk factors, the higher the pretest probability (hyperlipidemia > 6.20 mmol per L, hypertension: systolic > 140 mm Hg or a diastolic >90 mm Hg, smoking, diabetes mellitus, and history of MI or sudden death in a first-degree relative younger than 60 years).[23]

“In asymptomatic patients with diabetes mellitus, there is a higher risk of CAD in the presence of at least one of the following factors: age >35 years, type 2 diabetes >10 years, type 1 diabetes >15 years, microvascular disease e.g. proliferative retinopathy, nephropathy, or autonomic neuropathy. It is recommended that patients with (these) criteria undergo exercise stress testing before embarking on moderate-to high-intensity exercise.”[24]

Currently, the ACCF/AHA/SCAI Guidelines recommend that: In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. But routine, periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed. For cardiac rehabilitation purposes however, medically supervised exercise programs should be recommended to patients after PCI, particularly for moderate- to high-risk patients for whom supervised exercise training is warranted.[25]

Discussion

My malaise with these newer perplexing recommendations or restrictions is not intended to curb or straitjacket medical or cardiovascular practice. But, it is perhaps timely for us to seriously reconsider our own trajectory of clinical practice and professionalism.

Are we not somewhat complicit in inventing some new entities of health ailments, i.e. increasingly medicalising health? What are we trying to achieve as we push the boundaries and contemplate expanding such concepts as pre-diabetes, pre-hypertension and lower and lower acceptable levels of serum LDL-cholesterol, as we tag along more biological markers such as hs-CRP, hs-TNT, BNP, etc.? Already, many other entities such as serum homocysteine, fibrinogen, lipoprotein (a), PSA (arguably), have fallen by the wayside of bumf rather than useful reliable knowledge!

Who indeed do we serve as we trundle along with exciting if unproven new devices, new paradigms of interventionist procedures, as we become increasingly invasive even as we miniaturize our techniques and devices? Does the spirit of medical adventurism justify medicine’s push for cutting-edge innovation and advances? Does potential future benefits and ends for the many, justify the experimental risks as a means for a few and the now?

What about that ‘life sentence’ of medications for life or for as long as deemed necessary? Yes we appear to have many long-term prognostic outcome data that implies sustained therapies for the best effect — extending this or that survival by perhaps weeks or months, on a statistical basis.

But, how much of our patients’ lives are we interfering with and for what quantum of greater good or longer-term benefits, the possible lost opportunity costs and the inconvenience, that background intrusion into their lives? It is precisely this expropriation of health that philosopher Ivan Illich had lamented.[3] Has health become such a scarce even elusive commodity that the common man now has to “depend upon the consumption of Ambrosia”?+

But perhaps more importantly, we need to reignite our medical professionalism. We must become more critical and discerning, as we embrace change and development. We must learn to stand back from and reappraise the increasing use of industry-sponsored spectacles of ‘show-and-tell’ ‘live’ demonstration courses. We must re-evaluate the allure toward more procedures, devices and interventions than perhaps what might truly be necessary medical care, no matter how promising or how technically beguiling these appear to be!

This includes even pharmaceutical junkets, which invariably encourage greater use of newer, more expensive drugs among physicians. But this is not to say that we have to revert back into being Luddites, opposing everything that is new and good. We just have to be more circumspect, judicious, be really objective and evidence-based! We should be imbued with a healthier dose of common-sense skepticism!

The former editor of the British Medical Journal, Dr Richard Smith had this to say when he reviewed the life and work of Ivan Illich following the latter’s death in 2002 from debilitating cancer: “Technology can help, but modern medicine has gone too far — launching onto a godlike battle to eradicate death, pain and sickness. In doing so, it turns people into consumers or objects, destroying their capacity for health.” [26]

We must re-engage with our patients more candidly and transparently, and place them and their interests first and foremost, after all truth telling is one of the universally accepted pillars of ethics and professionalism. We should inform more openly and widely (to include risks, especially material risks peculiar to this or that patient). We should also propose and discuss alternative models of therapies and lifestyle modifications, so that we allow patients to decide on their own, which options to choose from and live by. This is perhaps the modern expectation of patient empowerment and choice.

Already there is declining trust and belief in physicians. We have to reclaim our trust. Dr Alice Jacobs, president of the AHA in 2005 stated that: “This issue is the erosion of trust. Lack of trust is a barrier between our intellectual renewal and our ability to deliver this new knowledge… to the bedside of our patients, and to the public. Trust is a vital, unseen, and essential element in diagnosis, treatment, and healing. So it is fundamental that we understand what it is, why it’s important in medicine, its recent decline, and what we can all do to rebuild trust in our profession.”[27]

“A 2005 U.S. News and World Report cover stated: ‘Who Needs Doctors? Your next doctor may not be an MD and you may be better off.’ Have we finally come this far, where the human touch of the physician can be replaced by healthcare reduced to guidelines, tests, algorithms, procedures, and drugs?”[28]

This is indeed a possible scenario as we move further and further along in that loosening of the physician-patient bond, that ever-widening chasm of information asymmetry, with Internet or email consultations, video computer-assisted medical appointments/consultations, telemedicine, etc. But at the end of every patient-physician encounter, what is still most needed is that caring empathetic relationship, with the physician serving as that trusted health caregiver who can provide the best that modern medical care can offer, in the best interest of the patient, and no one else! Above all, we are called upon to provide medical care well and prudently, no more and certainly no less.

References:

* historiography — the writing of history based on the critical examination of sources, the selection of particular details from the authentic materials in those sources, and the synthesis of those details into a narrative that stands the test of critical examination (Britannica.com).

+ Ambrosia — the divine potion, which gave the gods unending life.

[1] Susan Sontag. Illness as Metaphor. Doubleday, New York, 1978.

[2] Siddhartha Mukherjee. The Emperor of All Maladies: A Biography of Cancer. Scribner, New York, 2010.

[3] Ivan Illich. Medical nemesis. J Epidemiol Community Health 2003;57:919–922. This article is reprinted with permission from Elsevier (Lancet 1974;i:918–21). (http://www.elsevier.com/locate/lancet)

[4] National health accounts [online database]. Geneva, World Health Organization, 2010 (http://www.who.int/nha,

accessed 23 June 2010).

[5] World health statistics 2010. Geneva, World Health Organization, 2010.

[6] Grossman M. The demand for health. 30 years later: a very personal retrospective and prospective reflection. J Health Economics. 2004; 23:629-636

[7] Leibowitz. A. A. The demand for health and health concerns after 30 years. J Health Economics. 2004;23: 663-671

[8] Bunker JP. Medicine matters after all. J Roy Coll Physicians. 1995;29:105-12

[9] R. Moynihan, I Heath, D. Henry. “Selling Sickness: The Pharmaceutical Industry and Disease-Mongering”, British Med J. 2002; 324:886–891.

[10] Starfield B, Hyde J, Gervas, Heath I. ‘The Concept of Prevention: A Good Idea Gone Astray?’ J Epidemiol Community Health 2008;62:580–583. [doi:10.1136/jech.2007.071027] Quoted by Chan C.K. in ‘M. K. Rajakumar, Primary Care and Population Health’, in An Uncommon Hero, 2011 (in press), pp 308-320.

[11] Duff Wilson. Health Guideline Panels struggle with Conflicts of Interest. New York Times, Nov 2, 2011. http://www.nytimes.com/2011/11/03/health/policy/health-guideline-panels-struggle-with-conflicts-of-interest.html?src=un&feedurl=http://json8.nytimes.com/pages/health/policy/index.jsonp&pagewanted=all

[12] James Le Fanu. Beware the 'Janus face’ of modern medicine. The Telegraph, 14 Nov 2011. http://www.telegraph.co.uk/health/8883956/Beware-the-Janus-face-of-modern-medicine.html

[13] Kaptchuk TJ, Stason WB, Davis RB, et al. Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ 2006;332: 391–7.

[14] Judith S. Hochman, MD; Harmony R. Reynolds, MD; Vladimı´r Dzˇavı´k, et al. for the OAT Investigators. Long-Term Effects of Percutaneous Coronary Intervention of the Totally Occluded Infarct-Related Artery in the Subacute Phase After Myocardial Infarction. Circulation. 2011;124:00-00. (Published online Oct 24, 2011)

[15] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.

[16] Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease (COURAGE). N Engl J Med. 2007;356:1503–16.

[17] Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004; 109:1371– 8.

[18] Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, et al. Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet. 2009;373:911– 8.

[19] Roger Chou, Bhaskar Arora, Tracy Dana, Rongwei Fu, Miranda Walker, and Linda Humphrey. Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:375-385.

[20] Aktas MK, Ozduran V, Pothier CE, Lang R, Lauer MS. Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program. JAMA. 2004;292:1462-8. [PMID: 15383517]

[21] Cournot M, Taraszkiewicz D, Galinier M, Chamontin B, Boccalon H, Hanaire-Broutin H, et al. Is exercise testing useful to improve the prediction of coronary events in asymptomatic subjects? Eur J Cardiovasc Prev Rehabil. 2006;13:37-44. [PMID: 16449862]

[22] Michael S. Lauer. What Now With Screening Electrocardiography? Ann Intern Med. 2011;155:395-397.

[23] Bruce RA, DeRouen TA, Hossack KF. Pilot study examining the motivational effects of maximal exercise testing to modify risk factors and health habits. Cardiology. 1980;66:111–9.

[24] Diabetes mellitus and exercise. American Diabetes Association. Diabetes Care. 1997;20:1908–12.

[25] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.

[26] Smith R. Limits to medicine. Medical Nemesis: the expropriation of health. J Epidemiol Community Health 2003;57:928.

[27] Alice K. Jacobs. Rebuilding an Enduring Trust in Medicine: A Global Mandate. (Presidential Address American Heart Association Scientific Sessions 2004). Circulation. 2005;111:3494-3498.

[28] Brian Olshansky. Placebo and Nocebo in Cardiovascular Health: Implications for Healthcare, Research, and the Doctor-Patient Relationship. J. Am. Coll. Cardiol. 2007;49;415-421.

Medical Ethics and Personal vs. Public Conscience: a Malaysian context

2011-06-16T06:45:00.000-07:00

Medical Ethics and Personal vs. Public Conscience: a Malaysian context

By Dr David KL Quek, President, Malaysian Medical Association

[published recently:

Quek DKL. Medical Ethics and Personal vs. Public Conscience: a Malaysian Context.

World Med J. 2011; 57(1):2-4.]

Some time ago, New York Times columnist Professor Stanley Fish, (NY Times 12 April 2009)[i] wrote about “Conscience vs. Conscience”, where he discussed the conundrum about how people in general and physicians in particular, under different circumstances should or shouldn’t abide by their own conscience.

The contending issue was that physicians should not refuse treatment or procedures based on their own personal moral or religious grounds. Professor Fish argued that there is such a thing as a collective “public conscience” which should supersede that of one’s personal conscience and value systems, no matter how entrenched these may have been.

During the Bush administration, the culpable clause, called the Provider Refusal Rule, allows health care providers to refuse to participate in procedures they find objectionable for moral or religious reasons. The main bone of contention was of course regarding freedom to choose abortion, pro-choice, or conversely, pro-life.

In Fish’s article, he underscored an earlier statement by Mike Leavitt, Bush’s Secretary of Health and Human Services, who had said that, “Doctors and other health providers should not be forced to choose between good professional standing and violating their conscience.” The direction of the Bush doctrine was of course to urge the conservative right against unfettered abortion on demand, which continues to divide the American people.

Professor Fish reviewed the etymology of “conscience” as ascribed to English philosopher Thomas Hobbes. Here one of the earliest definitions of conscience, referred to those occasions “when two or more men know of one and the same fact . . . which is as much to know it together,” and where, violation of conscience meant that knowing together, men prefer their “secret thoughts” to what has been publicly established.

Fish acknowledged that Hobbes understood that many consider conscience to be the name of the private arbiter of right and wrong. But Hobbes regards this as a corrupted usage invented by those who wished to elevate “their own . . . opinions” to the status of reliable knowledge and try to do so by giving “their opinions . . . that reverenced name of Conscience.”

Hobbes’s main argument is that if one can prefer one’s own internal judgments to the judgments of authorized external bodies (legislatures, courts, professional associations), the result will be the undermining of public order and the substitution of personal whim for general decorums: “. . . because the Law is the public Conscience . . . in such diversity as there is of private Consciences, which are but private opinions, the Commonwealth must needs be distracted, and no man dare to obey the Sovereign Power farther than it shall seem good in his own eyes.”

Following his article, Fish was roundly criticized for being half-right in his interpretation of conflicting conscience, but intellectual disagreement continues to divide mostly implacable and partisan ethicists. Nancy Berlinger in an ensuing Hastings Center Report[ii] has this to say: ‘Stanley Fish… recognizes that defining “conscience” more loosely – as “moral intuition,” or those “secret thoughts”… does not solve our contemporary problem. When medical professionals believe that they are being forced to do harm or are prevented from doing good, the ethical solution may not always be the conscience-clause remedy of stepping away from troubling situations.’

Where does this leave the medical professional when it comes to ethical underpinnings of doing what’s right or wrong? Would our personal conscience suffice? Or, should we subsume to the greater wisdom of our collective professional voice (e.g. national medical associations, professional bodies, world medical association, medical councils, etc.), which through the long arduous passage of time and historical experiences, would have honed a burnished if straitjacketed version of what’s generally accepted as “ethically and publicly correct”?

Be that as it may, does this mean that the medical professional would then have no need to rely on his own personal conscience and moral standing? No, but surely if these are diametrically opposed to the greater wisdom of peers, then one has to justify one’s personal convictions all the more!

Again, this cannot be taken out of context of the prevailing society and sociopolitical situation. This becomes extremely relevant in societies such as in Malaysia and other quasi-democratic nations, where governments tend to be paternalistic, even arrogant or worse.[iii] The instruments and institutions of power are often abused to forcefully interpret laws or even medical findings in a slanted manner, which severely test the mettle and autonomy of physicians under their charge.

In certain authoritative or political circumstances, the medical professional is called upon to exercise extreme judgement calls, which can be sorely tested by either threats from or fears of authority (e.g. police, superior officers, military, even political powers) or worse, direct or indirect ‘rewards’ for passive compliance!

The 1^st century AD Hindu code, Charaka Samhita[iv], exhorts doctors to “endeavour for the relief of patients with all thy heart and soul; thou shall not desert or injure thy patient for the sake of thy life or living”, which have been restated in many codes of professional conduct including our own. Yet, these are often pushed to the backburner, when conflicts of duties, arise.

Recently in Malaysia, public spats on medical testimonials and reports have arguably cast long shadows as to the so-called impartiality, ethics or professionalism of some of our medical colleagues.[v] Forensic pathologists are facing some intense scrutiny of late, due to questionable lapses, incoherent practices and perhaps even perceived selective memories, and slipshod standards of duty of care.[vi]

Other physicians making medical reports are also put under the microscope for their perceived biasness or slant of their reports, one way or the other, until the truthfulness of one vs. the other, appears difficult or impossible to discover![vii]

Such ambiguous if disingenuous medical findings or reports cast a dismal if disappointing view on our profession.[viii] While some of these appear coerced, some might conceivably be simply venal, just as if medical veracity can be made to sway according to the purchasing power of the most damning and powerful!

Physicians must be reminded that for that patient (deceased or detainee) under his/her charge, there is frequently no other person whose interests can be represented, except from the physician’s unbiased assessment…

Sadly some of these dubious practices place us at odds with the perceived wisdom and conventions of some greater external collective conscience. These conventions although seemingly unenforceable, have long been articulated by world authorities such as the World Medical Association and even the United Nations Human Rights Commission.

The UN High Commission for Human Rights Istanbul Protocol[ix] is categorical in stating that:

“Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients. Such health professionals with dual obligations, owe a primary duty to the patient to promote that person’s best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat. They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient’s health interests and act accordingly.”

Unfortunately, this protection by convention appears so remote to the lonely physician standing in the grips of perceived authoritarian powers, whose influence are imaginably all-powerful!

Seen in this context, society must exert its moral imperative of the public good on a universal basis, and demand the application of such universal conventions, to protect the hapless physician at the centre of such political or partisan storms, lest such pressure lead to further erosion of already debilitated institutions.

Similarly, the onus is on members of the medical profession to remain steadfast to the doctrine of public conscience and universal principles rather than personal ones, when carrying out our duties, including when making judgement or pronouncement on some of our possibly errant colleagues. Sectarian perceptions whether religious or political, clearly must take a back seat, and should not be allowed to colour our thinking or decision making.

Personal bias or experience or even conviction should yield to the more nuanced, perhaps more balanced decision based on strict interpretations of statutes, codes of professional conduct, and perhaps legal precedents.

The US Supreme Court[x] has ruled that when the personal imperatives of one’s religion or morality lead to actions in violation of generally applicable laws — laws not promulgated with the intention of affronting anyone’s conscience — the violations will not be allowed and will certainly not be celebrated; because: “To permit this would be to make the professed doctrines of religious belief superior to the law of the land, and in effect to permit every citizen to become a law unto himself.” Therefore, we must be quite clear to dissect conscionably our dilemma of which is the superior right.

Similarly, in the context of political or authoritarian pressure, especially where democratic institutions are weak, and where risk to the individual may seem likely, it behooves the professional to be reminded about the World Medical Association’s Declaration of Geneva[xi], which is a modern restatement of the Hippocratic values, as well as to be cognizant of UN Conventions such as the Istanbul Protocol. Doctors are reminded that the health of their patients is their primary consideration and that we must devote themselves to the service of humanity with conscience and dignity.

We must learn from and adhere to our historical memories, which are collectively acknowledged as “correct” and first and foremost for our patients’ interests. Certainly, in this context, every professional should not let religious, political or sectarian reasons from influencing our decision-making.

But does this mean that these are fixtures which cannot or should not be modified with the passage of time and perhaps move in tandem with the “fashion” or faddism of current perceptions or even societal movement or direction?

Clearly this will depend on the circumstances and the human aspects of all patient-physician interactions. Although ethics these days are not as immovable or as permanently cast in stone, societal views do evolve. Like sometimes shifting tides, ethical perceptions may very gradually ebb and flow, but often with the anchored moorings and underpinnings of moral public good and greater and greater foundation of universal values.

So changes may occur, but again these must be based on contextual interpretation which should be carefully justified so that the newer interpretation can withstand scrutiny and/or rigorous re-examination, by an increasingly knowledgeable public and also by even more discerning generations of similar professionals.

Thus, personal conscience and public conscience must be employed together to shape our moral compass when we are dealing with ethics and medical professionalism. It helps when we all undertake to reexamine our own values and learn more and more as to how these ethical dilemmas and questions are evolving in this day and age. We must not be cowed into a mindset of convenient way out or of callous expediency.[xii]

References:

[i] Stanley Fish. Opinionator. Conscience vs. Conscience. The New York Times. The Opinion pages. 12 April, 2009. http://opinionator.blogs.nytimes.com/2009/04/12/conscience-vs-conscience/ (Accessed 26 Jan 2011)

[ii] Nancy Berlinger. Conscience: We’re Not Donne Yet. Bioethics Forum. The Hastings Center Report. 07 May 2009. http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=3404&blogid=140 (Accessed 26 Jan 2011)

[iii] David KL Quek. Unbiased treatment for all. Malaysiakini, March 23, 2010. http://myhealth-matters.blogspot.com/search?q=ethics+conscience (Accessed 26 Jan 2011)

[iv] Roy, P. Gupta, H. Charaka Samhita . A scientific synopsis. 2nd Ed., Indian National Science Academy, New Delhi, India, 1980.

