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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Professional Misconduct: Underestimate the Ethical Code at Your Own Risk…

Since I was elected into the Malaysian Medical Council in August 2004, I have had the privileged of sitting through some eye-opening complaints of professional misconduct allegedly perpetrated by some of our medical colleagues.

Contrary to what many may believe, the Medical Council (which currently comprises some 15 nominated—from the earlier 5 medical schools—and 9 elected members) takes an extremely serious but determined view with regards all queries of misdeeds or alleged wrongdoings made by the medical profession.

For whatever it is worth, it is the de facto watchdog body to police, discipline and regulate the medical profession.

It is not a paper tiger to protect and exonerate the errant medical practitioner! It is neither a band of sanctimonious old folks who are out of touch with modern medical practice, nor those who simply wish to impose their antiquated ideas of ethical propriety on to the doctors at large.

The most active and enthusiastic members of the Council are members who have been duly elected by you. They are elected volunteers who care enough about what happens to the medical profession that they serve in this often thankless task.

Council members represent generally the mainstream of medical practice in Malaysia. The nominated members are all senior members of the teaching staff of our medical colleges who have been entrusted by us to teach and nurture the development and training of our future doctors for Malaysia.

Importantly, we rely very closely on the Medical Act and its regulations as well as the strict interpretation of our Code of Professional Conduct, with the constant assistance of and references to our legal advisers.

In the coming revised Medical Act, some representatives from the lay public will be invited to sit in the Council, so as to ensure further transparency and impartiality of the Council proceedings.

In fact, through the painstaking efforts of four legally-instituted Preliminary Investigating Committees (PICs), tens of cases of alleged ethical breaches are scrutinized every year.

Although I was not previously aware of, all the members of the PICs are invited and nominated by the Director General of Health, from the ranks of our own peers—they are invariably medical professionals who are greatly respected for their solid reputation and seniority—they are one of us, too.

The investigative process is meticulous and often very thorough. And it is incumbent on the very experienced chairpersons of each PIC, to ensure that only relevant and unbiased inquiries are scrutinized, before determining if there was any case to answer.

These inquiries have been and are indeed time-consuming efforts. They offer generous latitude toward legal defences of the alleged perpetrators of any professional misconduct being investigated. Point-counterpoints are often made with legal challenges and rebuttals, but frequent absenteeism and last minute postponements, also draws out the tedious process sometimes interminably; and this has led to unfortunate impatient responses from both sides.

At any rate, every case is further dissected by the Council members at their monthly meetings, for a final judgment as to full acquittal or toward a formal full Council hearing, to be answered by the charged professional.

Nearly 2 full days out of every month are spent on such disciplinary hearings which consume some 80% of the work of the Council! And the complaints continue to mount, despite heroic efforts to clear quite a fair bit of the backlog caused by earlier tardiness from too frequent legal challenges and inappropriate deferments.

The past 2 years have seen the resolution of some of these cases, which augur well for the Council efforts, but also for the medical professionals who have been subject to such disciplinary inquiries—some closure will certainly help lighten the anxiety of the unknown.

Notwithstanding this, the Medical Council is duty bound to be impartial and abide by the strictures of the Medical Act and its solemn interpretation of the Code of Professional Conduct.

The MMC has to be seen to be fair first and foremost to the complainant who is more often than not, a member of the lay public. We have been reminded often that the MMC is not so much a rubber stamp to protect the rights of the medical professional.

Conversely, the MMC is there to protect the rights of the public so aggrieved, less their grievances go unanswered and unhappily resolved. Similarly, the genuine misdeeds or wayward behaviour or conduct of the medical professional should not be seen to go unpunished and unchecked.

Yet there have been cases of patient-physician misunderstanding and miscommunication which do not amount to professional misconduct and these unhappy miscues of happenstance have always been made known to the complainants, at the end of thoroughly exhaustive inquiries.

It is always understood that the aggrieved parties may choose to challenge the MMC decision, and apply to the courts for civil redress. Similarly, the punishment meted out by the MMC upon the medical professional can be challenged in High Court, through an appeal process if made within one month of the passed judgement.