[v] David KL Quek. Kugan’s Autopsy Findings & Inquiry: Unsettling Questions remain Malaysiakini 8 April 2009. http://myhealth-matters.blogspot.com/2009/04/kugans-autopsy-findings-inquiry.html (Accessed 26 Jan 2011)

[vi] David KL Quek. Ethics, medical confidentiality vs. political pressures. Malaysiakini July 31, 2008. http://dq-liberte.blogspot.com/2008/07/ethics-medical-confidentiality-vs.html (Accessed 26 Jan 2011)

[vii] Debra Chong. Teoh family disappointed with British pathologist’s report . Malaysian Insider 26 April 2010. http://www.themalaysianinsider.com/index.php/malaysia/61368-teoh-family-disappointed-with-british-pathologists-report (Accessed 26 January 2011)

[viii] David KL Quek. Physicians must be more vigilant. Malaysiakini 11 March 2009. http://myhealth-matters.blogspot.com/2009/03/doctors-must-be-vigilant-when-dealing.html (accessed 26 Jan 2011)

[ix] Istanbul Protocol. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. OFFICE OF THE UNITED NATIONS HIGH COMMISSIONER FOR HUMAN RIGHTS. United Nations, Geneva, 1999.
[x] Scalia, J., Opinion of the Court. SUPREME COURT OF THE UNITED STATES; 494 U.S. 872. Employment Division, Department of Human Resources of Oregon v. Smith. CERTIORARI TO THE SUPREME COURT OF OREGON No. 88-1213 Argued: Nov. 6, 1989; Decided: April 17, 1990

[xi] WMA Declaration of Geneva. Revised 173rd Council Session, Divonne-les-Bains, France, May 2006. http://www.wma.net/en/30publications/10policies/g1/index.html (Accessed 26 Jan 2011)

[xii] David KL Quek. A New Malaysia still possible. Malaysiakini, March 9, 2010. http://dq-liberte.blogspot.com/2010/03/malaysiakini-new-malaysia-still.html (accessed 26 Jan 2011)

Global Strategies in the Prevention of Cardiovascular Disease: Asia Pacific Perspectives

2011-06-16T06:18:00.000-07:00

Global Strategies in the Prevention of Cardiovascular Disease: Asia Pacific Perspectives

Dr David KL Quek, FRCP, FNHAM, FACC

In May 2009, the Non-Communicable Disease (NCD) Alliance launched a successful campaign for a United Nations High-Level Summit on Non-Communicable Diseases (NCDs). This will take place on 19-20 September 2011 in New York.[i] The convening of this NCD Summit will highlight the growing pandemic of preventable yet escalating risk factors, which predisposes more and more citizens around the world to premature death and morbidity.

One of its major premises is to “prioritize measures to reduce the NCD burden in developed and developing countries by strengthening health systems and primary care infrastructures across the continuum of care – prevention, early diagnosis, treatment, adherence and ongoing disease management.”

An important NCD Alliance resolution recognizes “the lack of sufficient statistical data on non-communicable diseases, particularly in developing countries, and the need for the development and wide utilization of a set of standardized indicators for data collection and information on trends in respect of non-communicable diseases and their risk factors at the global, regional and national levels.”

Development, Ageing & Lifestyle changes in Asia Pacific populations

In Asia Pacific countries, population health profiles have been changing drastically, with greater percentages of their population ageing rapidly. Cardiovascular diseases have become the predominant causes of mortality and morbidity. In 2005, Asia Pacific countries account for more than half the world’s Disability Adjusted Life Years (DALYs) lost due to CVD for both men and women.[ii]

In the United States, cardiovascular disease accounts for >800 000 deaths, >7 million hospital discharges and chronically affects >80 million adults, per year.[iii] The projected US healthcare cost of CVD in 2010 is half a trillion dollars. Although CVD death rates among younger Americans (35-54 years)[iv] appear to have plateaued, the overall future CVD burden is projected to increase due to population ageing and increasing prevalence of obesity and diabetes.[v]

Similarly in the Asia Pacific region, rapid economic development has also led to the rising prevalence of overweight and obesity, with diabetes increasing even more quickly.[vi] A moderate increase in body mass index and central obesity makes South Asians more prone to insulin resistance. In Malaysia, our population rate for diabetes has reached 14.9% of adults (>30 years old), surveyed recently in 2006.[vii] But there are ethnic differences in the association between diabetes mellitus, ischemic heart disease and stroke within Asian populations.[viii]^,[ix]

Women, Menopause and CV Risks

Globally there is increased awareness that women have been neglected somewhat in our approach to the management or under-identification of cardiovascular risks and disease. We are increasingly aware that women could become the next potential health risk explosion in CVD. As more and more women outlive men and join the ranks of the elderly, they would become the next under-estimated cohort of CVD patients.

Post-menopausal changes are recognized as influencing more adverse CV risk profiles for women. In Malaysia, the National Heart Association of Malaysia has formed our WH²O, (Women Heart Health Organisation) to re-emphasise our commitment to addressing this societal need.

The SWAN (Study of Women’s Health Across the Nation) studied the influence of aging and menopause on cardiovascular risk factors in a subset of 1,054 women.[x] Matthews et al., found that following menopause and beyond 50 years of age, lipid profiles change for the worse, i.e. total cholesterol, LDL-cholesterol, apo-B lipoprotein increase, while HDL-cholesterol and apo-A1 lipoprotein decrease. Whether the threshold levels for lipid-lowering therapy should change around the time of menopause or whether the absolute or relative degree of change in lipids (independent of premenopausal levels) predicts future CHD events merits further study.[xi] However, the menopause-associated changes in total cholesterol, LDL-C, and Apo B probably contribute to women’s increased risk of CHD in the post-menopausal years.

Major take-home points for the clinician are that risk factor levels do change around the menopausal transition, in part due to chronologic aging and some related to the climacteric itself. Women should be made aware that their cardiovascular risk is likely to increase during this period. They should be counseled to emphasize therapeutic lifestyle changes to combat such increases. During this time it may be prudent to increase the frequency of risk factor monitoring to identify higher risk women, who may benefit from pharmacologic management of their risk factors beyond simply lifestyle modification.¹¹

Lifetime Risk of Developing Coronary Heart Disease (CHD)

Lifetime risk of developing CHD increases with age, primarily because of progressive atherosclerosis due to deteriorating risk profiles, which affects the ageing vascular system.

At any given age however, men are at greater risk (49% higher) for CHD than women (32% higher), after the age of 40 years. Coronary Heart Disease (CHD) rates in women after menopause are 2 to 3 times higher than in women of the same age before menopause.[xii]

In a 1999 analysis of the Framingham Study database, 7733 patients were followed up for a total of 109 948 person-years. Overall, 1157 participants developed coronary heart disease. 1312 died from non-coronary heart disease causes. Lifetime risk of coronary heart disease at age 40 years was 48.6% (95% CI 45.8—51.3) for men and 31.7% (29.2—34.2) for women. At age 70 years, lifetime risk was 34.9% (31.2—38.7) for men and 24.2% (21.4—27.0) for women. After excluding isolated angina pectoris as an initial event, the lifetime risk of coronary artery disease events at age 40 years was 42·4% for men and 24·9% for women. Lifetime risk at age 40 years is one in two for men and one in three for women. Even at age 70 years it is one in three for men and one in four for women.[xiii]

A 2006 re-analysis of the Framingham data yielded and confirmed that lifetime prediction of CV risks can be carried out consistently.[xiv] The test cohort studied included all Framingham Heart Study participants who were free of CVD (myocardial infarction, coronary insufficiency, angina, stroke, claudication) at 50 years of age. Lifetime risks to 95 years of age were estimated for men and women, with death free of CVD as a competing event. 3564 men and 4362 women were followed for 111,777 person-years.

1757 had CVD events and 1641 died free of CVD. At 50 years of age, lifetime risks were 51.7% (95% CI, 49.3 to 54.2) for men and 39.2% (95% CI, 37.0 to 41.4) for women, with median survivals of 30 and 36 years, respectively. With more adverse levels of single risk factors, lifetime risks increased and median survivals decreased. Compared with participants with 2 major risk factors, those with optimal levels had substantially lower lifetime risks (5.2% versus 68.9% in men, 8.2% versus 50.2% in women) and markedly longer median survivals (39 versus 28 years in men, 39 versus 31 years in women).

Data from the UK also show similar outcomes: those with optimal CV risks (optimal cholesterol level, non-smoking, BP levels) have clearly better survival curves.[xv] In brief, those who have lowest CV risks at age 50 years are expected to have longer life expectancies by up to as many as 10 years over those who are of the highest CV risks!

Current Status & Controversies of CVD Prevention

An impressive array of epidemiological data has suggested that primary prevention is now a must to meaningfully impact on health outcomes for most nations of the world. Together with evidence-based medical and procedural therapies, we can now decrease case-fatality and reduce recurrent CVD events very aggressively (secondary prevention).

But primary prevention, i.e. to reduce chances of first event, is difficult to implement. Often, resources for the public who are relatively ‘well’ or symptom-free are limited and sporadic. Convincing the relevant authorities is difficult and large-scale community level projects are expensive and compete with other more urgent and concrete pressing social needs and services. Getting the public themselves to abide by or buy into prevention programmes is at best voluntary and may not be sustainable. These are often seen as unnecessary, imposing and restrictive, especially on lifestyle choices!

Many CVD patients have common predisposing risk factors, i.e. smoking, adverse dietary patterns, overweight, and sedentary lifestyles — leading to adverse blood lipid, blood glucose, & blood pressure levels. However, the majority of first CVD events occur in individuals with average or only mildly elevated levels of risk factors (who would not typically qualify for intensive prevention efforts).[xvi] In this category of indeterminate risks, the problem arises as to how we can recommend any wide-scale public health measure.

We currently have studies, which show that treating pre-hypertension,[xvii] or pre-diabetes[xviii]^,[xix],[xx] may actually delay the full-fledged development of hypertensive or diabetic complications and sequelae. Just how we can persuade ‘well’ but just marginally-off (the bell-curve tails) patients to consider long-term medications, remains a challenge. We do not have longer outcome data to convince us that survival and/or quality of life are actually improved and that the adverse effects of prolonged medications are entirely benign.

Even though we do have extensive and convincing primary prevention data on lowering LDL cholesterol,[xxi]^,[xxii] many among the public remain unconvinced that using statins interminably and aggressively is the answer. There are lingering public fears that longer term adverse effects remain undisclosed or worse suppressed by the ‘drug’ vendors![xxiii]^{,[xxiv],[xxv]}The respected Cochrane database systematic review stated that while the benefits of statin use in primary prevention is proven with no major adverse effects, caution should still be taken in prescribing statins for primary prevention among people at ‘low’ cardiovascular risk.²⁴

Controversy therefore remainswhether there are any subsets (high CRP?) of patients with supposedly higher risks that really need treatment.[xxvi] Thus, population-based CVD prevention should still best be achieved through lifestyle and environmental modifications. Long-term and indiscriminate or blunderbuss medication prescription is still considered inappropriate by many,[xxvii] and other strategies are needed to shift the entire distribution of risk. Over-the-counter statin (simvastatin 10 mg) policy changes in the UK have not reached thresholds to make this a meaningful public health programme a success story, even as of now.

Primordial Prevention: Moving beyond primary and secondary prevention

Recently, there has been wider discussion on targeting the population for modification, even before some of these risk factors rear their heads—a term titled primordial prevention. Primordial prevention strategies have the potential to reduce the population burden of CVD substantially by preventing the development of adverse risk factors.³

This radical concept is gaining ground. Recent studies show that individuals, who maintain a profile of ideal cardiovascular risk factor levels from young adulthood into middle age, can essentially avoid (even escape) major CV events for their remaining lifetime. Indeed, achieving ideal cardiovascular profiles younger can reduce both CVD and non-CVD mortality rates, resulting in an average additional 10 years of longevity!^13,14 These individuals also have markedly better health-related quality of life at older ages and also have lower annual Medicare costs. Conversely, any adverse level of a risk factor in middle age substantially increases lifetime risks for CVD. The American Heart Association recently endorsed primordial prevention as a powerful new mechanism for improving cardiovascular health in all Americans in the coming decade.⁵

Capewell et al,³ argued that if a majority of the population attains middle age with a prescribed ideal or optimal ‘phenotype’, more than 90% of the coronary heart disease deaths otherwise expected, might be prevented. However, barely 5% of the US population now maintains this ideal CV profile into middle age. It is likely that in Malaysia this is also the case, if not worse.

Thus, it begs an important question: Which effective public health policies could promote primordial prevention and maintain ideal cardiovascular health into middle age? This change would require a drastically different but conducive environment that supports health, rather than, as now, promoting obesity, hypertension, hyperlipidemia, diabetes, and inactivity.

Effective CV Prevention Strategies[xxviii]

Prevention efforts are classified into 2 complementary categories: “high-risk” and “population-based” strategies. High-risk strategies focus on identifying, detecting and treating individuals, who have high short-term risk for CVD. High-risk strategies are medically based and usually proven effective for persons with high CVD risk. These are immediately result-oriented and are usually very cost-effective even if rather costly, on a per individual basis.

Complementary “population-based” strategies aim to improve the entire population by favorably shifting the distribution of risk factors. They modify or force behavioural change for the masses. Population-based strategies while difficult to implement are surprisingly effective and have resulted in quite rapid measurable benefits.

Several meta-analyses and reviews on indoor smoking bans and secondhand smoke in the United States, Canada Italy and Scotland have shown "remarkable consistency" in the association between bans and reductions in heart attack rates, ranging from 6 % to 47 %.[xxix]^{,[xxx],[xxxi]}

Likewise, CVD rates in Poland decreased within 3 years after the repeal of subsidies for meat and animal fats in the early1990s.[xxxii]

The successful North Karelia Project, begun in Finland in the 1970s, is the classic example of a national public health policy at its best. Its comprehensive, community-based and national policy interventions, which focused on favorably influencing dietary habits (drastically discouraging fatty meat and dairy product consumption) and reducing smoking, resulted in huge decreases (80%) in CVD mortality rates over 25 years.[xxxiii]

CV Prevention: Regulatory & Dietary Options[xxxiv]

National and local governments and health organizations are now addressing CVD prevention with both such approaches.

First, physicians must be actively encouraged to identify and treat individuals at high cardiovascular risk. Second, policy and regulatory initiatives must be enacted, to incentivize population-wide behavioural change (e.g. promoting good dietary habits, smoke-free legislation, salt or sugar reduction, regular physical activity).

However, some government policies may sometimes be conflicted; e.g. continued subsidies for certain crops (tobacco, corn) that can promote disease rather than health. Agricultural subsidies can be used more positively; e.g. encouraging or incentivizing a farming shift from dairy to berry production; and making fruits cheap and favoured for schoolchildren.

Enlightened governments may also provide favorable subsidies or policies that promote and prefer polyunsaturated vegetable oils, skim milk, whole grains, or fresh fruits and vegetables. Regulation, legislation, and partnering with the food industry have great potential too. Concerted and consistent efforts of reducing salt in the food chain can also lead to substantial benefits. Likewise, potentially large benefits might occur from implementation of broader dietary strategies for reducing or avoiding intake of greasy high-calorie fast foods, re-used trans fats and/or saturated fats.

Economic concerns[xxxv]

Rising health care cost is a perennial problem for all governments, globally. Cardiovascular disease burden is rising worldwide. The Asia Pacific region is poised to taking the lead of being affected by disproportionately highest rates of disease-adjusted life years (DALYs) lost due to CVD!

This growing CVD economic burden is driven by 3 factors: new technology and tertiary specialist care such as revascularization procedures, hospital care, and prescriptions for costly medications, e.g. statins, antihypertensive, diabetes, and obesity drugs. Thus, reliable cost-effective strategies and estimates for preventive interventions are critically important.

Thus far, medication-based primary prevention appears relatively costly; the number needed to treat (NNT) statistic remains to be better refined and improved to the point of acceptable cost-efficacy pertinent to every socio-economic entity and nation. Initial outlays for these measures for poorer countries must be made affordable through the wider and more appropriate use of cheaper and yet equivalently effective generic medicines.

The cost of these on a nationwide scale must not compete with budgets for other more pressing social needs and priorities. Conversely, primordial prevention interventions might generate savings when targeting specific behaviors such as smoking cessation, dietary cholesterol reduction, or increasing physical activity; but such measures are difficult to inculcate as a population or cultural behaviour change.

Studies from United States, Australia, and United Kingdom consistently suggest & show that population-wide prevention programs substantially reduce health care expenditures. Thus, these must be taken as effective role models to emulate.

An economic model commissioned by the UK National Institute for Health and Clinical Excellence (NICE) was recently developed for the entire UK population of 60 million.[xxxvi] Conservative estimates suggest that any policy intervention, which results to a 1% population-wide reduction in CVD risk factor level, would be cost saving. Reducing mean population cholesterol levels or blood pressure levels by 5% or enacting legislation to eliminate trans fats or reduce dietary salt intake by 3 g per day, was each estimated to cost save in excess of $1 billion per year!

Greater Commitment to Prevention Strategies for the Population

Health officials, including doctors and patients, need a better understanding of the consequences of conflicting trends in CVD risk factors and the different options for reducing the future burden of CVD globally. Ideally, large population-based research should compare various mixes of intervention strategies, but many such studies are not readily feasible or forthcoming.

Large-scale prevention strategies need to be validated via policy models. The best models use extensive data-mining of population risk-factor profiles and disease prevalence, with subsequent computer-intense simulation of the effects of different interventions. But developing nations must allocate more resources and training personnel to collecting basic and more in-depth data of their own population’s health profiles, disease patterns and needs.

We need greater understanding of the potential benefits and optimal mix of current and future preventive strategies. Escalating current and future projected health care costs and the huge immediate costs of implementing long-term CVD prevention programs, may hamper and delay effective strategies for CVD prevention. The status quo is not acceptable politically, ethically, or economically.

Disclosure & Provenance statement

No conflict of interest or disclosure is relevant in the writing of this paper. Certain points in the above paper have been presented as a lecture “Managing Cardiovascular Disease in the Asia Pacific”, at the 4th Scientific Meeting of the Asia Pacific Menopause Federation (APMF) in Sydney, Australia on 26-29 September 2010.

References:

[i] World Health Organization, 64th World Health Assembly, Geneva, 86th plenary meeting, 13-20 May 2010. Resolution adopted by the General Assembly 64/265. Prevention and control of non-communicable diseases.

[ii] Mathers CD. Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine, 2006, 3(1), e442.

[iii] Simon Capewell; Donald M. Lloyd-Jones. Optimal Cardiovascular Prevention Strategies for the 21st Century. JAMA. 2010;304(18):2057-2058

[iv] Ford ES, Capewell S. Coronary heart disease mortality among young adults in the US from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol. 2007;50(22):2128-2132

[v] Lloyd-Jones D, Adams RJ, Brown TM, et al; American Heart Association Statistics. Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121(7):e46-e215.

[vi] Shigetake Sasayama. Heart Disease in Asia. Circulation 2008; 118:2669-2671.

[vii] Institute of Public Health, Ministry of Health. The Third National Health & Morbidity Survey 2006, Malaysia, 2008

[viii] WHO global database: data for saving lives. Geneva, World Health Organisation. See: http:// www.who.int/infobase/compare.aspx.

[ix] Ueshima H, Sekikawa A, Miura K, Turin CT, Kadowaki T, Nakamura Y, Okamura T. Takashima N, Kita Y, Watanabe M, Kadota A, Okuda N. Cardiovascular Disease and Risk Factors in Asia: A Selected Review. Circulation 2008;118;2702-2709

[x] Karen A. Matthews, Sybil L. Crawford, Claudia U. Chae, Susan A. Everson-Rose, Mary Fran Sowers, Barbara Sternfeld,

Kim Sutton-Tyrrell. Are Changes in Cardiovascular Disease Risk Factors in Midlife Women Due to Chronological Aging or to the Menopausal Transition? J. Am. Coll. Cardiol. 2009;54;2366-2373

[xi] Vera Bittner. Menopause, Age, and Cardiovascular Risk: A Complex Relationship. J. Am. Coll. Cardiol. 2009;54;2374-2375

[xii] American Heart Association. Heart Disease and Stroke Statistics: 2005 Update. Dallas, Tex: American Heart Association; 2004.

[xiii] Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary artery disease.. Lancet 1999; 353: 89-92.

[xiv] Lloyd-Jones DM, Leip EP, Larson MG, D’Agostino RB, Beiser A, Wilson PWF, Wolf PA, and Levy D. Prediction of Lifetime Risk for Cardiovascular Disease by Risk Factor Burden at 50 Years of Age. Circulation 2006;113: 791-798

[xv] Silvia Ulrich, Aroon D Hingorani, John Martin, Patrick Vallance. Lifetime risk of developing coronary heart disease. The Lancet, 1999; 353(9156): 925.

[xvi] GuptaAK, BrashearMM, Johnson WD.Coexisting prehypertension and prediabetes in healthy adults: a pathway for accelerated cardiovascular events. Hypertension Research (2011) 34, 456–461

[xvii] Thompson AM, Hu T, Eshelbrenner CL, Reynolds K, He J, Bazzano LA. Antihypertensive Treatment and Secondary

Prevention of Cardiovascular Disease Events Among Persons Without Hypertension: A Meta-analysis. JAMA. 2011;305(9):913-922

[xviii] Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393-403.

[xix] Li CL, Pan CY, Lu JM, Zhu Y, Wang JH, Deng XX, et al. Effect of metformin on patients with impaired glucose tolerance. Diabet Med 1999;16(6):477-81.

[xx] Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;48(2):289-97.

[xxi] Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med 1995; 333:1301.

[xxii] Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008; 359:2195.

[xxiii] Caro J, Klittich W, McGuire A, et al. International economic analysis of primary prevention of cardiovascular disease with pravastatin in WOSCOPS. West of Scotland Coronary Prevention Study. Eur Heart J 1999; 20:263.

[xxiv] Taylor F, Ward K, Moore TH, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2011; 1:CD004816.

[xxv] Ray KK, Seshasai SR, Erqou S, et al. Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med 2010; 170:1024.

[xxvi] Wolfgang Koenig; Paul M Ridker. Rosuvastatin for Primary Prevention in Patients with European Systematic Coronary Risk Evaluation Risk ≥5% or Framingham Risk >20% Post Hoc Analyses of the JUPITER Trial Requested by European Health Authorities. European Heart Journal. 2011;32(1):75-83.

[xxvii] de Lorgeril M, Salen P, Abramson J, Dodin S, Hamazaki T, Kostucki W, Okuyama H, Pavy B, Rabaeus M. Cholesterol Lowering, Cardiovascular Diseases, and the Rosuvastatin – JUPITER Controversy A Critical Reappraisal. Arch Intern Med. 2010; 170(12): 1032-1036 .

[xxviii] Rose G. The Strategy of Preventive Medicine. Oxford, England: Oxford University Press; 1992.

[xxix] Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Report Brief: October 2009.

[xxx] Bartecchi, C., R. N. Alsever, C. Nevin-Woods, W. M. Thomas, R. O. Estacio, B. B. Bartelson, and M. J. Krantz. 2006. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation 114(14):1490-1496.

[xxxi] Meyers DG. Meyers, Neuberger, He J. Cardiovascular Effect of Bans on Smoking in Public Places: A Systematic Review and Meta-Analysi. J Am Coll Cardiol 2009;54:1249–55

[xxxii] Zatonski W, Campos H, Willett W. Rapid declines in coronary heart disease mortality in Eastern Europe are associated with increased consumption of oils rich in alpha-linolenic acid. Eur J Epidemiol. 2008;23(1):3-10

[xxxiii] Puska P, Vartiainen E, Tuohmilehto J, Salomaa V, Nissinen A. Changes in premature deaths in Finland: successful long-term prevention of cardiovascular diseases. Bull World Health Organ. 1998;76(4):419-425

[xxxiv] Capewell S, Ford ES, Croft JB, Critchley JA, Greenlund KJ, Labarthe DR. Cardiovascular

risk factor trends and potential for reducing coronary heart disease mortality in the United States of America. Bull World Health Organ. 2010;88(2):120-130.

[xxxv] Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med. 2010; 362(7):590-599.

[xxxvi] National Institute of Health and Clinical Excellence. NICE Public Health Guidance 25: Prevention of Cardiovascular Disease at Population Level. London, England: National Institute of Health and Clinical Excellence; 2010.

Low Diagnostic Coronary Angiography Yields: Perhaps we need a higher threshold to perform

2010-03-24T10:15:00.001-07:00

Low Diagnostic Coronary Angiography Yields:

Perhaps we need a higher threshold to perform

Dr David KL Quek, FNHAM, FACC (Published NHAM Pulse, April 2010, pg2)

A recent research paper by the Duke Clinical Research Institute (Patel MR, et al. Low Diagnostic Yield of Elective Coronary Angiography. N Engl J Med 2010;362:886-95.) should prod every cardiologist to review his or her threshold in the performance of ‘routine’ coronary angiography for the diagnosis of significant coronary artery disease.

This concept to justify clinical performance processes to help check potentially over-used procedures and testing has now become more and more crucial in the era of evidence-based medical practice and health costs constraints.

More importantly on a practical basis, we are exhorted to contribute more actively towards checking escalating health care cost by becoming more thoughtful and judicious in our clinical decision-making.

Justifiable Diagnostic Screening still Unresolved

In the USA, some USD14.1 billion is spent on imaging diagnostic testing annually by Medicare alone. More and more are now spent on early diagnostic procedures in the hope of detecting and treating potentially lethal coronary artery disease, but which seems to elude the very best of our diagnostic efforts and risk stratifying strategies.

Cardiologists have an unenviable position with regards to the heightened awareness of risks of coronary artery disease, among the general public globally.

Because of the huge success of our diagnostic and therapeutic capabilities, and the very many high profile celebrities surviving or even dying from heart attacks, widespread health promotional education has enlightened the public as never before.

It would be true to say that nearly every one has heard of the dangers of heart attacks and perhaps too all the major risk
factors. Thus, it is not difficult to envisage that whenever any one person feels some twinges in the chest or suspect that he or she might be suffering a heart ailment, many present themselves to physicians for clarification and testing, and perhaps especially for reassurance that all is well, or otherwise.

Hence, there is a rising demand for health screening testing including exclusion of significant heart disease.

Unfortunately, even as we get more sophisticated, we do know that the diagnostic yield of most health screening tests for significant heart disease is disappointingly low. From simple risk factor assessments and stratification, stress ECG, stress echocardiograms to even calcium scoring to MSCT-angiogram, we are still only finding tiny incremental yields to help us not miss potentially lethal heart disease or sudden death.

Perhaps, this is the result of greater unrealistic expectations from both patients and physicians alike. We have become more enamoured by our abilities to reduce the scourge of heart disease, so much so, that we are continuously looking for the Holy Grail at preventing earlier and earlier unstable plaques, which can trigger sudden loss of life. Some harbour hopes of totally eradicating coronary artery disease itself!

A few years ago, a group of eminent cardiologists in their enthusiasm to advocate earlier detection of heart disease, pushed for a public health program to screen more aggressively for heart disease and unstable plaques, the MDCT was the touted approach then for mass screening. However, this was not universally adopted when clearer views of such a program were scrutinized. The less than consistent detection rates, resolution discrepancies, artifacts, radiation risks of mass screening with CT angiogram has stalled the more widespread use of this modality.

Then, there have been others, (cardiologists, both academic and private sector) who have swung even farther to the right of ‘gold-standardising’ diagnosis with routine coronary angiography, on demand even to detect or to exclude significant coronary stenosis. They persuade their patients that this is the only sure way of not missing anything to do with their heart, except that this is disingenuous: there is no guarantee that a heart attack would not occur in the future!

This approach is clearly unacceptable and when used as a casual screening tool, almost universally regarded as Class III indication, or worse that which may cause harm. Risks of tachyarrhythmias, embolic phenomena, CVAs, renal impairment or even untoward unexpected bleeding, while very low, are not zero. The latest analysis of the ACC National Cardiovascular registry database therefore lends weight to the fact that indiscriminate testing with unnecessary coronary angiography has low yields, which cannot be justified!

The American College of Cardiology National Cardiovascular Data Registry (NCDR) Results:

Of the nearly 2 million coronary angiographies performed in the NCDR database, some 60.3% had significant obstructive CAD (Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of the

left main coronary artery or stenosis of 70% or more of the diameter of a major epicardial or branch vessel that was more than 2.0 mm diameter. When sensitivity was broadened to any stenosis of 50% or more for any coronary vessel, this increased diagnostic yield results by some 4%.)

When acute coronary syndromes, cardiogenic shock, proven past CAD, past histories of revascularisation procedures, and other defined indications were excluded, some 397,954 were eligible for analysis. Of these, the yields are as shown in the figure below:

Noninvasive testing (resting electrocardiography, echocardiography, computed tomography [CT], or a stress test) was performed in 83.9% of the patients before invasive angiography, of which 68.6% had a positive test result. Patients with a positive noninvasive test result had higher rate of obstructive coronary artery disease than those who did not, before angiography (41.0% vs. 35.0%, P<0.001); the rate of obstructive CAD among patients with a positive test result was also higher than the rate among those with equivocal or negative test results (41.3%, vs. 27.1% and 28.3%, respectively).

Since the data set included asymptomatic and symptomatic patients, the association between rates of obstructive coronary artery disease and the results of noninvasive tests are presented in Figure 2 according to Framingham risk-score categories (low, intermediate, or high) and symptom categories (no symptoms, atypical symptoms, or angina). The diagnostic yield for obstructive coronary artery disease increased with a higher Framingham risk score, as well as with the presence of angina
(P<0.001 for both analyses).

Figure 3 below shows the model’s predictive ability when symptom characteristics, i.e. beyond Framingham risk scores alone were analysed. However, stratifying Framingham risk levels, with positive, equivocal or negative noninvasive test was associated with very small incremental yields for presence of obstructive coronary artery disease (C-statistic, 0.764; 95% CI, 0.762 to 0.765), for all three Framingham risk levels.

It appears that less than 4 in 10 among those undergoing invasive coronary angiography (37.6%) had obstructive CAD (i.e., ≥50% stenosis of the left main coronary artery or ≥70% stenosis of a major epicardial vessel). The percentage was similar (41.0%) when the definition of obstructive disease was expanded to include stenosis of 50% or more of any coronary vessel.

Thus, although certain demographic and clinical characteristics could be useful in determining the likelihood that obstructive coronary artery disease would be present, the incremental value of a positive result on a noninvasive test (including any of a broad range of tests such as resting electrocardiography, echocardiography, CT, or stress test) was limited.

This begs the question whether such diagnostic tests should be promoted in a systematic way. Of course, this does not mean that those with clear indications should not be referred for such testing, if not for therapeutic options, then for risk stratification strategies and management.

But, this poses challenges for cardiologists and physicians who should be very clear in discussing with their patients the realistic clinical utility of non-invasive testing and especially for coronary angiography. For those with not much or typical symptoms, then most of these tests may not serve to enlighten either the doctor or the patient as to his or her status of cardiac health!

So, What should Cardiologists Do?

In Malaysia, we do have an unhealthy love affair with all that is new and fashionable, especially technology-driven equipment and techniques. These are touted as must-have amenities bordering on questionable competition for who has the newest, most advanced equipment. There are about 20 ultra-fast multi-detector CT scanners in the Klang valley; and another 15 or so cardiac catheterisation laboratories as well.

Business people in collaboration with physicians, usually fund such huge capital-intensive enterprises, which then demand quick returns on their investments. Thus, there is an unspoken nudge toward greater utilization of such facilities to help justify their purchases. To compound the problem, it is not inconceivable that cardiologists are also venally encouraged to use more of these testing modalities, because they would personally benefit from procedure fees—the sort of asymmetrical moral hazard, which has been decried by many health economists.

In several reports now, a few cardiologists in the USA have been charged and indicted for fraud for performing un-indicated coronary angiography, and even unnecessary angioplasties. Linked hospitals have also been fined huge sums for condoning over-utilisation of such procedures without sufficient oversight or appropriate audit.

With the NCDR data in mind we should now seriously reconsider our penchant for early invasive testing, and resort to better evidence-based medicine to offer our patients the optimum care without fear of under-diagnosing or missing non-critical disease, which are usually not life-threatening (this is not addressed in this analysis). But we do have past precedents, the COURAGE study had shown quite conclusively that when given optimal medical therapy, even significant but stable coronary artery disease can be managed quite well, with no increase in mortality or major adverse complications.

Let’s give more thought as to how we practice cardiovascular medicine and remind ourselves that the best medicine is one that is evidence-based and purely for the patient’s benefit, not ours or our personal financial gain per se.

We have to learn to stay our reflexive tendency to diagnostic or therapeutic procedures which may not improve risk assessment or clinical management for our patients, but which may instead increase their potential harms and incur unnecessary costs.

Unless we rein in our free-for-all approach, the escalation in costs may actually impose external oversight and imposition of audits and cost-constraints for reimbursements, through case-mix or DRG models.

Worse, callous over-utilisation of procedures including coronary angiography may demean the trust and esteem which the public has for the physician, the cardiologist, and impeach our much-vaunted medical professionalism!

Medicine—Reigniting our Passion…

2009-08-18T06:45:00.000-07:00

Medicine—Reigniting our Passion…

Dr David KL Quek, drquek@gmail.com

“Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?”
~ T.S. Eliot. The Rock, 1934

“Physicians combine two diverse tendencies in their daily functioning, a scientific mode of thinking and a clinical commitment to healing. The former requires us to be rigorous, dispassionate, objective, loath to reach conclusions until incontrovertible facts have been assembled. The clinical, or professional, component, on the other hand, compelled by the urgency to assuage suffering and to defend life, demands immediate action even in the absence of complete data." ~ Bernard Lown, M.D. in Prescription for Survival: A Doctor’s Journey to end Nuclear Madness. Berrett-Koehler Publishers, Inc., San Francisco, 2008, p.61.

Traditional roots of medicine demand some personal reflection…

Some thirty years of practising as a doctor can certainly embolden one to try and reflect upon a profession that so intimately inhabits one’s personal universe. Nevertheless, I do so with trepidation that I may have overstepped my expertise, my uncertain moral position in the august footsteps of so many unmatchable giants of our medical profession.

Yet, I have been impelled to do so, to try and set down my nebulous thoughts as to what and how the concept of the modern doctor is changing or taking shape, amidst the tremendous transformations and challenges that have swept the medical profession and health care scene.

Being a medical doctor is certainly one profession, which can become an all-consuming life and living itself—one learns to eat, drink, and breathe medicine.

Our thoughts and thought processes are submerged within the lingering echoes and ethos of a Hippocratic ancien regime: one of highly-structured codified dos and don’ts and exhortations of an intricately-crafted analytical process. Many are now lamenting the relevance of these methods and constraints, the seemingly outmoded sweeping codes, so enshrined within its antiquarian Aesculapian confines.

Nevertheless this singular system has continually defined and redefined itself, with modernizing inputs from our forefathers—all highly regarded stalwart champions of principled medical practices and professionalism. On the basis of the Hippocratic tradition, medical practice has been transformed increasingly into a more rigorous scientific system—one that is better evidence-based, with consistent veridical facts, and most importantly, one that is able to deliver reliable repeatable quality of care and cure outcomes.

No longer is the practice of medicine simply the handed down legacies of trusted wisdom and opinions of a few experienced if authoritative masters. Direct challenges to untested even if persistently accepted practices from long ago have helped democratize and expand the scientific reach of medicine into more solid bases of substantiation.

Science and art meld together in an intertwined universe of shifting and ratifying complexities, which ultimately give up its ghost in some form of a therapeutic modus operandi. At least, that is what appears to be the articulated goal of medicine—to comfort always, to heal sometimes, and hopefully never to cause harm: Primum non Nocere (First, do no harm).

Most importantly but often forgotten in the glitzy or fevered attempts at dealing with modern ailments and newly-medicalized disorders, we should remember that our patients are our raison d’étre. Medicine exists because there are patients out there who need or deserve our services, our care. The converse is not necessarily true, and may indeed not be to our patients’ benefit.

These days, it is possible to forget that oftentimes, tangential rather than exceptional discoveries create new demands for newer approaches which may have become too all-inclusive: our healthcare lattice is thrown far too wide and spread too thinly. So much so that lifestyle, ageing-related or other psychosocial aberrations have become incorporated within new designations as novel ailments.

Some have suggested that such ready ‘medicalisation’ may be too indiscriminate and inappropriate. Some have been promoted and perhaps may even have been invented by “Big Pharma”. Some of these disorders have become propagandized and marketed as “real” ailments, which need to be diagnosed, investigated, and yes, even treated aggressively.

Evolving evidence-based Medicine

From folkloric herbs, bone setting, stone cutting, etc. we have now entered into a new era of thrust for evidence-based medical practice, or at least that’s what has been loudly proclaimed of late.

Out of the ashes of historical anecdotes and passing down of learned experiences, accepted ‘truths’ have been systematically debunked when put to more rigorous testing and ratification. Many pearls of long-accepted wisdom have been crushed under the weight of new evidence, and in their places have arisen newer concepts of better-tested, better proven ideas. However, the reality is that medical practice is not all based on rigorous or dogmatic scientific facts. We still have so many incomplete answers or limited comprehension on countless ailments.

Complicating this is the fact that different ailments affect different patients differently: some more gently, while others more catastrophically and perhaps even fatally. Such is the inconsistency of occurrences which doctors have labelled as ‘idiosyncrasies’, i.e. chance events and effects, which affect individual patients in peculiar, unexpected and often inexplicable ways.

Unbeknownst to some of our frustrated patients out there (who wonder why we sometimes cannot be more definite or sure, or why some unexpected outcomes or complications continue to take place), doctors still don’t know quite enough, at least, not for each and every medical illness or variant. We still puzzle over why certain twists and turns occur despite the rigorous implementation of what’s considered proper treatment, which are guided by evidence and research. The human body still escapes total understanding and occasionally behaves erratically and outside the rigid boundaries of expectation.

Even the most brilliantly gifted or polymath amongst us, would shy away from presuming that they know everything. However, there are those who do perceive of themselves as ‘gods’, the know-all who can dispense largesse and treat without any qualms of uncertainty but with the dogmatic conviction of a cocksure pedant—the expert extraordinaire. But with the relentless onslaught of scientific evidence constantly permeating the information universe, it would certainly be foolhardy to be so presumptuous, leaving far too little for cautious error or acknowledgement of possible uncertainties.

Medicine’s self-correcting mechanisms may be slow, erratic and staggered…

By espousing a self-correcting mechanism based on scientific tenets, western-style allopathic medicine has been marching along relentlessly, almost always improving upon itself, whilst dumping wrong or inaccurate concepts, measures, or treatment modalities. Sometimes a long-discarded or long-forgotten concept is revitalized and rejuvenated as more discoveries prove its better consistency and veracity.

This flip-flopping of ideas and beliefs can be confusing to the layperson, who wonders why if medicine is a science, there is this shifting or changing of premises. How can some medical ‘facts’ suddenly be overthrown tomorrow by some newer discoveries, or newer ‘truths’? How can a drug, long prescribed for a certain indication, be suddenly hazardous for another condition, so that it has to be withdrawn?