Notwithstanding this potential for reversal of the judgment and sentence, the MMC has never failed to take stern actions against the delinquent medical professional when it feels that serious professional misconduct has taken place.

It is very rare for the MMC to fail in its pronouncements of guilt, although some of the MMC’s sentences had in the past been mitigated by the Courts, which felt some punishments might have been too harsh.

It is useful to remind ourselves that these are punishments that have been deliberated long and hard not so much by vengeance or vindictiveness, but by peer-reviewed concepts of what constitutes the highest standards of medical professionalism, and what falls miserably short.

No one on record had been exonerated i.e. totally vindicated by having the judgment overturned, by the Courts to date.

Therefore, the MMC’s role and actions should be viewed very seriously and every medical practitioner must be cognizant as to what and how he or she should practice ethically, and not place the medical profession under the harsh odium of disrepute and tarnish its professional standards and good name.

The lightest sentence imposed by the MMC is one of reprimand. This carries the stigma of having the professional’s name being circulated to the press and public, and the errant professional loses his right to exercise his vote for five years.

He would also not be able to receive a letter of good standing should he or she choose to work overseas as a doctor. This meted punishment is also a permanent record and stain which cannot be expunged unless directed by a higher court. Recurrent misdeeds by the same practitioner would then be seen in a far more severe light which can lead to suspension or even deregistration.

Hence even a reprimand is a very solemn affair and every medical professional should take due recognition as to its serious implications before indulging in scurrilous misconduct without thinking about it.

Of course, the order of suspension (for a duration of time, months to years) or deregistration carries much more sinister import—which materially deprives that practitioner of his livelihood and profession! Besides the obvious personal grief and stigma, the doctor’s reputation would be seriously damaged in the eyes of the public and peers.

This publication in the press will needless to say seriously undermine the credibility and reputation of that doctor and his standing in society. Importantly the errant practitioner will not be able to practice medicine anymore during the period of suspension, or henceforth, if struck off the medical register!

Clearly too, to earn such a punishment would mean that the medical practitioner had been found guilty of engaging in some very egregious and serious professional misconduct, which in the eyes of the Council of peers, makes the misbehaving doctor unfit to practice medicine for some time, or permanently.

What are some of the recent disciplinary problems faced by some of our medical practitioners?
Most complaints against doctors relate to their practices which caused some unhappiness among the treated patients or their families.

This might be related to overcharging, rudeness and lack of caring attitudes, wrongful deaths, or alleged poor or substandard medical care or unforeseen unfavourable outcomes. These fall under the loose categories 1.1 through 1.2, of the Code of Professional Conduct (CPC), under “Responsibility for Standards of Medical Care to Patients.”

A large number of these pertain to poor physician-patient communication, which leaves the aggrieved parties too many unanswered (and unsatisfactory) queries to fester upon and infuriating their sense of justice and sense of proportion.

Many of these complainants seek to punish the doctors’ purported error or misconduct. Some complain out of the need to obtain redress for their perceived wronged experience. Sometimes, a little give and take and further explanations from the miscued practitioner may resolve the problems altogether.

Sometimes however, these complaints underline a more serious consistency of misbehaviour on the part of the physician, when more serious MMC actions would be mandated. These fall under the category 2.2 under “Abuse of Privileges Conferred by Custom”.

Another more serious category involves the poor record keeping of dangerous drugs under the Poisons’ Schedule. These Schedule B drugs have been dispensed indiscriminately and without proper obligatory record-keeping—such that this action can be misconstrued as unethical distribution of drugs without proper medical indication or examination. This falls under the general category 2.1 under “Abuse of Privileges conferred by Law”.

Many of these cases pertain to psychotropic drugs and syrups which have been misused for drug addicts without proper documentation, drug rehabilitation programs or counselling. The use, storage and distribution of banned substances also fall into this category (CPC 2.1.1, 2.1.2, 2.1.3). This can be construed and have been taken to mean some form of drug trafficking offence, if the authorities so choose to do so, when charging these errant doctors.