This is especially so when news-breaking clinical studies show adverse outcomes much to the consternation and confusion of the research scientists who had predicted otherwise.

Just a few years ago, an arthritis pain-relieving drug Vioxx (refocoxib) was found to be associated with increased heart attack and stroke rates especially after prolonged use, and had to be withdrawn. But this later action was reluctantly foisted upon the company only after costly legal battles; Vioxx had earlier been approved for global use for several years. Thus, while Vioxx was very good at its narrowly-defined efficacy, it was unfortunately putting more people at risk of suffering and succumbing to seemingly unrelated cardiovascular disease. This covert but delayed safety issue was regrettably not uncovered soon enough, but was clearly not acceptable for treatment of non-life-threatening chronic disorders when there are safer alternatives available.

Another example relates to some changed surgical decision pathways. Why indeed have some long-established surgeries now been deemed unneeded, outdated and even passé? Yet at other times why have drastic, occasionally mutilating, surgeries to be emergently performed to save a tenuous life?

Gastric surgery comes to mind as a glaring example, when aggressive antibiotic-acid reduction medications have supplanted gastric resection for ulcer disease. A previously well-hidden bacterium (helicobacter pylori) is now established as the cause of most of stomach ulcers and even cancers. Yet, conversely some life-saving gastrectomies might still be necessary in severely bleeding and exsanguinating gastritis, when medical therapy fails.

Another controversial if more personally-decided surgery is that regarding the option for radical mastectomy or simple lumpectomy for breast cancer. Questions of staging and lymph gland involvement are not readily clear for many patients, who frequently opt for less mutilating if incomplete surgery. Then, there’s that question of whether every patient should have that expensive not-readily available PET-CT scan to determine if the cancer had spread beyond its usual boundaries…

The choice for complex angioplasties versus coronary bypass surgery for multi-vessel coronary artery disease is another point of contention, which sometimes border on personal patient-physician preference rather than hard scientific evidence. Such evidence bases unfortunately fluctuate in time-dependent verifiable specifics, which are sometimes dictated by contemporary changes or refinements in technique or device advances.

Thus, are there really any unfailing medical ‘truths’ out there? Perhaps there never will be. This is because modern medicine is often about evolving comprehension and continual scientific ratification of concepts and practices. Some of these may indeed be revolutionary and requiring paradigmatic change in mindset and orientation.

Best Fit Medicine ever changing, updating…

Modern medicine these days is constantly adopting what’s currently the best fit, the most appropriately cohesive model, to the best of our up-to-date understanding, as we dip our curious minds into the flowing river of advances and new knowledge. We can never really dip into the same river twice without its nourishing waters having moved along… but it is through this ever-changing experience that we can hope to harness the best that modern medical knowledge can offer.

Thus, we really cannot afford to simply sit back and be idly complacent while the inexorable advances of medical and scientific research and discoveries unravel with such accelerating paces—we have to update our knowledge base and skills all the time—hopefully on a lifelong journey of continuing professional development (previously known as continuing medical education), so clichéd, yet so much a desired mandate for today’s physicians.

The Internet, the World Wide Web and the explosive information expansion has not helped alleviate this dilemma of how to make practical sense of what’s good and what works. Because, for each of our individual patients—ultimately and in a very curiously uneconomic way—being a doctor usually means dealing with that one patient and his/her problem, piecemeal.

[Only in epidemics or potentially public health calamities e.g. avian influenza or SARS (severe acute respiratory syndrome) and the current A(H1N1) pandemic, do we engage our autocratic prerogative, which collectively and without exception, corral our resources and authorise therapeutic or prophylactic measures on a designated at risk or exposed population.]

Medicine can and does consume our souls if we let it, and it can and probably should dictate a mystical ethical code of conduct which should exhort us to rise way above all others, in our dealings with humanity and with our patients in particular.

“Deprofessionalization”

However, these days, in some areas, the practice of medicine appears to have been lost in translation. Many doctors are disenchanted with the so-called practice as usual—many are now feeling a greater and greater sense of loss of autonomy and a growing sense of ‘deprofessionalization’, where insurers, third party payers, and managed care organisations are dictating how they practice, who they can treat and when, and how much can be reimbursed or not at all.

In 2006, the roll-out of the private healthcare facilities and services regulations for Malaysian doctors, added more fuel to the firestorm of practice issues which seem to overwhelm the wretched medical practitioner!

So what do some doctors do? They have become angry and feel quite betrayed. Practising clinical medicine had become a grinding drudge for some: mounting paper-work, senseless work-flow charts and reports, with ‘ludicrous’ micromanaging oversights, which seem excessive and demoralizing. Many had described these harsh regulatory articles and especially the prescribed punishments as criminalizing and degrading.

Such laws seem to imply that doctors who had been practising autonomously all along with little intrusion or mishaps, have become potential felons (in one fell swoop of the enactment of the Regulations by the Minister of Health) and that if some of these practice issues are not modified or adhered to, they are to be regarded as criminals with stiff fines and even jail time! Some had indignantly expressed their intentions to quit practising medicine altogether, others are defiantly recalcitrant.

Some doctors have become so unhappy, angst-driven and frustrated that they have lost their zeal and passion for their medical practice—the former patient-doctor relationship have become sundered with suspicion and regulatory mess-up, which trespass into their sense of justice and professionalism.

Dabbling in Fringe Therapies…

Quite a number of the more enterprising have moved laterally to fringe margins of allied health disciplines. Dabbling or even full-time engagement with beauty or aesthetic health care appears simpler, i.e. away from the more demanding and challenging clinical practice of general or family practice.

Some also have moved into the even more lucrative anti-ageing or drug-dependency programmes, which once again seem to be more rewarding and satisfying, even if less taxing mentally or intellectually!

Others indulge in fringe, obscure if esoteric “techno-babble” pseudo-medical practices (e.g. electro-diagnostic analysis for general health promotion, live blood analysis as screening procedure for possible medical ailments, whole body aura analysis, colonic washout therapy, qi gong for all ailments, ozone therapy, chelation therapy, etc.) which creates a semblance of ‘scientism’ and rational modernity, but which are at best hocus-pocus quackery at its most sophisticated.

Some are embracing complementary alternative medicine, which appears to be increasingly popular and in sync with the more suggestible public out there, despite the fact that their scientific bases are so much less proved, or none at all.

Erosion of youthful dreams, reigniting compassion and vocation…

When as a young teenager I dreamt of becoming a doctor, my fledgling youthful hopes and ambitions now seem so wonderfully fervid and overpowering. Back then, the starry-eyed passion and awe seamlessly suffused through my senses and waking moments and enveloped my entire psyche and persona. Then too, my concept of altruistic high-mindedness appeared to overwhelm all other considerations.

How far-away these thoughts and feelings now sometimes appear, how nebulous, how child-like and oh, how evanescent… That naïveté, which I have so blurry-eyed conceptualised, now seems so distant a memory, sometimes… Hard-nosed reality these days shatters our childlike dreams of simplicity, equanimity.

It is against this backdrop, that we should address the issue of where our medical profession is heading. With the onslaught of rising commercialism, market-driven personal consumerism, and greater patient autonomy, it is becoming increasingly hard for the medical professional to practice as a doctor.

To be that quintessential compassionate, empathetic health care provider so to speak, can be extremely demanding and challenging, what with the inherent diagnostic/therapeutic uncertainties, the spectre of fees and costs, medico-legal and other pecuniary considerations impinging upon the doctor’s and the patient’s consciousness.

During the coming two years of my presidency I wish to address some of these issues through the prism of a physician who passionately believes that medical doctors can make a difference, that health care can and must be engaged to make it as human and humane as possible, while staving off the onslaughts of rising commercialism, medicalisation, political and/or third-party oversight and progressive loss of our physician autonomy.

I hope to inspire a new look into the possible art of healing which appears to have taken a backseat with the rising tide of challenges and the onslaught of de-motivating practice issues. We must learn to reclaim our sense of purpose, our vocational goal, and reassert our meaningful role in modern society.

2009-08-17T10:01:00.000-07:00

Privatisation of Healthcare Services: Assessing the Accessibility, Cost and Social Dimensions of Private Healthcare

Dr David KL Quek,

President (2009-2011), Malaysian Medical Association

ASLI 3^rd Annual Series of Asia Healthcare 2009 Conference

“Charting a Blueprint for Your Healthcare Businesses and Services in Asia”,

Session 7, 17-18^th August, 2009

Maya Hotel, Kuala Lumpur

Abstract

Privatisation of healthcare services began in earnest following the opening up of the Malaysian economy in the Mahathir era in the 1980s. Prior to this, there were only a few private smaller scale community hospitals, maternity homes and scattered private clinics in urban areas. The growth became exponential (10-fold increase in hospital beds) in the 1980s, with the expansion of private wings of University hospitals and the corporatised entities of the Institut Jantung Negara (IJN) and National Eye Hospital. At the same time large state-controlled corporations such as Johor SEDC (Kumpulan Pelaburan Johor, KPJ) and Khazanah (the investment arm of the Ministry of Finance) began to make extended forays into the private healthcare business.

Until recently, private health care professionals comprise some 55% of the physician portion of the health care services of Malaysia. Since end of last month however, with greater numbers of young graduates returning in the droves, this proportion has reversed. Now some 10,070 doctors are in private sector, while there are more than 25,000 doctors in the public sector i.e. Ministry of Health, MOH.

Ironically, the public sector continues to cater to the bulk of the population, with the private sector seeing only around 30% of the patient population. This discrepancy meant that there is a luxury bias toward the private-paying patient, where there are more facilities and physician personnel looking after a select group of patients who are self-paying, or where there is a third party payer (insurance, managed care organisation or employer benefits).

There is disgruntlement among the citizens that for the poorer segment of the population, access and affordability healthcare issues are growing. Long delays, queue jumping or outright denial of certain expensive or very specialised but skilful therapies are points of contention, dissatisfaction and anger among the deprived or uninsured.

There is therefore considerable debate about the need or the future of private healthcare services, and a push toward a single national health service where access is guaranteed for every citizen based only on need and urgency. There is also rising concern at the push toward greater medical tourism by liberalization advocates of the government, when there is already this under-performance of our healthcare services at the ground level, where citizens’ health issues have yet to be optimized.

1. PRIVATE HEALTHCARE SECTOR

Private healthcare expansion began in earnest during the Mahathir premiership in the 1980s, where private hospital beds increased nearly 10-fold (from 1,171 to 10,405 between 1980 to 2003), and the private sector’s share of hospital beds increased from 3.9-5.8% to 23.4-26.7%.[1]^,[2]

The private sector has always attracted both general and family physicians who had opted out by opening individual clinics or by joining more established group practices; while specialists join the better-paying more personalised care practices in urban private medical centres. There has been a move to group more clinics together under single larger management entities; e.g. Qualitas Healthcare group which has been buying over clinics, with the purpose of consolidating, computerising, bulk purchasing, and bulk bargaining panel-negotiation goals. This group has been listed in the Singapore Stock Exchange at end 2008.

On average over the years depending on the economic circumstances, this private sector constitutes around 55% of all registered doctors, who look after some 25% of the population, most on a self-paying fee-for-service arrangement, and increasingly through some third party paying (e.g. health insurance) mechanisms.[3]

Since the end of last month however, with greater numbers of young graduates returning in the droves, this proportion has reversed. Now some 10,070 doctors are in private sector, while there are more than 25,862 doctors in the public sector i.e. Ministry of Health, MOH. There is concern that in the public sector, many of those in service tend to be younger, less skilled/experienced doctors, while many more experienced and senior doctors have left for the more lucrative private sector, usually looking after fewer and more select group of self-paying patients.

1.1 General Practitioner Clinics

Importantly nationwide, private clinics cater to most of the fee-for-service self-paying public, which include: private sector employees through panel doctor contract/insurance arrangement; thus relieving the already overloaded Ministry of Health’s public clinics.

In general, the citizens’ choice for such private clinic consultations and treatment is due to its easier access, simpler registration and appointment, and shorter waiting times. There is also possibly greater continuity of care with better personal attention from one’s own family physician or general practitioner—i.e. superior personal touches and closer encounters are the added values in private clinic visits, despite greater fees for consultation and medicines, which are frequently bundled together.

Some crossover of services however exists. Depending on patients’ demands or choices, these generally complement each other for the greater benefit of the patients concerned. Dissatisfaction or uncertainty with services from either sector has had on many occasions led to patients seeking second opinions and/or therapies from the opposite sector, and vice-versa.

Although there have been counter-accusations of poor and/or unprofessional care, or mismanagement issues, each sector does cater to the differing demands and expectations of the public. In economic terms there is some duplication of services, and possibly over-utilisation and wastage of resources, but patient choice is preserved as a right.

Thus, urban GP clinics provide easy care for common ailments and simple trauma/injury management, at very reasonable costs, especially for areas outside the main capital city—Kuala Lumpur-Klang Valley, and complement the public sector in helping alleviate the patient congestion on their severely overloaded outpatient clinics.

However, of late, with the mushrooming of many GP clinics in close proximity to one another, competition for patients has become keener, and many clinics are simply eking out a living, struggling to keep afloat, financially. Some have resorted to creative complementary alternative medicine or aesthetic/beauty health care models, to supplement or even revamp their practices. Still the MMA continues to receive complaints of there being too little work and income for a sizable number of clinics in larger urban locales.

This underutilisation of many urban clinics is wasteful. This problem of underutilisation could perhaps be explored as one mechanism to help out the overcrowded public sector outpatient clinics.

Redistributing public sector patients who sometimes have to wait several hours, to a panel of urban or suburban private clinics nearer their home, can be a real option for better patient care and attention. A payment mechanism can be worked out to address this purchasing of services, which will generate a win-win scenario for all concerned. However, logistics and bureaucratic red tape and registration exercises have made this approach of sharing of services impossible to carry out at the present moment. We understand that the Ministry of Health is looking into this potential public-private partnership to enhance the healthcare services to the public.

1.2 Private Medical Centres & Hospitals

For more serious illness and injuries, hospital care through well-equipped emergency departments (EDs) is now the expected practice. These medical emergencies are previously offered only at larger public sector general or district hospitals. These days however, most private medical centres boast of state-of-the-art emergency care at more luxurious settings and costs. Personal and more attentive specialist care are now demanded and offered at many of these private EDs, where many orthopaedic surgeons and neurosurgeons now practice privately.

However, private medical centres are not simply for emergency and/or trauma care. Most are now developed as competitive consumer-driven full-fledged healthcare facilities to cater for the more discerning public who would pay more to obtain perhaps better (perceptibly), more personalised, faster (less or no waiting time) and possibly more comfortable and/or luxurious medical care.

Health insurance or maintenance organisations have also bought into this system to offer more premium benefits to their clients, particularly those of the corporate world, where risk-averse and delay-averse market-driven results are expected. Executives and staff are offered contracted quicker and direct access to possibly more expert specialised care, with faster turnaround times and earlier return to work expectations.

Of late, the entry of different national and transnational capital flow into the private healthcare system has further developed the service capacities of this sector. Healthcare industry players such as the state-owned KPJ group (Johor State Development Board), Parkway Holdings (Singapore-based, American-invested), and latterly Khazanah National Berhad (a Ministry of Finance Malaysian GLC) have greatly influenced the direction and expansion of these private services, while at the same time inflating the cost of private health care services by offering more sophisticated amenities and newer technology-driven expert care.

Together with the Association of Private Hospitals (APHM), there has been a move to expand the services toward attracting foreign medical tourists, which is targeted to grow to 30% in 2008, and nearly 1 billion ringgit as of 2005.[4]

1.3 Purchasing Private/Corporate Sector Expertise

Migration of trained staff especially medical specialists to the private sector continues to bug the system. This then causes the expert service to stall, when the requisite expertise is lost. In critically short-staffed services such as neurosurgery, the public sector has to occasionally buy the services of private neurosurgeons to attend to their patients, especially during emergencies.

Currently, in Kota Kinabalu, Sabah, cardiology and cardiac surgical services are purchased with weekly rotations of specialists from the corporatized IJN, at hefty prices. Also being a corporatized medical centre, the IJN has been billing the government to take care of its public servants, pensioners and referrals from its MOH hospitals and clinics. This comes at a premium, with the government reimbursing some RM 31.3 to 144.5 million per year, from 1993 through 2004, respectively, for these services.[5] It is estimated that for 2008, the financial subsidy for IJN approached 250 million Ringgit.

However, because of higher wages and better work conditions/benefits, specialists at the IJN appear to have less rapid turnover (3% annually), and thus enjoy greater consistency and continuity of services.[6] This resource stability also makes continuing allied health care and specialist training possible, to enable it to maintain its reputation as a centre of excellence. But obviously this comes at a higher cost—perhaps this expenditure is more realistic in terms of healthcare economics. This successful model has now made it an object for takeover by a GLC, Sime Darby Bhd.²

So this model of public-private partnership appears to be successful and beneficial and attempts have been made to have it emulated. However, there have been serious misgivings about this concept of healthcare reform because of its wider socio-economic implications; the Coalition Against Health Care Privatisation has been most vocal against any development toward the passing of any extra cost to the public.[7]^,8,16

Poor planning and maintenance has led to infrastructure failures such as has been recently highlighted in KK’s Queen Elizabeth General Hospital, where an entire wing has been condemned, shutting down essential services such as intensive care and surgical operating units. This ad hoc approach has in the past few years, forced the urgent if expensive purchase of the former Sabah Medical Centre to be converted to the Likas’ Maternity Hospital. Now, there are plans to purchase the newer year-old 171-bed SMC at Luyang, to replace the condemned section of the main hospital in KK for the public![9]

1.4 Full Paying Patient

In 2005, another patient fee-paying system was introduced at certain premier public hospitals i.e. Full Paying Patient (FPP) scheme, where part of the fees were used for physicians’ reimbursement to supplement their income/allowance. Thus, this scheme provides those who are willing to pay more, quicker access and shorter waiting times for elective surgeries and other therapies. While this is one mechanism to recover some costs for the healthcare system, it is only a minor fraction of what the system truly costs. There has been great unhappiness that this will only encourage queue jumping from those who are well-to-do, and therefore penalise the poor and less-financially endowed, and consumer pressure groups have called for their abandonment.^15,16

Still, the sporadic but unending attrition of losing specialist to the private sector has long been the problem of the public healthcare sector, and staff and expertise retention is a perennial problem, which has yet to be resolved or tackled sensibly and judiciously. Some 300 doctors and 50 specialists leave the public sector annually.^7,[10],15

2. Private Healthcare Facilities and Services Act/Regulations

Currently, the Private Health Care Facilities and Services Act (PHCFSA)[11] and Regulations (PHCFSR)[12] have prodded the private sector to transform for the better, purportedly for safeguarding the safety of patients. But forced administrative micro-management, stiff fines and restrictions have angered many private medical practitioners.[13] Many are unhappy with the highhanded tone and manner of the regulations, inspections and implementation, which have been construed as trying to criminalise doctors.[14] At least one physician had been jailed for technical non-registration, and a few have been fined heavily because of technical breaches of these new regulations. Some clinics have been inspected with disdain and rudeness.[15]

3. HEALTHCARE SPENDING & ACCESS ISSUES²

Healthcare spending is still suboptimum in Malaysia, the government spending just 6.9% of its total expenditure on health care services (i.e. 2.2% of the GDP). However, the latest available data from the National Health Accounts have reflected a higher rate of spending for Malaysia as of 2007.

According to the National Health Accounts database (WHO website) Malaysia spends about 12.5 billion ringgit or 6.9% of its budgetary expenditure on healthcare as of 2007. For Malaysia, total health care expenditure in 2007 amounts to just around 4.4% of our GDP (with the public and private sector contributing 2.0% and 2.4% of the GDP respectively), but I foresee that this will have to grow to accommodate the rising demands from a more enlightened, more empowered population.[16]

In 2003, Malaysians spend just USD 374 in total (Purchasing Power Parity or international dollar rate) per person per year on healthcare expenditure, with the government contributing USD 218.⁵ In 2007, this has gone up to USD 591 per capita.^16,[17]

This compares with USD 1156 for Singapore, USD 260 for Thailand, USD 2244 for Japan, USD 1074 for South Korea, USD 2874 for Australia, USD 2389 for the United Kingdom and USD 5711 for the United States of America.⁵ As can be seen, although we pride ourselves as becoming more developed than many other nations around us, we have yet to emulate those with better and arguably more advanced healthcare services.

Out-of-pocket spending as a percentage of private expenditure on health takes up about 73-75% of the total costs, with some form of private prepaid plans (e.g. insurance) contributing 11.9 to 14.4% over the years from 1999 to 2007. Social security expenditure as a percentage of general government spending on health hovers around 0.8% only, mostly from requested withdrawals from the specific allowable account within the Employee Providence Fund savings (EPF).^5,16

3.1 Public Aversion to Paying More

Because of the ingrained norm of having to pay so little or not at all in public hospitals and clinics (which are almost totally subsidised), the Malaysian public does not feel that it has to budget for health or medical care, and this is reflected in many of our pensioners complaining of costly unplanned-for medical care. This is also reflected in our government’s paltry allocation of importance toward healthcare spending in our national budget.

There has been flip-flopping ambiguity from the MOH, as whether to allow market forces to dictate healthcare costs, but overall, there has been no public will to enact what could be unpopular.² Suggestions to end free treatment at public hospitals and highlighting that rising healthcare cost is too heavy a burden or political cost for the government, had not been too well-received by the citizens.[18]^,[19]

This strategy seemed to have disappeared following the recent electoral setbacks of the incumbent government. In a recent interview for internet media Malaysiakini, the new health minister Dato’ Sri Liow admitted that the public hospital services are heavily subsidised by the government: RM12.9 billion or 98% of the entire budget, while patients paid only 2%! But, Dato’ Sri Liow reiterated his views that government subsidies for patients utilising public healthcare facilities would continue (RM1 for outpatients clinic visits, RM5 for specialist clinic visits, and maximum RM50 for third-class ward hospitalisation costs), and pledged the populist view that such a quantum would continue, despite this being unchanged since the 1970s![20]

There is great expectation that the government of the day should not jeopardise this by instituting any mechanism, which can change this status quo—hence there is very little public or open debate on these issues.

3.2 Access Failure & Medical Assistance Fund

But concerns as to failures in access continue to pop up sporadically in the mass media.[21] Poorer patients have resorted to the mass media appealing for financial assistance to help defray medical costs, especially for some costly or tertiary specialist care—e.g. in one week alone in October 2007, there were at least 3 appeals for help.[22]^,[23],[24]

Thus, this has prompted some stopgap measures such as setting up a Medical Assistance Fund (MAF) of RM 25 million, by the Ministry of Health. However, this fund can only be utilised at public or quasi-governmental healthcare facilities, and appeals have to be vetted stringently to ensure need and priority, which had drawn sharp criticisms of this being too bureaucratic and slow, even unfair.[25] Yet another Emergency Fund (D’tik, an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara) has been set up. This fund of RM5 million, provides critically ill patients access to treatment within 24 to 72 hours, but is currently only available at Kuala Lumpur Hospital as its pilot medical facility to kick-start the programme.^8,26

Clearly, such setbacks and failure of access implied that the public healthcare sector needed a revamp to enhance its capacities. Providing such services at huge or near-total subsidy appears untenable and unsustainable, and still left gaps, which had to be filled by creation of some extra mechanism to expedite access (predominantly by offering extraneous funds and/or donations). Thus, this explains in some way the government’s overt encouragement for the private sector to flourish and develop, in order to cater to the more willing, discerning, paying citizens, and leaving the public sector to look after the less endowed.

3.3 Corporatisation / Privatisation Controversy

Earlier hints that the public sector health services should be restructured into a government-owned non-profit entity, made economic sense in its first offering. This ‘corporatisation’ model implied converting most of the larger public hospitals into operating as quasi-private entities. This would avoid creating a two-tier system, and would facilitate disbursement of funds when a single payer health insurance scheme was introduced.[26] At least that is what had been planned.

However, many are still quite in the dark as to when or if these would be enacted, and serious doubts and anxiety have been raised. This ambivalence is now quite understandable because earlier attempts to corporatize these public hospitals and facilities were scuttled after news leaks prompted severe backlashes from some consumer and pressure groups and opposition politicians.^{15,16,17,[27]}

4. Skim Insurans Kesihatan Kebangsaan (SIKK)

This brings us to the question of having a single payer system, which has been earlier mooted as the preferred system for encouraging or implementing universal access to health for all.⁷

The much-awaited National Healthcare Financing Scheme, now rebranded as the National Health Insurance Scheme (Skim Insurans Kesihatan Kebangsaan, or SIKK), appears to be a political deadweight. Following the formation of the new government, this has once again been deferred for fears of public disavowal and protests. Perhaps, there are just too many variables inherent in the Malaysian system, which renders such a scheme too politically incorrect, too inexpedient to implement.[28]^,[29],[30]

Interestingly, when it was raised earlier, the MOH tried to allay public fears by announcing that civil servants (which number 1.2 million people, including military and police personnel) and their dependants, 200,000 disabled persons, 435,000 pensioners, 250,000 hardcore poor and an unknown number of unemployed individuals, would be exempt from the SIKK. What is not clear is whether the government would pay the premiums for these people or that they will continue under the present system of healthcare. The latter option would defeat the purpose, because this would undermine the community-rated concept of the SIKK.¹⁵

Also considering the fact that only 1.2 million Malaysians pay any taxes, collection of such a mandatory ‘health tax’ would be a struggle and challenge. It has been calculated that based on an estimated 4.63 million families in Malaysia (25 million population, average family size 5.4), this sharing of the burden (RM13 billion as of 2003) would encumber each family household around RM2,808 per year or RM235 per month.¹⁵ Clearly, many would not be able to pay, because more than 58% of Malaysians earn less than RM2000 per month, per family; and paying more than 10% of the salary on healthcare premiums would be too high! Besides, the government would still have to cough up possibly billions of ringgit to sustain the shortfalls and other preventive health care measures. This scheme has been criticised and rejected by the Coalition Against Healthcare Privatisation, as putting the onus of premium paying on the lower- and middle-income private sector employees and citizens.^{15, 16}

So, forthe foreseeable future into the next 4-5 years at least, it is very unlikely that there will be any attempts to resurrect such a tendentious issue as a national health insurance mechanism. Our current system which has been described by Chee H. L.¹⁹ as segmented, polarising and eventually untenable, is therefore likely to be the status quo for the time being, and making this work better for our citizens should be the way forward, at least for the interim.

5. PARTNERSHIP: COLLABORATION VS. INTEGRATION OF SERVICES

The health minister Dato’ Liow has said that “Government and private sectors should work together. Because the doctors that we train are for the nation, irrespective of (whether they work for the) government or private. Doctors are serving the people. In Malaysia, 41 percent of our population go to private hospitals and clinics and 59 percent go to public health institutions. Therefore, the private sector is playing an important role to ease the burden and also the workload in government hospitals.”²⁶

It is heartening that the current health minister is enlightened and positive about this private sector contribution. Therefore, this is an opportune time to ensure that the mechanisms for better partnership between public and private healthcare sectors be forged to facilitate closer and more meaningful collaboration.

5.1 Is More Privatisation the Way Forward?

One way to further this is by privatising more of the public healthcare facilities, but this is fraught with uncertainties, although such exercises might make administrative and economic sense and offer greater balance sheet accountability. One inevitable problem will be the almost inescapable escalation of the cost of services to ‘real’ terms, with progressively less subsidies. The poor unfortunately, could be left out of the loop with uncertain safety nets to cushion their plight.

The recent suggestion by Sime Darby Healthcare to acquire a stake in IJN (now a corporatized entity 99.99% owned by the Ministry of Finance) has already brought a swift and negative dissident response from a newspaper editor.[xxxi] Gunasegaram P. has stated his dismay that “for large sections of the Malaysian public, the very idea of privatising IJN is shocking because charges will rise to astronomical levels.” He questioned whether there is any net benefit to the public or government, and that if there were any reasonable doubt, this privatisation should not be undertaken. He alluded to past experiences that previous privatisation exercise of other services had not brought down costs for the public or government. He concluded that “(t)here are some things that should not be up for sale at any price. Affordable health care for the general public is one of them.”[32]

In another article in The Edge Daily, it was reported that the health minister and his ministry is not too happy with this divestment, either.[33] However, the Prime Minster and his deputy appears to have already endorsed the plan, just cautioning the GLC against forgetting its social responsibility to the poor, and they seem to imply that this exercise would allow the private healthcare sector to grow even more.[34]

Latest reports suggest that this takeover bid by Sime Darby has been deferred indefinitely due to public outcry, and possible political fallout.[35]^,[36] The former Health Minister Datuk Seri Chua Soi Lek has also condemned this sell-off bid, which he said has put paid the good will of the government, despite it costing the government just a ‘paltry’ RM 200 million a year (about 2.5% of the national health budget) to run the IJN.[37] Thus, there is this incessant tussle for public need/good versus free-trade market-driven practices from administrative or financial/budgetary realities points of view.

5.2 ‘Rentier Capital’ Divestment Concerns

There are of course, also worries about ‘rentier capital’ economics where state assets are divested to politically well-connected private entities through a system of political patronage, perpetuating mutual dependence between the business elite and the political rulers, i.e. the ‘crony capitalist’ model that supervenes the true nature of this form of take-over. Most economists believe that this form of rentier capitalist model unfairly enriches these business elites at the expense of costlier services and goods to the public at large, and is therefore, wasteful and counterintuitive toward better productivity.[38]

5.3 Toward a More Efficient System

In his book on ‘Good and Bad Power’, Geoff Mulgan (a British political scientist) discusses that while most governments provide the structure, it is the more comprehensive, well thought-of infrastructure provisions that lead to transformative services—that “much of the recent thinking about service… has adopted models from the private sector… largely drawn on industrial… models favouring speed, standardization, flow and efficiency.” He went on to describe: “(t)hese services are human, immediate, personalized and rich in communication, anticipating need rather than just meeting it and ‘going the extra step.’ In the case of therapeutic services the servant’s job is to change the master, to make him healthier, fitter, and happier.”[39]

In a paper on the Singapore model of public-private partnership, Dr MK Lim identifies 3 key questions which should be answered: (a) how to raise revenues to pay for health care; (b) how to pool risks and resources; and (c) how to organise and deliver health care in the most efficient and cost-effective manner.

It is clear that there is no foolproof system anywhere on the globe. Some of the more successful models involve a mix of safety nets with monitored privatization/corporatization of services and allowing ‘coopetition’ (competition and cooperation) to thrive.[40] He further argues that “even in Europe, the sustainability of health care systems founded on egalitarian welfarism is increasingly being challenged as growth in demand outstrips supply. The debate is no longer about ‘who should pay?’ or ‘who should provide?’ but ‘who can do the job more efficiently?’”

5.4 Fine-Tuning Private-Public Partnership/Collaboration

Thus, as our two-tiered system is now so well entrenched, we should find ways and means to ensure that it works better and more efficiently, where we can synergise our efforts to provide good quality, safe, and cost-effective healthcare for our patients. However, this must not only be affordable but also be self-funding and self-sufficient.

Where too much bureaucracy bogs down the better productivity and efficiency, these should be dismantled and restructured in ways that encourage best practices, and which empowers and benefits the patient ultimately.

Practice issues such as difficulty in cross-referring patients between private and public sectors should be eliminated; data and medical information portability and sharing should be facilitated and unified. Where there is excess of amenities on either side, these should be shared with crossovers of public to private sector and vice-versa. Conversely, more cross-purchases of services should be facilitated where there are shortages. Arbitrary turf protectionist methods to deny either patient or physician access to information or services of either sector should be removed.

Information exchange can be made more efficient through the use of a unified system of health information portability mechanisms, e.g. MyKad or some other central access information systems, while safeguarding and ensuring patient confidentiality and privacy.

Full integration of private-public healthcare sectors appears unlikely, but better partnership and collaboration of services can be aspired to, where the best of each system can be harnessed for the healthcare betterment of our citizens. We should aim for a more cost-effective system, although not necessarily a lower cost one. A single or easily portable system of reimbursement should also be considered.

While corporatisation/privatisation is still much feared, as a model of divesting central control of unavoidable rising costs and developmental constraints, this might be the way to go, if the model for market-driven healthcare is adopted. This is the model practiced by Singapore, with its well-tried and tested schemes that can be tweaked to respond to the many diverse facets of healthcare peculiarities.⁴⁰ Or conversely, a single-payer (and/or single insurance) National Health Service mechanism could be introduced, learning from the examples of say, Taiwan, Canada or the UK.[41],[42]

Whatever the decision, the government must make greater efforts to engage and explain to the public the policy directions that it wants the country to advance with regards healthcare services. This is especially urgent because by 2010, when trade and services liberalisation is set to take place in ASEAN (Association of South East Asian Nations), with the roll-out of the AFTA/WTO (ASEAN Free Trade Area/World Trade Organisation) agreements, there will be other considerations of foreign participation and entry into this economically important sector.

References

[1] Ministry of Health (MOH) (various years). Annual report.

[2] Ministry of Health (MOH) (2003, 2004). Indicators for monitoring and evaluation of strategy for health for all.

[3] Chee H. L. Ownership, control, and contention: Challenge for the future of healthcare in Malaysia. Social Science & Medicine (2008); 66: 2145-2156.

[4] APHM (Association of Private Hospitals Malaysia) website (2007), Available from: http://www.hospitals-malaysia.org/index.cfm (Accessed 13.12.08)

[5] Chua SL. Speech by YB Dato Dr. Chua Soi Lek, Minister of Health Malaysia, At The Annual Scientific Meeting 2005 of the National Heart Association, Hotel Hilton, Kuala Lumpur, 15 April 2005. Text obtained from <www.moh.gov.my/MohPortal/DownloadServlet?id=413&type=2> (Accessed 15.12.2008)

[6] IJN doctors: Don’t make us scapegoats. The Star online. 19 December 2008. (Accessed 19 December 2008) <http://thestar.com.my/news/story.asp?file=/2008/12/19/nation/20081219151718&sec=nation>

[7] Quek D.K.L. Imminent Corporatization of Public Health – Causes for Concern. Editorial. MMA News, 1999; Vol. 29 (May): pg7. Accessed on 15.12.2008 at

[8] Subramaniam Pillay. (for Coalition Against Health Care Privatisation) Can we afford to fall sick?

Aliran Monthly Vol. 25 (2005): Issue 4 <http://www.aliran.com/oldsite/monthly/2005a/4e.html> (Accessed 15.12.2008 )

[9] Joe Fernandez. Politicians ticked off over KK hospital woes. <http://www.malaysiakini.com/news/103275> (accessed 28.04.09)

[10] Citizens’ Health Manifesto for Malaysians. (Accessed 15.12.2008) <http://prn.usm.my/chi/main.html>

[11] Private Health Care Facilities and Services Act 1998 (Act 586). PCNB, Malaysia, 1998.

[xii] Private Health Care Facilities and Services Regulations 2006 (P.U. (A) 137/2006). PCNB, Malaysia, 2006.

[13] Quek D. K. L. Regulations now Enforceable—Cui Bono? (Who Benefits?). MMA News, 2006 (June), Vol. 36 (6):pg7.

[14] Quek D. K. L. Physicians under Siege: Sensing the Pulse of Doctors… MMA News, 2007 (Feb) Vol. 37 (2):pg7.

[15] Ong H. T. Private Healthcare Facilities and Services Act. (Letters to Editor). MMA News, 2008 (Oct) Vol. 38 (9):pg23.

[16] National Health Accounts, Malaysia, WHO Country information. http://www.who.int/nha/country/mys/en/ (accessed 4 June 2009)

[17] World Health Statistics 2008, World Health Organisation, France, 2008

[18] Paying more for healthcare: rising cost a heavy burden on government. The New Straits Times, 16 December 2004.

[19] Free treatment at public hospitals to end next year. The New Straits Times, 26 April 2005.

[20] Ong A. Private and public health can grow in tandem. Malaysiakini June 28, 2008. (Accessed 17 Dec 2008) <http://www.malaysiakini.com/news/85221>

[21] Mazlinda Mahmood. Affordable reproductive health services for the poor, The New Straits Times, Saturday, 27 October 2007, p N24.

[22] Little Kin Wai hopes to walk tall—He needs funds to help him grow, The Star, Saturday, 20 October, 2007, p N18.

[23] Single mum needs aid for kidney transplant in China, The Star, Friday 19 October 2007, p N26

[24] In need of aid to treat his burns, The New Straits Times, Monday, 22 October 2007, p N17

[25] Annie Freeda Cruez, Poor can apply to medical fund. The New Straits Times 17 Oct 2007.

[26] Ministry of Health (MOH) 2003. Malaysia’s health 2003: technical report of the director-general of health Malaysia 2003. Kuala Lumpur: Ministry of Health (pg 44-57)

[27] Jeyakumar Devaraj, Health Is Not A Commodity, Parti Sosialis Malaysia Press Statement: 8 June 2007.

[28] Authority for universal coverage could be set up this year—national health finance plan ready. The Sun, 4 March 2001.

[29] National healthcare not an insurance scheme: Chua. Sun2Surf, 15 April 2005.

[30] Skim insurans ganti penjagaan kesihatan: SIKK (Skim Insurans Kesihatan Kebangsaan) dua tahun lagi. Utusan Malaysia, 2 April 2005.

[31] Law K. C. Sime Darby seeks stake in IJN. The Star, Thursday, 18 December 2008; pgB1-B2.

[32] Gunasegaram P. Don’t privatise the National Heart Institute. The Star, Thursday, 18 December 2008; pgB2.

[33] Lim S-L. Sime Darby eyes IJN. The Edge Daily, 17 December 2008 (Accessed 18.12.2008) <http://www.theedgedaily.com/cms/content.jsp?id=com.tms.cms.article.Article_42e08286-cb73c03a-53897400-82ddada1>

[34] Teoh S. Najib: Sime Darby must commit to poor in takeover of IJN. The Malaysian Insider, 18 Dec 2008. <http://www.themalaysianinsider.com/index.php/business/14417-najib-sime-darby-must-commit-to-poor-in-takeover-of-ijn> (Accessed 18.12.2008)

[35] Cabinet hits pause button on IJN Sale. Malaysiakini, 19 December 2008. http://www.malaysiakini.com/news/95152 (Accessed 19 December 2008)

[36] Choo C.M. & Chong D. Cabinet all but kills Sime Darby’s bid for IJN. The Malaysian Insider, 19 December 2008. http://www.themalaysianinsider.com/index.php/malaysia/14503-cabinet-all-but-kills-sime-darbys-bid-for-ijn (Accessed 19 December 2008)

[37] Chua S. L. IJN Dollars and Cents.

<http://drchua9.blogspot.com/2008/12/ijn-dollars-and-cents.html> (Accessed 30 December 2008.)

[38] Jomo K.S. and Gomez E.T. (2000) The Malaysian development dilemma. In M.H. Khan, & K.S. Jomo (Eds.), Rents, rent-seeking and economic development: theory and evidence in Asia. Cambridge; Cambridge University Press.

[39] Geoff Mulgan. Civic Commitment (chapter 12). In Good and Bad Power: The ideals and betrayals of government. (2006), London, Penguin Books (pg 226-251).