Some of these doctors have been hauled up by ‘sting operations’ by the enforcing officers of the Pharmaceutical arm of the Ministry of Health, and have been charged and found guilty by our courts.

We are now aware that the police are now adopting the more serious charge of Drug Trafficking for those caught selling, distributing or hoarding banned drugs/syrups which contain opiates—these charges carry the mandatory death sentence!

It is important to state here, that the medical practitioner should not take the easy way out to plead guilty so as to pay a small fine and then get on with his practice, purportedly for convenience’s sake. Pleading guilty is taken to mean the same as being found guilty in the court of law and this will impute that the guilty doctor had breached our ethical code of conduct and will be found to have engaged in serious professional misconduct. The ensuing punishment by the MMC has thus far been severe and harsh, i.e. usually a suspension if not deregistration, depending upon the gravity of the cases.

Careless selling of medical certificates or sick chits without examination (CPC 2.1.4), can also lead to serious consequences of professional misconduct, and has led to suspension of the medical licence to practice. The MMC is aware of several creative versions of excuses which errant doctors propose to limit or exonerate the offences of their clinics or practitioners.

Yet another serious violation involves having unqualified medical assistants or unregistered doctors (including the use of provisionally registered house officers) to run registered clinics. This breach (CPC 1.4, under “Improper Delegation of Medical Duties”) is a very serious offence, which the MMC views very unsympathetically.

Other offences which doctors have been found guilty of in the Malaysian Courts and which have a bearing on the professionalism of the medical practitioners have also been the focus of some charges of professional misconduct brought before the MMC.

Some of these involve cases of cheating, fraud or business malpractices, and have been brought up due to the reliance on the strict interpretation of the current code of conduct (CPC 3.2.2; under “Personal Behaviour. Dishonesty: Improper Financial Transactions”). The CPC stipulates that that those who have been found guilty or who have been fined in the courts, would also be guilty of gross professional misconduct.

However, the MMC is aware that unless these directly pertain to professional matters, the question of double jeopardy should be avoided. However, the onus is on the errant practitioner to prove this separation of personal versus professional misconduct.

Commercial undertakings by medical doctors are a right, but these should be cautiously applied as they can be embroiled in conflict of interest situations. A recent case involves the use of unproven technology and products to advertise for a commercial undertaking which a doctor had a financial interest and shareholding. Because there was a complaint from some other party (which may be a fellow medical practitioner, a medically-related society, a professional organization or even a consumer association), who knows this to be so, the practitioner was charged and found guilty of serious professional misconduct and subsequently suspended. This falls under the CPC category of 3.4 and 4.1.

Of late one of the most common complaints come from our own fraternity of medical practitioners, who complained that some of their fellow practitioners have been engaging in blatant advertising and canvassing in the press and media. Although in this day and age, many of our younger doctors out there may feel that this is now an antiquated ruling, it is nevertheless very much an accepted code for our community which by and large still frowns upon such behaviour as unethical and callous.

We are aware that advertising by physicians is allowed under the Physician’s Code of Professional Conduct in the United States of America. However, as we are more closely bound to the British and Commonwealth statutes and laws, our system mirrors more accurately that of the latter.

Similarly our Ethical Code closely resembles that of the General Medical Council’s Code of professional conduct of the United Kingdom. Unless and until this changes, the Malaysian medical professional has to abide with the strictures and rules of our own CPC.

In the recent review of the Malaysian Code of Professional Conduct and the attendant Medical Act revision (in March 2005), most of this statute and its core contents have been retained with very minor variations or relaxation of this ethical code on “Advertising, Canvassing and related Professional offences”, CPC 4.1, 4.2.

Therefore, medical professionals in Malaysia must not only be aware but must also be very familiar with our Code. Furthermore, it must be made very clear and categorical that ignorance of this code of conduct does not absolve them from blame or censure if these breaches have been brought up to the MMC.

Press statements or invitation to press reporters to cover or interview medical professionals should be carried out with as little embellishment as possible. There should be no attempt at directing undue attention to the practitioner’s so-called expertise or skill. In clarifying new techniques or technology the practitioner should not resort to deprecating his fellow practitioners, so as to promote his own professional advantage, and thereby attracting patients unfairly.