[40]Lim MK. Transforming Singapore health care: public-private partnership. Ann Acad Med Singapore 2005; 34:461-7

[41] Susanne Grosse-Tebbe and Josep Figueras.(eds.)Snapshots of health systems in 16 countries. WHO, 2004. (Accessed 15 December 2008.)

[42] Physicians for a National Health Program. International Health systems. PNHP, 2008. <http://www.pnhp.org/facts/international_health_systems.php?> (Accessed 15 December 2008.)

-------------ooooooooo0000000000oooooooo------------------

Poetic Licence: “Another Kind of Magic”

2009-05-23T02:35:00.000-07:00

A Critique of "Poems by Dr Ng Kian Seng"

I must first confess that I am neither a literary critic, nor a poet. But I love reading, writing, passionate causes and sensitive literature, which have I believed, coloured my approach to life.

My first contact with Kian Seng was when he first submitted some of his poems to the MMA News (Berita MMA) for publication. I remembered that this was almost 12-13 years ago, when this little known physician from a small town in Kluang, Johor, would submit these pithy if esoteric verses that verge on religiosity and perhaps a dash of erudition, so long forgotten in this era of byte-size throw-away ephemeral simplicity.

Since then, I have learnt that Kian Seng is indeed a phenomenon in his own style and panache. He has published his verses widely in more than 52 publications; indeed he gained a PhD for his work linking poetry, aesthetics to Christian themes. His poems have filled 3 previous books of verses. Another Kind of Magic is his fourth.

He is an accomplished batik water-colorist, as well as a lay-pastor, besides being an Internist Physician. His literary works including some short stories, have won several prizes nationally and globally, and his website alwaysmorebeyond.blogspot.com carries a treasure trove of collections of his works, which showcase the breadth and depth of his talents.

I remembered arguing with my editorial board members then, that we had to publish these poems because, if for nothing else, they appeared to impinge upon my untutored mind as extraordinary pieces of creativity, which touched my heart, and penetrated my cloistered senses. I have always believed that the practice of medicine must encompass more of the humanities, i.e. the greater gentler Art to temper the stone-cold Science of dispassion.

We started tentatively, but soon, I believe, Kian Seng’s poetical influence began to ignite others, other doctors to create their own, if less polished endeavours. Thus, began our foray into the literary world of single column poems and verses. Dr Ng Kian Seng is one of that rare breed of physicians, whose artistic talent and sensibility beacons sweep stroboscopic swathes of spotlights on our otherwise hidden perceptional recesses, igniting our hitherto hibernating sensitivities. Perhaps, these might have helped make us that little bit more human!

In the increasingly senseless, humdrum lives of physicians, Kian Seng has used his considerable creativity to prod and hone the subtle sensitivity of others less endowed. His cerebral if picturesque imageries exude a sensuousness, which mirrors some of our longings, our unspoken if déjà vu glimpses that elude the more mundane amongst us.

With considerable ease, his carefully crafted style snatches and melds together contrasting snapshots from medical, biblical, Homeric and even contemporary (David Blaine, Dan Brown, Leslie Cheung!) templates, as well as from gleanings of a wide array of poets and renowned literati.

Underlying the poetic licence of juxtaposed thought-provoking contradictions, I perceive a tugging of irrational belief, of faith leaping off the ‘magical’, the inexplicable, even as we choose to be scientistic, in a world where popular agnosticism is widespread among many nowadays.

Yet, I believe that the underpinning Christian faith of Kian Seng effortlessly merges well-read erudition with insightful sagacious interpretations, making sense of the otherwise senseless…

Using metaphors from common day-to-day examples, even historic ones, Kian Seng manages to weave together ‘haiku’-like stanzas of unique expressions of hope/despair and contrapuntal puzzlement. Consider “Lights, Lamps & Leaping Flames” where in the 3rd piece The Unhallowed Ground: “There are no bushfires / in New York, only Twin Towering / fires and religion the unhallowed / ground on which terrorist boots / stomped.” The horror of 9/11 is quizzically remembered, juxtaposing bushfire passion with religious intolerance, hence terrorism.

Yet underlying it all, one senses the religiosity and his Christian roots bursting through: “Is it not the still / small voice that Elijah heard?” and “Shall it be then, my hand / upon yours, my finger writing / on your palm, wordlessly, the single / resolute Word Who will say / what I feel and feel what / I say?"

In Another Kind of Magician, he subdivides his thoughts into the biblical Genesis of 7 days: Beginning, Musing, Seeing, Praising, Mirroring, Meaning, Resting. When he thinks aloud on Infinity within the section on Mirroring, his God-guided logic emerges: “When my gaze / is not on myself, I see / in parallel mirrors my reflections / creating an image of God. / This then is poetry / where the law of physics / is multiplied infinitely.” There is thus, much to absorb, to muse ourselves, to enjoy in the occasionally quixotic and the sacred.

In The Final Diagnosis, medical themes stretch from musings of madness, schizophrenia, Parkinsonism and dementia, to suicide, drug addiction, patient woes, to headaches and healing. These exploit the urgent and the cryptic breadth of medicine’s less than clear-cut diagnoses, their unfamiliar less-explored nuances, from the vantage points not just of the patient’s but clearly too, of the physician’s.

For the uninitiated however, some of these medicalese or jargon may be less accessible, but the emotions attendant to the evoked verses still ring true with vivid colors of uncommon understanding and penetrating perceptiveness. An example of ironic contrapuntal realities blending disease with emotion is seen in the following: “But the pain is the greater / cancer, it spreads not into adjacent / organs but metastasizes by jumping / across chasms, from body to mind, / the secondaries in the psyche / causing the greater distress.”

In “God does hear your cries of pain…” you can almost feel and sense the pulse of the hospital setting: “Do you not hear them too? / The sigh of a hospital-pale / bouquet as it sheds tears / of petals. The high strung / weeping of morphine as it travels / a plastic route from bottle / to body. The sobbing of the cardiac / monitor as the screen numbers / the minutes of a fluttering / heart. The groans of the trolley / wheeling in the many last / suppers………………………”

Thus, doctors interested in the offbeat literary aspect of medicine, would do well to read and digest the sensibilities of these ailments behind the façade of pure doctor-patient encounter and the accustomed cold comfort of case-diagnosis compartmentalization and barriers, which physicians are so prone to erect, and shield themselves…

Perhaps our more human, humane side would be better served, by being prodded on to contemplate on some of the themes so magically put together by Kian Seng.

Another Kind of Magic is worth many moments of musing and contemplation, to realize or to reignite our passion, our vocation, our common humanity and perhaps to experience the God-centred inspirations of a fine doctor steeped in the tradition of the Arts and indeed the Humanities!

Dr David KL Quek,
Kuala Lumpur, May 2009

A Book Review: “MEDICAL ETHICS, ETIQUETTE AND LAW”

2009-05-15T08:54:00.000-07:00

A Book Review:
“MEDICAL ETHICS, ETIQUETTE AND LAW”
written by Dato Dr Abdul Hamid Abdul Kadir

This book “Medical Ethics, Etiquette and Law”[1] appears at first glance to be a primer for the medical student and graduate, but perhaps, may be appropriate even for the doctor who wishes to refresh and renew his/her basics in medical professionalism.

It harks back to the times of good ‘old-fashioned’ clinical teaching—perhaps, as a judicious reminder of a lost art. In our rush to produce annually, the thousands of doctors from our medical colleges, many are now feeling that the art of practicing medicine has been lost in the translation. With rising numbers, come increasing complaints and criticisms about unprepared, uncouth even unethical, uncaring, stressed-out medical graduates. [2]

Some academicians and senior consultants have decried that medical ethics and professional etiquette seemed to have taken a backseat in our modern day medical teaching institutions. [3] Even more remote from the minds of many graduating doctors is the proper understanding about the ethical moorings and legal aspects of modern medical practice.

It seems we are constantly enthralled and overwhelmed by the stupendous enormity of scientific advances and factual knowledge. We enthuse excitedly about newfangled ideas and theories, and dabble in many less-than-evidence-based therapies.[2] Yet, we frequently neglect or pass over what truly matters—the clinical encounter with our patients.

In our mundane day-to-day clinical encounters we often pay too little attention, and sometimes unwittingly short-shrift our patients with our callous disregard, or unintended inattention. In some instances this lack of communication or miscommunication has resulted in untoward responses which contribute to so much angst and chagrin to those involved. [4]

We are sometimes baffled by the competing demands of apposite medical practices, personal biases, moral hazard (i.e. conflict of interest decision making) and the pervasive market-driven consumerism, so much so that we have subsumed our nobler instincts, and have lost our humane compassionate touch. Professor Bernard Lown, Nobel Peace laureate and outstanding cardiologist, has described this in an aptly titled book “The Lost Art of Healing.” [5]

The author Dato Dr Abdul Hamid has been an exemplary medical professional par excellence. He cuts a distinguished career spanning more than 40 years, with stints in the Malaysian Military as a full Colonel, when he was seconded to Universiti Kebangsaan Malaysia as department head and professor of orthopedic surgery until retirement, when he then ventured into private practice.

Dr Abdul Hamid has spent significant portions of his entire professional life fully aware of the niceties and the challenges of clinical medical practice, medical ethics and professionalism, as these evolve through the decades.

But it is by being fully engaged in the profession, its regulations and laws, that Dr Hamid has excelled himself; and this shows out prominently in his writing, and in this book.

Perhaps, the disciplined military experience and mindset has influenced the way Dr Hamid views the practice of medicine. Perhaps, that is why those who know Dr Hamid can attest to his very austere demeanour and his almost unshakable strength of character as well as his sometimes seemingly immovable observance to strict interpretation of ethics—the near-inflexible interpretation of right and wrong with scant leeway for errors of judgement.

But perhaps, this is how morals, ethics and etiquette should be perceived and practiced, as we march along in our contemporary universe of increasing moral relativism! Perhaps, our varying shades of grey in viewing through too many relativistic lenses have become too distorted from the newfound gravitational pulls of too many pseudo-viewpoints. [6]

Thus, we have become inured into subconsciously respecting too many false values and rights. Many are tempted to tread expedient rather than rightful paths. Ultimately our greying vision reflects the murky lack of courage to defend greater universal values. Should all traditional values and practices give way to modernistic ‘politically-correct’ interpretations just to stay current and fashionable? [7] Many would argue otherwise, and Dr Hamid has not shied away from saying so.

However, this is not to say that Dr Hamid is self-righteous, but that Dr Hamid has been consistently and morally courageous to stay his conscience. Dr Hamid is an unapologetic champion toward a very rightful approach to life and living—an approach most of us would be too timorous or find too challenging to adhere to, every time. Indeed, these very exacting tenets of living as a principled medical practitioner can be very hard acts to follow. [8]

Yet, there are poignant moments when his humane leniency shine through with a penetrating understanding of human nature that can only come from involved experience. I believe it is this luminous passion of Dr Hamid that makes him want to share his vision of what should still remain a core part of the medical profession—good solid values of medical ethics and etiquette, well-buttressed by a confident knowledge of legal boundaries!

Be that as it may, Dr Hamid has been the singular professional moral compass to which many peers now look up to for guidance. Perhaps that would explain how as a medical professional, Dr Hamid has been elected by his peers over the past 20-odd years to the MMC—a regulatory authority to safeguard and guide doctors on how they should ethically interact with their patients, with compassion, propriety and safety.

Since 1983, Dr Hamid has been involved with the Malaysian Medical Council, without a break—a truly remarkable achievement and a professional continuity of some 25 years. This places him in an enviable position to experience, witness, influence, as well as to perhaps, help bring about the changes and development of good clinical practice and medical ethics standards through almost a generation. [9]

Indeed, such is his moral authority that he has been appointed to chair the MMC ethics committee, as well as to other respected expert committees to oversee and arbitrate on many professional issues.

But Dr Hamid’s experience is not parochially wrought in a vacuum, but from real clinical practice out there, from the converging standpoints of a practicing doctor, a teacher and a long-serving regulator. In the interim, Dr Hamid had been presidents of the MMA, ASPMP and Council member of the Academy of Medicine, and thus he understands the multifarious leanings of different professional medical groups and vested interests.

Notwithstanding these dissimilar tuggings of disparate interest groups, this wealth of experience has not diluted the fervour of his enthusiasm to maintain that some things cannot be changed just because of the whims of time, caprice and fashion.

For Dr Hamid, and I believe, for a growing number of us mere mortals, medical ethics and professionalism remains the bulwark through which the medical profession must find some anchorage. Most relevantly his avid espousal of very strict adherence to strong moral and ethical standards has always put him at the forefront of professional issues which affect the doctor.

With his almost encyclopaedic knowledge of the Medical Act and its regulations and his uncanny ability to parse through difficult texts and legalese, Dr Hamid has always been approached to distil for many groups in the medical profession, the simple interpretation of basics from the abstruse intricacies of confusing laws and regulations. [10]

Dr Hamid is thus, keenly aware that medical professionalism, ethics and standards can and should be disseminated, taught and inculcated as widely as possible. Hence, I believe the gestation and fruition of this book (over several thought-provoking years!) for the medical profession—one that should guide doctors in an authoritative yet easily digestible manner.

This 138-page book is a crisp and succinct exhortation to the clinician—whether a budding house officer or a seasoned practitioner—to be more humane and compassionate. Above all the doctor is taken on a ride through many solicitous snippets and nuggets of practical issues which he or she can encounter in daily clinical work.

Clear thoughtful discussions abound in the pages, on how to take a good history, perform a thorough physical examination, while paying close attention to patients’ anxieties and sensitivities. Communication skills are woven comprehensively into a story-like discourse, to help the doctor avoid medico-ethical challenges and/or medicolegal suits.

Discussions on how much information to disclose, how to take comprehensive notes and make accurate records, how to transfer care, debating on the need to refer especially when our individual professional skills are limited, how to avoid pitfalls of consent taking, and what to do when adverse unexpected events occur, are discussed sensitively, with attention on how to avoid or lessen their impact.

The how and the need to write appropriately-detailed medical notes and legible prescriptions, record keeping, patient confidentiality is also well-detailed. Proper above-board patient-doctor relationships, careful attention to the use of chaperone, are also exhorted so as to forestall accusations of impropriety.

Cordial relationships and professional courtesies with colleagues are also encouraged with particular attention to avoid criticising (even if inadvertently) a fellow practitioner, as these often form the nidus for complaints and dissatisfaction by patients.

Report writing, practice issues, information dissemination, and pertinent ethics issues such as sick certification, locum tenens employment, non-therapeutic abortions, clinical trials and research issues are also briefly touched upon.

The latter part of the book discusses negligence, disciplinary matters and the various medical acts including registration and licensing issues, medicolegal issues (briefly shifting from the Bolam test to the Bolitho modification and latterly to the Rogers vs Whitaker standard) and the role and duties of the MMC.[10]

The last 16 pages are devoted to the Oaths taken by the various medical schools as well as summaries on some international medical codes such as: the declaration of Tokyo against medical involvement in torture; Nuremberg code and principles for wartime conduct for doctors; the Helsinki and Oslo declarations on biomedical research and abortion issues.

Together these overarching themes serve to bolster the ethical framework from which our medical profession anchors. This book represents a lucid extension of the MMC’s ‘Good Clinical Practice’ guidelines—which every medical practitioner should familiarize him/herself with—and, which is readily available from the MMC. [11]

Is this book useful? Definitely. The short but subtitled topics make for easy references. Therefore, if a practitioner wishes to check on a particular aspect of medical practice for which he is unsure as to the etiquette or proper ethics, this can easily be located and read on its own.

Thus, on a doctor’s book shelf, this can be a ready guide for day-to-day clinical reminders and reference, to be quickly retrieved by topics or by chapters.

Of course, it would be good to give this book a complete read once over—I did, and it took just over three thoughtful hours. But these are hours of refreshing reminiscences of how the best of caring, compassionate and ethically guided medical practice can be carried out—great practical tips and pointers on finding a greater balance of what is good and heartening in medicine.

Are there any deficiencies? Not really, because this book does not pretend to be a comprehensive treatise on all things ethical and legal—thus, its references and index are relatively sparse. It should thus serve as an excellent primer, except for the academically-inclined, for whom this might be a drawback. But it is a highly accessible book which distils all the practical wisdom from decades of clinical and regulatory experience, and deeply ingrained moral confidence.

The etiquette aspects so seamlessly embedded within the text may be a personal statement on what feels or sounds right within the context of an ethnically-plural society like ours. In some areas it is possible to disagree with the recommendations, which may bias toward more caution and rectitude than contemporary universally-accepted practices.

However, norms of etiquette are often societally determined, and would vary any way from society to society, country to country even. Be that as it may, as a safeguard against misunderstanding or breaching sensitivities, these exhortations on proper etiquette would, on balance, be considered prudent and ‘right’ in our Malaysian context.[11]

I would have preferred more anecdotes and practical discussions on hypothetical or learning cases which can then highlight the ethical and practice dilemmas a little bit more cogently and concretely. But this might in turn make the book a lot less readable and more unwieldy. Those who want a more academic and legalistic approach in this genre should consider the recently published “Medicine, Patients and the Law” (Penguin Books, 3rd edition, 2003, 560pp) by Law Professor Margaret Brazier of Manchester University.[12]

Finally, Dr Hamid’s book is current, authoritative and comprehensive enough to be read by all, not just once but even again and again, as it serves to remind us of so many experiential clinical issues which have been so fluidly woven into the fabric of this short treatise. I would wholeheartedly recommend that this book be read as a timely refresher by all medical practitioners, and perhaps also by those who aspire to join our ranks—the medical students.

For the lay person, this book may help to empower the would-be patient to know how and what a doctor can and maybe should practice medicine, perhaps as good as it gets. He or she might also better understand that the intricacies of medicine can be more complex than his/her accustomed expectations. [13]

Perhaps the would-be patient can even better recognize how intricate the medical encounter can be, but also increase his/her knowledge as to what his/her responsibilities and rights are. I believe knowledge always empowers, thus both parties can benefit enormously.

What about this book for the legal professional interested in Medical Law? This might be more difficult as the scope of legal details discussed in this book is rather limited. However, the interested lawyer can perhaps come to a greater grasp as to the multifaceted aspects of the medical encounter and its inherent complexities.

Perhaps, reading this book might also help them understand that litigious challenge is not always the best approach to address every patient-doctor conflict or contention of unfair, incompetent, unethical or negligent practice.

This book might reasonably raise the bar of ethical medical practice as well as help reduce the risk of medico-legal complaints for the modern doctor. Thus, this book can only succeed.

Reviewed by
Dr David KL Quek, FRCP FAMM FACC
28 Feb 2008

References:
1. Abdul Hamid Abdul Kadir. Medical Ethics, Etiquette and Law. University of Malaya Press, Kuala Lumpur, 2008
2. Merican MI. Is Medical Ethics and Professionalism at the Crossroads? Berita Academi, Dec 2007, pp3-7.
3. Quek DKL. Commercialisation in Medical Education—Where do Ethics come in? Paper presented at the Academy of Medicine of Malaysia National Ethics Seminar, December 1, 2007, at IHM, Bangsar, Kuala Lumpur.
4. Quek DKL. Is the Hippocratic Tradition still Relevant in Today’s Medical Practice? Berita MMA, Jan 1999, pp7-8
5. Lown B. The Lost Art of Healing. Ballantine Books, New York, 1999
6. Quek DKL. Ethical Concerns for Challenging Times. Berita MMA, May 1998, pp7-9
7. Pellegrino E. Doctors and Ethics, Morals and Manuals. Ann Intern Med 1998; 128:569-71
8. Rebecca Rosen, Steve Dewar. On Being A Doctor: Redefining medical professionalism for better patient care. King’s Fund, London, 2004
9. Abdul Hamid Abdul Kadir (Editor-Chair of Ethics Committee) Malaysian Medical Council. Guidelines of the Malaysian Medical Council, MMC-MOH, 2006
10. Abdul Hamid Abdul Kadir. Implications of Judicial Decisions on Medical Practice. Paper presented at ASPMP Medico-Legal Seminar, Pantai Medical Centre, Bangsar, Kuala Lumpur, April 1, 2007
11. Malaysian Medical Council. Good Medical Practice, Malaysia, 2001
12. Brazier M. Medicine, Patients and the Law. 3rd edition. Penguin Books, London, 2003
13. Puteri Nemie Jahn Kassim. Medical Negligence Law in Malaysia. International Law Book Services. Kuala Lumpur, 2003

Malaise in Malaysian Health Care Services Development & Procurement

2009-03-30T05:45:00.000-07:00

Anti-Corruption Summit: Zero Tolerance for Corruption
30-31, March 2009, Sime Darby Convention Centre, Bukit Kiara, KL

Dr David KL Quek, drquek@gmail.com
Hon. Gen. Secretary, Physicians for Peace & Social Responsibility (PPSR),
President-elect, Malaysian Medial Association (MMA)

Healthcare Development in Malaysia while laudable is still Suboptimal
The right to health is increasingly seen as an inclusive human right, which includes safe drinking water, adequate sanitation, food, nutrition, housing, healthy working conditions, education, information and gender equality.

Thus, this right encompasses certain freedoms as well as entitlements, such as the right to choose non-consensual medical treatment, freedom from torture or other inhuman cruel or degrading treatment or punishment; as well as the right to health protection with equal opportunity to attain the highest possible level of health. This includes the right to prevention, control and treatment of disease and access to essential medicines, maternal, child and reproductive health, at reasonable and affordable costs.

In many respects, Malaysia has done relatively well in ensuring that most Malaysians have fairly decent access to some form of basic as well as some excellent tertiary level health care. However, quality access is still sporadic and not enjoyed by every single citizen. Malaysia is still not a nation that professes to offer universal access to health care for all its citizens.

Malaysia spends just around RM13 billion on health care per year, as of 2006. This amounts to 3.8% of the GDP, with the government (public sector) contributing some 2.2%, and the private sector the other 1.6%. In terms of the national budget expenditure however, this amounts to 6.9%. This expenditure of just 3.8% is significantly below the recommendations of W.H.O., which has advocated an allocation of around 8% of the GDP for sustainable and accessible health care for all.

Opaque Mechanisms of Procurement/Divestment Processes
In Malaysia, many local and international economists (such as Jagdish N. Bhagwati , K. S. Jomo , Edmund T. Gomez , Rajah Rasiah , Ismail Md. Salleh ) have pointedly raised concerns that many developing nations’ government procurement practices, divestment of state interests, assets or services had been opaque and should be made more transparent to improve cost-efficiency and benefits. For example, many instances on the planning, procurement, development, divestment and allocation of public services and infrastructure, are troubling and obscure.

There is that lack of transparency in awarding of contracts, and the seeming arbitrary dispersal of public services to preferred parties, dependent on whom one knows, on who are politically- or personally-connected, or who are in the ‘official’ loop of often closely guarded ‘secret’ negotiations or plans. Therefore, these are parceled out to many intermediary or third parties (concessionaires), without the necessary open tenders to vet the cost-benefits or expertise to carry out these services to the best of their capabilities. In short, we are not getting the “best bang for the buck”, so to speak.

These privileged concessionaires then enjoy protected monopolies for decades, ensuring circumscribed profits, which no other private company can ever hope to attain. Worse, these are made with guarantees of subsidies by the government or its agencies should there be shortfalls in expectations of lowered profits or losses. It appears that this system of favoured patronage (more often along political and possibly business connections) exists for many of these allocations and options, and appears to be fully ensconced in the Malaysian landscape.

I will discuss some of the more publicly known examples in the health care service, which serve as worrisome opaque exercises of government authority, and which to my mind, borders on wastage and profligacy—escalating the already high costs of health care spending, without the necessary return of investments or benefits to the general public, the tax payers and citizens.

Ambivalence on Free-Market Forces vs. Universal Coverage or Subsidy
Malaysia currently has a dichotomous public-private system of health care services. From what was largely a government-led and funded public service enterprise since the time of independence, our healthcare service has over the decades (since the 1980s), transformed into a buoyant dual-tiered parallel system, with a sizable and thriving private sector. But, we have not approached a unified system that is a declared national healthcare policy of offering universal access to every citizen.

There appears to be strong ambivalence as to whether to fully tap into the free market system for healthcare provision and funding or to resort to a single payer publicly controlled system where universal healthcare access is assured. Some mix of these two disparate systems seems to be in play at the current moment.

To be fair, for the past 50 years or so, there has always been an overarching concern for the common citizen, especially the poorer segment of Malaysian society, where there is an implied social contract and acknowledged ‘right’. There is a deep-seated commitment of the Malaysian government to eradicate poverty and develop human capital.

It is expected that the government guarantees a comprehensive provider function at greatly subsidised rates or at token sums—that taxes and other contributions should provide adequately for most if not all its citizens, with the government taking up the shortfalls for unexpected costs due to catastrophic or chronic ailments.

On the other hand however, there appears to be a covert if unannounced shift in thinking that eventual corporatization or privatisation of the public sector facilities and services should be allowed to unfold, where market forces dictate the price, extent and quality of the services offered.

The ultimate aim is that the government should play only a regulatory, monitoring and facilitator role to safeguard the welfare of its citizens, while at the same time encouraging growth of the less-bureaucratic, better-run and more competitive private sector. This thus appears to be in tandem with a globalised world, with free trade looming and all trade barriers lifted in due course.

However, what are the realities on the ground regarding our health care services?

Structural Problems remain
What is still inherently unpalatable is that while we have a relatively enviable primary health care system, there remain many questions on the uncertain and inconsistent delivery of medical care options in the expertise or tertiary level. Many of our health officials boast of our world-acclaimed excellent network of primary health care facilities—these allow for a reasonable reach to any public healthcare facility within a radius of 5 km for any citizen.

But not every of these amenities are adequately staffed, and certainly not with a doctor in every instance, thus there are still potential gaps when more serious illness arise. Delays and lapses in diagnosis and treatment are possible but real issues, which can affect many of the less fortunate and the poor.

Yet despite such shortcomings, our life expectancy at birth has risen from 55.8 years and 58.2 years for men and women, respectively in 1957, to 71.8 and 76.3 years, respectively for 2006; which places us near the middle rung of human development goals.2,

Hospitals Built at Huge Costs without proper assessment as to need, manpower planning
From an infrastructure point of view, the modernisation of our health care facilities and hospitals has been impressive.

Tertiary health care facilities have been built in most major towns in the country, but with more concentrated in the Klang Valley. But most of these have been built at huge costs, but whose performance as public utilities has been less than stellar.

Over the past decade or so, half a dozen new hospitals had been built, each costing upwards of 350 million ringgit, with one reported to cost nearly one billion ringgit! We have at least 5 tertiary hospitals within the vicinity of KL: Selayang, Serdang, Ampang, Sungei Buloh, and Putrajaya, excluding IJN, UMMC, HUKM and HKL. However, despite these huge expenses, which were due in part to turn-key B-O-T or B-O-O arrangements, facility or equipment maintenance and inconsistent expertise staffing remain mired in serious recurrent inadequacies.

Poor Maintenance of Healthcare facilities
Recent years had also seen hospital facilities (new hospital in Johor Bahru, KL hospital, etc.) beset with scandalous structural failures such as roof/air-conditioning leakages, moldy infiltration of wards, operating rooms, including the recent sudden closure (because of failure to pass fitness inspection) of the tower wing of the Queen Elizabeth Hospital in Kota Kinabalu, Sabah, which has caused untold hardships on the citizens of Sabah. In the latter case, expensive purchases of private health care services have to be made at ‘non-negotiable’ prices, which further burden the limited coffers of the government and the tax-payers.

Such snafus in construction and maintenance reflect shoddy or shortchanged work and/or careless management and oversight. They buttress the suspicion of possible corrupt or totally inept control of personnel and misplaced distribution of funds at systemic or local-regional levels.

Therefore, while many new state-of-the-art health facilities have been constructed in most major towns, these have been expensive, and not necessarily the most efficiently equipped or staffed.
With changes in leadership i.e. ministers of health, haphazard rather than a systematic structured planning appears to be the disjointed results of individual whims or persuasions. , Very short-term planning appears to be the hallmark of our healthcare system restructuring, despite the many reports which have been generated all these years.

We appear to be more engrossed with new modern structures rather than up-keeping and maintaining existing ones to become exemplary centres of excellence, maybe because there is little money to be made in this! Former PM Mahathir Mohamed had gone on to lament the fact that we appear to have “first world infrastructure, but third world mentality!” The Star newspaper managing editor, P. Gunasegaram, had only recently begged to differ when he asserted that even our infrastructure is “third rate and getting worse”.

Personnel and Staffing Development still wanting
Sadly, after so many years, we are still incapable of having a robust sustainable programme of producing or developing sufficient trained specialists, who can adequately staff our public facilities, in all the necessary disciplines. We are losing well-trained experienced specialist physicians and surgeons to the private sector at such alarming rates that we are almost always perennially understaffed!

We then resort to hiring questionably qualified or possibly substandard overseas doctors, who speak little or no local language, which undermines their competence and communication with our citizens. Furthermore, various ministers have been dangling carrots and offering unfair exemption rulings aimed at luring back foreign-trained specialists to fill in the vacancies at less popular remote centres. Many public sector doctors who have loyally stayed within the service feel unjustly discriminated against. Why should those who have followed the system and sacrifice their remuneration advantage be penalized?

Physician Discontent Continues
We’ve had countless debates and discussions on the whys and wherefores of such a predicament, yet we’ve never had the courage or the conviction to do what is necessary to keep our experts. We still get bogged down with bureaucratic impossibilities and narrow-minded constricts of what can or can’t be done. Numerous national health plans have been made but problematic issues remain.

The MMA (Malaysian Medical Association), through its Section Concerning House Officers, Medical Officers and Specialists (SCHOMOS) has been arguing for more structured deployment planning, such that even with these incentives, there should be detailed contractual undertakings that these personnel would be re-deployed to bigger centres of their choice, (for clearer career development programmes or pathway) once they have completed their ‘hardship’ service in the interior.

Failure to appreciate these doctors in particular, have led to many younger doctors complaining that the government is not concerned about their welfare and their future. Thus after such remote postings which they view with some discomfort, many are ready to throw in the towel and leave once their service contracts in compulsory service is over. By showing more concern and offering more incentives, we may be able to hold on to more of our public service staff, rather than losing them immediately after these postings.

The medical profession has been clamouring for an independent Commission and scheme, which can then truly address the concerns and special needs of our profession, not because we demand exceptional benefits, but because the realities demand so. Singapore has managed to keep most of their healthcare expertise by providing a special remuneration scheme and benefits which cuts down the disparity between the public sector physician and those of the private sector—it is not foolproof, but it works.

Public sector medical care inconsistent, overstretched
Except for some tertiary quasi-corporatised medical centres, such as the IJN, Selayang, Putrajaya, Kuching, Penang and Serdang Hospitals, more sophisticated tertiary care appears to be still lacking, and are often piecemeal and associated with inconsistent quality and unreasonable waiting times, or excessive cost sharing. Importantly as our citizens gain more empowerment and knowledge, their demands and their expectations too escalate, but on many an occasion, are not met.

Notwithstanding these unreliable deliveries of health care, Malaysian health care costs are still very affordable and heavily subsidised by the government, so much so that nearly free access is almost guaranteed of emergency or primary care for everyone. Of course, for more sophisticated care, due to shortage and maldistribution of expertise in the public sector physicians, these still have to be rationed and triaged according to needs, which have caused some to wait in inordinately long queues.

Paradoxically, nearly free healthcare from public facilities is not always appreciated. There is that perception that free care may not be up to the mark. Medical errors have been highlighted particularly with rushed prescription mistakes often made due to very short interaction times with over-stretched overworked doctors.

In busy public outpatient clinics, endless queues of up to 150 patients per doctor on duty per session, can exert severe stresses on the hapless doctor. The doctor is pressured to quickly see through each patient in as quickly a manner as possible, often with little thinking or proper analysis of each individual complaint. Such cursory 2-to-3-minute attention makes a mockery of the patient-doctor encounter, which then creates tension, fosters poor communication, and unleashes unsatisfactory, unhappy patient experiences.

Although the majority of civil servants and the lower income citizens are not necessarily unhappy with the services of the public sector, many in the urban/suburban areas still frequent the many GP clinics for more convenient access, on a fee-for-service or employer-provided or insurance-covered arrangements. Compared to many of our neighbouring countries, GP care is still very affordable and relatively cheap. Nevertheless, Malaysia does not have a declared universal access to health care for all its citizens.

This includes foreign workers (whether legal or otherwise), although this had bred unhappiness and occasional discrimination to try and ensure that these illegal immigrant peoples pay in full. Some citizen groups have even urged for these people to barred from accessing our public health care facilities, because in many cases, public hospital beds have been over-utilised by these immigrants to the crowding out of locals. These occurrences have been particularly acute in Sabah, where southern Filipino migrants have dominated the use of healthcare facilities to the point of angering locals. Labelled PTIs (Pengdatang Tanpa Izin), these ‘displaced peoples are unwelcome, although they do provide and have provided some services at very low cost which have served the needs of the lower economies of the underclass.

Heavily Subsidised health care: Public Aversion to Paying More
Because of the ingrained norm of having to pay so little or not at all in public hospitals and clinics (which are almost totally subsidised), the Malaysian public does not feel that it has to budget for health or medical care, and this is reflected in many of our pensioners complaining of costly unplanned-for medical care. This is also reflected in our government’s paltry allocation of importance toward healthcare spending in our national budget.

There has been flip-flopping ambiguity from the MOH, as whether to allow market forces to dictate healthcare costs, but overall, there has been no public will to enact what could be unpopular.2 Suggestions to end free treatment at public hospitals and highlighting that rising healthcare cost is too heavy a burden for the government, had not been too well-received by the citizens.

This strategy seemed to have disappeared following the recent electoral setbacks of the incumbent government. In a recent interview for internet media Malaysiakini, the new health minister Dato’ Liow admitted that the public hospital services are heavily subsidised by the government: RM12.9 billion or 98% of the entire budget, while patients paid only 2%!

But, Dato’ Liow reiterated his views that government subsidies for patients utilising public healthcare facilities would continue (RM1 for outpatients clinic visits, RM5 for specialist clinic visits, and maximum RM50 for third-class ward hospitalisation costs), and pledged the populist view that such a quantum would continue, despite this being unchanged since the 1970s!

There is great expectation that the government of the day should not jeopardise this by instituting any mechanism, which can change this status quo—hence there is relatively very little public or open debate on these issues.

Access Failure & Medical Assistance Fund
But concerns as to failures in access continue to pop up sporadically in the mass media. Poorer patients have resorted to the mass media appealing for financial assistance to help defray medical costs, especially for some costly or tertiary specialist care—e.g. in one week alone in October 2007, there were at least 3 appeals for help.

Thus, this has prompted some stopgap measures such as setting up a Medical Assistance Fund (MAF) of RM 25 million, by the Ministry of Health. However, this fund can only be utilised at public or quasi-governmental healthcare facilities, and appeals have to be vetted stringently to ensure need and priority, which had drawn sharp criticisms of this being too bureaucratic and slow, even unfair.

Yet another Emergency Fund (D’tik, an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara) has been set up. This fund of RM5 million, provides critically ill patients access to treatment within 24 to 72 hours, but is currently only available at Kuala Lumpur Hospital as its pilot medical facility to kick-start the programme.

Clearly, such setbacks and failure of access implied that the public healthcare sector needed a revamp to enhance its capacities. Providing such services at huge or near-total subsidy appears untenable and unsustainable, and still left gaps, which had to be filled by creation of some extra mechanism to expedite access (predominantly by offering extraneous funds and/or donations).

Thus, this explains in some way the government’s overt encouragement for the private sector to flourish and develop, in order to cater to the more willing, discerning, paying citizens, and leaving the public sector to look after the less endowed.

Corporatisation / Privatisation Controversy
Earlier hints that the public sector health services should be restructured into a government-owned non-profit entity, made economic sense in its first offering. This ‘corporatisation’ model implied converting most of the larger public hospitals into operating as quasi-private entities. This would avoid creating a two-tier system, and would facilitate disbursement of funds when a single payer health insurance scheme was introduced.

At least that is what had been planned. However, many are still quite in the dark as to when or if these would be enacted, and serious doubts and anxiety have been raised. This ambivalence is now quite understandable because earlier attempts to corporatize these public hospitals and facilities were scuttled after news leaks prompted severe backlashes from some consumer and pressure groups and opposition politicians.

Ensuring greater transparency in MOH decisions and planning
The health minister Dato’ Liow has said that “Government and private sectors should work together. Because the doctors that we train are for the nation, irrespective of (whether they work for the) government or private. Doctors are serving the people. In Malaysia, 41 percent of our population go to private hospitals and clinics and 59 percent go to public health institutions. Therefore, the private sector is playing an important role to ease the burden and also the workload in government hospitals.”

It is heartening that the current health minister is enlightened and positive about this private sector contribution. Therefore, this is an opportune time to ensure that the mechanisms for better partnership between public and private healthcare sectors be forged to facilitate closer and more meaningful collaboration.

Purchasing Private/Corporate Sector Expertise
Migration of trained staff especially medical specialists to the private sector continues to bug the system, which then causes the expert service to stall, because the requisite expertise had been lost. In critically short-staffed services such as neurosurgery, the public sector has to occasionally buy the services of private neurosurgeons to attend to their patients, especially during emergencies.

Currently, in Kota Kinabalu, Sabah, cardiology and cardiac surgical services are purchased with weekly rotations of specialists from the corporatized IJN, at hefty prices. Also being a corporatized medical centre, the IJN has been billing the government to take care of its public servants, pensioners and referrals from its MOH hospitals and clinics. This comes at a premium, with the government reimbursing some RM 31.3 to 144.5 million per year, from 1993 through 2004, respectively, for these services. Last year, the MOF subsidy to IJN is reported to be around RM250 million.

However, because of higher wages and better work conditions/benefits, specialists at the IJN appear to have less rapid turnover (3% annually), and thus enjoy greater consistency and continuity of services. This also makes continuing manpower and specialist training possible, too, to enable it to maintain its reputation as a centre of excellence. But obviously this comes at a higher cost—perhaps this expenditure is more realistic in terms of healthcare economics. This successful model has now made it an object for takeover by a GLC, Sime Darby Bhd.

So this model of public-private partnership appears to be successful and beneficial and attempts have been made to have it emulated. However, there have been serious misgivings about this concept of healthcare reform because of its wider socio-economic implications; the Coalition Against Health Care Privatisation has been most vocal against any development toward the passing of any extra cost to the public. , ,

Health Support Services – Divestment through Patronage System (‘Rentier’ Capitalism?)
Earlier examples of unpopular and expensive divestment of public services to several concessionaires have left many with mistrust, and had generated debate as to the fairness or opportunity-costs of some of these practices.

Despite public dissent, over the past 20 years or so, there have been sporadic if partially successful attempts to privatize or corporatize various components of the public health sector, e.g. the government’s drug procurement and distribution centre (to UEM’s subsidiary Southern Task, later renamed as Remedi Pharmaceuticals, then as Pharmaniaga); and the divestment of its support services (cleaning, linen, laundry, clinical waste management, biomedical engineering maintenance) to Pantai Medivest, Radicare and Faber Mediverse.

In the former case, the cost of critical drugs rose several fold upon divestment of the government medical store, e.g. drugs such as morphine and pethidine for pain relief, used routinely post-operatively by most if not all hospitals! Even after public hue and cry, the prices of some of these essential drugs were reduced but remained higher than before or even from alternate private sources!

Thus, this sort of divestment of critical services to private entities, appears to enrich the favoured party which had close links and ties to the government. And because such profits are assured, without the necessary business risks of true free market forces, economists have labelled this sort of practice as ‘rentier’ or rent-seeking capitalism.

‘Rentier capital’ economics applies when state assets are divested to politically well-connected private entities through a system of political patronage, perpetuating mutual dependence between the business elite and the political rulers, i.e. the ‘crony capitalist’ model that supervenes the true nature of this form of take-over.

Most economists believe that this form of rent-seeking capitalist model unfairly enriches these business elites at the expense of costlier services and goods to the public at large, and is therefore, wasteful and counterintuitive toward better productivity.

Is a single-payer National Healthcare Insurance/Financing Scheme the best way forward? Skim Insurans Kesihatan Kebangsaan (SIKK)
This brings us to the question of having a single payer system, which has been earlier mooted as the preferred system for encouraging or implementing universal access to health for all.7
The much-awaited National Healthcare Financing Scheme, now rebranded as the National Health Insurance Scheme (Skim Insurans Kesihatan Kebangsaan, or SIKK), appears to be a political deadweight.

Following the formation of the new government, this has once again been deferred for fears of public disavowal and protests. Perhaps, there are just too many variables inherent in the Malaysian system, which renders such a scheme too politically incorrect, too inexpedient to implement.

Interestingly, when it was raised earlier, the MOH tried to allay public fears by announcing that civil servants (which number 1.2 million people, including military and police personnel) and their dependants, 200,000 disabled persons, 435,000 pensioners, 250,000 hardcore poor and an unknown number of unemployed individuals, would be exempt from the SIKK. What is not clear is whether the government would pay the premiums for these people or that they will continue under the present system of healthcare. The latter option would defeat the purpose, because this would undermine the community-rated concept of the SIKK.

Also considering the fact that only 1.2 million Malaysians pay any taxes, collection of such a mandatory ‘health tax’ would be a struggle and challenge. It has been calculated that based on an estimated 4.63 million families in Malaysia (25 million population, average family size 5.4), this sharing of the burden (RM13 billion as of 2003) would encumber each family household around RM2,808 per year or RM235 per month.

Clearly, many would not be able to pay, because more than 58% of Malaysians earn less than RM2000 per month, per family; and paying more than 10% of the salary on healthcare premiums would be too high! Besides, the government would still have to cough up possibly billions of ringgit to sustain the shortfalls and other preventive health care measures. This scheme has been criticised and rejected by the Coalition Against Healthcare Privatisation, as putting the onus of premium paying on the lower- and middle-income private sector employees and citizens.

So, for the foreseeable future into the next 4-5 years at least, it is very unlikely that there will be any attempts to resurrect such a tendentious issue as a national health insurance mechanism. Our current system which has been described by Chee H. L. as segmented, polarising and eventually untenable, is therefore likely to be the status quo for the time being, and making this work better for our citizens should be the way forward, at least for the interim.

EPU-dominance, Political Patronage and Rentier Capitalist methods fraught with problems: FOMEMA
When this agency was initiated in the late 1990s, it was met with lots of objections from medical practitioners and the MMA, who felt that every doctor should be empowered to conduct these tests, and not just some panels of registered doctors.

FOMEMA, is an agency mooted by the EPU and certain officers of the Health ministry, to monitor the screening of foreign workers in Malaysia, especially the initial examination and testing to help isolate infectious diseases from entering the country, and thus pose a threat to the health of Malaysians. Unfortunately it had morphed into a patronage-endowed profit-making concession, which appeared to have exceeded its terms of reference.

Worse, it appeared not to have curbed the timely detection of infections, which was its main mandate. Its aggressive business-like tactics to squeeze greater profits from its subsidiary partners such as pathology laboratories, may actually undermine the quality and accuracy of the testing. It has been reported that instead of the earlier agreement of RM65-75 for testing, FOMEMA has been coercing laboratories to accept a discounted fee of as little as RM25 per patient. This means that there is greater profit to be made on top of its management service fee, which had been pegged at RM25.

Incidentally, Fomema had filed with the Companies Commission of Malaysia that, for the 18 months to June 30, 2002, it had a turnover of RM127.2 million, while its profit-after-tax was RM387,496. Adding carry-forward retained earnings of RM842,714 from 2000, profits available for appropriation were RM1.23 million. Add to that ordinary dividends (paid and proposed) of RM456,711, Fomema retained a profit of RM773,499.

Despite this assured profitability, many problems beset such an agency. Because many shortcomings have been complained about, there has been suggestions that the MOH takes over the screening process as has been done by the Singapore health ministry. In view of the repeated shortfalls associated with the screening procedures for foreign workers, Consumer Association of Penang, CAP, calls on the Health Ministry to halt the use of Fomema’s services and let the medical screening of foreign workers come under the direct control of the ministry itself.

e-Kesihatan
Another covert but highly controversial attempt by the government to allow a private company to run its medical check-up scheme for commercial vehicle drivers, has run into huge objections, by the public, as well as the Malaysian Medical Association. The scheme, called e-Kesihatan, will instead be handled by the Road Transport Department (JPJ).

The e-Kesihatan scheme was originally proposed to curb fraud in commercial vehicle driver medical check-ups where medical approvals were said to be “sold”. However, while the concept is good, many felt that this should not be another attempt to pass off some public asset-services to a monopoly to act as third party manager, with nearly assured profits.

Under pressure from the then Health Minister Datuk Chua Soi Lek, the Transport Minister Datuk Ong Tee Keat held discussions with various parties including the Economic Planning Unit (EPU), Health Ministry, industry players and the medical fraternity to help revamp the schemes. Fees for medical check-ups would be renegotiated, the tests would only cover relevant ones, and more doctors and not just a selected panel would be allowed to conduct the medical check-ups.

The move to appoint Supremme Systems as well as the limited number of panel clinics and the high fees for check-ups drew criticism from the Malaysian Medical Association and associations representing the commercial vehicle drivers.

The strong opposition resulted in the ministry shelving the scheme. Ong said with the revocation of the private company’s role in the scheme may lead to legal problems. The programme would now be expanded to accommodate any doctor registered with the Health Ministry. “We want to do it in a way where it is not monopolised by groups or cartels,” he said.

Sadly, now the company that claimed to have been given the contract has demanded compensation for breach of contract. Supremme Systems Sdn. Bhd. is demanding huge compensation for the aborted concession, which it claims to have had planned and partially implemented, and RM 70 million for loss of reputation! This was disclosed by Deputy Transport Minister Lajim Ukim at the Dewan Rakyat, who said that: "On Sept 19 last year, SSSB cancelled the (e-Kesihatan) agreement with the government and demanded that we pay them RM103 million in compensation."

Even Khazanah is making a foray into Private Hospital Services
Of late, there has been full and implicit encouragement of the private sector to flourish with differing modes of financing and capital injection. Government-linked corporations (GLCs) such as the KPJ (Kumpulan Pelaburan Johor) and Sime Darby groups and latterly the Ministry of Finance investment arm, Khazanah, have been pushed to become major players in modernizing and extending the reach of the private health care services in Malaysia and beyond.

Is More Privatisation acceptable to the Rakyat? Aborted Sale of IJN Debacle…
One way to further this is by privatising more of the public healthcare facilities, but this is fraught with uncertainties, although such exercises might make administrative and economic sense and offer greater balance sheet accountability. One inevitable problem will be the almost inescapable escalation of the cost of services to ‘real’ terms, with progressively less subsidies. The poor unfortunately, could be left out of the loop with uncertain safety nets to cushion their plight.

The recent application to the EPU by Sime Darby Healthcare S/B to acquire a stake in IJN (now a corporatized entity 99.99% owned by the Ministry of Finance) has already brought a swift and negative dissident response from a newspaper editor. Gunasegaram P. has stated his dismay that “for large sections of the Malaysian public, the very idea of privatising IJN is shocking because charges will rise to astronomical levels.”

He questioned whether there is any net benefit to the public or government, and that if there were any reasonable doubt, this privatisation should not be undertaken. He alluded to past experiences that previous privatisation exercise of other services had not brought down costs for the public or government. He concluded that “(t)here are some things that should not be up for sale at any price. Affordable health care for the general public is one of them.”

In another article in The Edge Daily, it was reported that the health minister and his ministry is not too happy with this divestment, either. However, the Prime Minster and his deputy appears to have already endorsed the plan, just cautioning the GLC against forgetting its social responsibility to the poor, and they seem to imply that this exercise would allow the private healthcare sector to grow even more.

Latest reports suggest that this takeover bid by Sime Darby has been deferred indefinitely due to public outcry, and possible political fallout. The former Health Minister Datuk Seri Chua Soi Lek has also condemned this sell-off bid, which he said has put paid the good will of the government, despite it costing the government just a ‘paltry’ RM 200 million a year (about 2.5% of the national health budget) to run the IJN. Thus, there is this incessant tussle for public need/good versus free-trade market-driven practices from administrative or financial/budgetary realities points of view.

References

Office of the United Nations High Commissioner for Human Rights/W.H.O. The Right to Health (Fact Sheet no. 31). United Nations, Geneva, June 2008.
UNDP Human Development Report 2006. The Human Development Index ranks Malaysia 61st, with a literacy rate of 88.7%, Education index of 0.84, life expectancy index 0.81 and PPP GDP of USD 10,276. Malaysia spent some 8% of the GDP on education with the government spending some 28% of the total budget on education alone with 36.5% for tertiary education. http://hdr.undp.org/hdr2006/pdfs/report/HDR06-complet.pdf. Pgs. 302, 320. Accessed 21 October 2008.
The World Health Report 2006: Working together for health. WHO, Geneva.
Bhagwati, Jagdish N. Directly Unproductive, Profit-seeking (DUP) Activities, Journal of Political Economy 1982; 90 (51):988-1002.
Jomo K. S. (ed.) Privatising Malaysia: Rents, Rhetoric, Realities. Boulder, Westview Press, London, 1995.
Gomez, E. T. & Jomo K. S. Privatising State Asset, In Malaysia’s Political economy: Politics Patronage and Profits. 2nd Edn. Cambridge University Press, Cambridge, 1999, pgs75-116.
Rasiah, Rajah. State intervention, rents and Malaysian industrialization, in John Borrego, Alejandro Alvarex and Jomo K. S. (eds). Capital, the State and Late Industrialization: Comparative Perspectives from the Pacific Rim. Boulder; Westview Press, London, 1995.
Ismail Md. Salleh. The Privatisation of Public Enterprises: A Case Study if Malaysia, in Geeta Gouri (ed.) Privatisation and Public Enterprise. The Asia-Pacific Experience, New Delhi, Oxford and IBH Publishing Co. Ltd. 1991.
Economic Planning Unit. Prime Minister’s Department. Malaysia: 30 years of poverty reduction, growth, and racial harmony. A case study report. Scaling Up Poverty Reduction: A Global Learning Process and Conference, Shanghai, May 25-27, 2004. A World Bank report.
Teoh S. PM wants Sime Darby to guarantee treatment for poor if it takes over IJN. The Malaysian Insider, 18 Dec. 2008. (Accessed 18 Dec 2008.)
Malaysian Medical Association, MMA. Health for All: Reforming Health Care in Malaysia. Academe Art & Printing Services, Selangor, 1999.
Quek D. K. L. Equitable Access to Health Care for All: Is this still a Pipe Dream for Malaysians? A Medical Professional’s Perspective. Paper presented at Suhakam’s “Human Rights & Access to Equitable Healthcare” Dialogue, Kota Kinabalu, Sabah, 08 January 2008
Merican M. I. Medicine and Healthcare in 2020. Berita Academi, 2007, Vol 16;3, Pg.2.
Free treatment at public hospitals to end next year. The New Straits Times, 26 April 2005.
Paying more for healthcare: rising cost a heavy burden on government. The New Straits Times, 16 December 2004.
Gunasegaram P. Ten Things Najib can do for business. The Star, Starbizweek, Saturday 28 March 2009, pg. SBW3.
Ong A. Private and public health can grow in tandem. Malaysiakini June 28, 2008. (Accessed 17 Dec 2008)
Mastura Ismail. Budget 2009: Increment of Specialist Allowance. MMA News, 2008 (October), Vol. 38 (9):pg14.
Ministry of Health (MOH) 2003. Malaysia’s health 2003: technical report of the director-general of health Malaysia 2003. Kuala Lumpur: Ministry of Health (pg 44-57)
Ministry of Health (MOH) (various years). Annual report.
Ministry of Health (MOH) (2003, 2004). Indicators for monitoring and evaluation of strategy for health for all.
Mastura Ismail. Budget 2009: Increment of Specialist Allowance. MMA News, 2008 (October), Vol. 38 (9):pg14.
Lim MK. Transforming Singapore health care: public-private partnership. Ann Acad Med Singapore 2005; 34:461-7
Mazlinda Mahmood. Affordable reproductive health services for the poor, The New Straits Times, Saturday, 27 October 2007, p N24.
Annie Freeda Cruez, Poor can apply to medical fund. The New Straits Times 17 Oct 2007.
SM Mohamed Idris. Alert public of alarming medical error statistics. Malaysiakini, March 20, 2009. (accessed 26 March, 2009)
Paying more for healthcare: rising cost a heavy burden on government. The New Straits Times, 16 December 2004.
Free treatment at public hospitals to end next year. The New Straits Times, 26 April 2005.
Ong A. Private and public health can grow in tandem. Malaysiakini June 28, 2008. (Accessed 17 Dec 2008)
Mazlinda Mahmood. Affordable reproductive health services for the poor, The New Straits Times, Saturday, 27 October 2007, p N24.
Little Kin Wai hopes to walk tall—He needs funds to help him grow, The Star, Saturday, 20 October, 2007, p N18.
Single mum needs aid for kidney transplant in China, The Star, Friday 19 October 2007, p N26
In need of aid to treat his burns, The New Straits Times, Monday, 22 October 2007, p N17
Annie Freeda Cruez, Poor can apply to medical fund. The New Straits Times 17 Oct 2007.
Ministry of Health (MOH) 2003. Malaysia’s health 2003: technical report of the director-general of health Malaysia 2003. Kuala Lumpur: Ministry of Health (pg 44-57)
Jeyakumar Devaraj, Health Is Not A Commodity, Parti Sosialis Malaysia Press Statement: 8 June 2007.
Chua SL. Speech by YB Dato Dr. Chua Soi Lek, Minister of Health Malaysia, At The Annual Scientific Meeting 2005 of the National Heart Association, Hotel Hilton, Kuala Lumpur, 15 April 2005. Text obtained from (Accessed 15.12.2008)
IJN doctors: Don’t make us scapegoats. The Star online. 19 December 2008. (Accessed 19 December 2008)
Quek D.K.L. Imminent Corporatization of Public Health – Causes for Concern. Editorial. MMA News, 1999; Vol. 29 (May): pg7. Accessed on 15.12.2008 at
Subramaniam Pillay. (for Coalition Against Health Care Privatisation) Can we afford to fall sick? Aliran Monthly Vol. 25 (2005): Issue 4 Accessed 15.12.2008
Citizens’ Health Manifesto for Malaysians. (Accessed 15.12.2008)
Chee H. L. Ownership, control, and contention: Challenge for the future of healthcare in Malaysia. Social Science & Medicine (2008); 66: 2145-2156.
Jomo K.S. and Gomez E.T. (2000) The Malaysian development dilemma. In M.H. Khan, & K.S. Jomo (Eds.), Rents, rent-seeking and economic development: theory and evidence in Asia. Cambridge; Cambridge University Press.
Authority for universal coverage could be set up this year—national health finance plan ready. The Sun, 4 March 2001.
National healthcare not an insurance scheme: Chua. Sun2Surf, 15 April 2005.
Skim insurans ganti penjagaan kesihatan: SIKK (Skim Insurans Kesihatan Kebangsaan) dua tahun lagi. Utusan Malaysia, 2 April 2005.
Seelen Sakran. Is anything ailing Fomema? Malaysian Business, Jul 16, 2004. <> (accessed 30 March 2009)
Idris, SMM. Halt the use of Fomema services. Malaysiakini May 29, 2009. (accessed March 30, 2009)
Teh E. H. e-Kesihatan plan taken away from private firm and could be cheaper. The Star, Monday, October 6, 2008. < file="/2008/10/6/nation/2197800&sec="nation"> (Accessed 30 March 2009.)
Syed Jaymal Zahiid. e-Kesihatan: Company demands RM103mil. malaysiakini, Nov 3, 08. <> (accessed 30 March, 2009)
Law K. C. Sime Darby seeks stake in IJN. The Star, Thursday, 18 December 2008; pgB1-B2.
Gunasegaram P. Don’t privatise the National Heart Institute. The Star, Thursday, 18 December 2008; pgB2.
Lim S-L. Sime Darby eyes IJN. The Edge Daily, 17 December 2008 (Accessed 18.12.2008)
Teoh S. Najib: Sime Darby must commit to poor in takeover of IJN. The Malaysian Insider, 18 Dec 2008. (Accessed 18.12.2008)
Cabinet hits pause button on IJN Sale. Malaysiakini, 19 December 2008. http://www.malaysiakini.com/news/95152 (Accessed 19 December 2008)
Choo C.M. & Chong D. Cabinet all but kills Sime Darby’s bid for IJN. The Malaysian Insider, 19 December 2008. http://www.themalaysianinsider.com/index.php/malaysia/14503-cabinet-all-but-kills-sime-darbys-bid-for-ijn (Accessed 19 December 2008)
Chua S. L. IJN Dollars and Cents. (Accessed 30 December 2008.)

Moments of Madness…

2009-02-02T01:23:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Essays

Medical Practice under Scrutiny: How much care is too much?

Medical Ethics and Personal vs. Public Conscience: a Malaysian context

[v] David KL Quek. Kugan’s Autopsy Findings & Inquiry: Unsettling Questions remain Malaysiakini 8 April 2009. http://myhealth-matters.blogspot.com/2009/04/kugans-autopsy-findings-inquiry.html (Accessed 26 Jan 2011)

[vii] Debra Chong. Teoh family disappointed with British pathologist’s report . Malaysian Insider 26 April 2010. http://www.themalaysianinsider.com/index.php/malaysia/61368-teoh-family-disappointed-with-british-pathologists-report (Accessed 26 January 2011)

Global Strategies in the Prevention of Cardiovascular Disease: Asia Pacific Perspectives

[xxvii] de Lorgeril M, Salen P, Abramson J, Dodin S, Hamazaki T, Kostucki W, Okuyama H, Pavy B, Rabaeus M. Cholesterol Lowering, Cardiovascular Diseases, and the Rosuvastatin – JUPITER Controversy A Critical Reappraisal. Arch Intern Med. 2010; 170(12): 1032-1036 .

Low Diagnostic Coronary Angiography Yields: Perhaps we need a higher threshold to perform

Medicine—Reigniting our Passion…

1. PRIVATE HEALTHCARE SECTOR

3. HEALTHCARE SPENDING & ACCESS ISSUES2

5. PARTNERSHIP: COLLABORATION VS. INTEGRATION OF SERVICES

Poetic Licence: “Another Kind of Magic”

A Book Review: “MEDICAL ETHICS, ETIQUETTE AND LAW”

Malaise in Malaysian Health Care Services Development & Procurement

Moments of Madness…

3. HEALTHCARE SPENDING & ACCESS ISSUES²