Medical facts and advances can be disseminated but without calling gratuitous attention to the expertise or singular praise for a particular practitioner or medical centre. Inducements such as free or discounted testing or other benefits would be considered as particularly unethical, and would be in breach of serious professional conduct. Promoting untested and unproven technology or medical equipment could also be deemed unethical and the practitioner may be called to answer to the MMC for unethical practices.

In general, the MMC is for promotion and dissemination of new and important information on medical advances and techniques, and their availability in Malaysia. However, unregulated and unrelenting publicity with unfair advantage to promote any particular medical centre or medical practitioner is frowned upon, especially when this is done to entice unwitting patients from the public at large.

So it behooves the medical practitioner to review his knowledge and concept of the code of professional conduct. We have to acknowledge that by and large each and every one of us medical doctors need to constantly remind ourselves that we are privileged practitioners only because this has been empowered upon us by some special laws and codes of the land. We must understand that as doctors we have far more stringent boundaries of ethics than the population at large.

We need to understand that we sometimes have to police ourselves and failing which there is that authority out there which will do so for us. We have to put out act together, so that the standing and prestige of our professionalism can withstand scrutiny and the passage of time. We must earn the trust so long placed upon the profession since time immemorial. We hold that public trust which must remain unshakable and undiminished.

[The booklet, Code of Professional Conduct, is freely available upon request to any medical practitioner who is registered with the MMC]

(MMA News Editorial, April 2005)

Acedia and Pastiche in Modern Life and Medicine—Can Medicine Escape the Stranglehold of Modernism?

“We live in a Mickey Mouse world in which images flicker with the speed of animation, and confusion is treated as a good. The result is a crisis of values undermined, certainties discarded and fears excited. Trapped in ‘future shock’ by the fear of unprecedented, uncontrollable change, refugees scurry into muddle. Pluralism gets stuck in pastiche.” ~ Felipe Fernandez-Armesto, in Truth – and a Guide for the Perplexed, Bantam Press, 1997, p2.

“Anything must be true before it can significantly claim other merits. Without Truth, all else is worthless.” ~ Gellner E, in Postmodernism, Reason and Religion.

“You see, I went on with this research just the way it led me... You cannot imagine what this means to an investigator, what an intellectual passion grows upon him. You cannot imagine the strange colorless delight of these intellectual desires... To this day I have never troubled about the ethics of the matter. The study of Nature makes a man at last as remorseless as Nature.” ~ Dr. Moreau explaining his research to Edward Prendick, in HG Wells’, The Island of Dr. Moreau, 1896

For many of us, modern life is one individual experience that is singularly all-consuming and intensely personal. There can be no denying our mounting self-importance and our enthrallment with ourselves.

However, for many of us this overriding individualism is veering perilously close to total disregard for others and our so-called humanistic, spiritual or moral values.

Universally, man is losing his spirituality and his awe of the Immanent. Our all-consuming immersion into the here and now has overwhelmed and superseded our previous engagement with our spiritual souls and exhausted our humanistic wonder.

Increasingly we appear to drift through life with a callous listlessness and spiritual apathy—this acedia—which can demean our humanness. (Although having recently read John Gray’s book “Straw Dogs”, one wonders if there is indeed any real or consistent postmodern humanist ethic at all…)

Our self-absorption and self-centredness have now taken centre stage of most of our lives. Other people appear to play only marginal or peripheral roles far remote from our conscience and immediate consciousness.

We are thus poised on the cusp of tremendous changes and profound paradigm shifts which threaten to undermine our humanity.

Our truths are becoming more and more relative. And our science—rigorous as it has been this last hundred years—is becoming more uncertain.

Indeed our scientific revolutionary era may perhaps be entering its own hubris of deconstruction and diminishing power as a social construct and determinant of truth and reality.

It would appear that Heisenberg’s uncertainty principle is rearing its fuzzy head by impinging into many of the tenets of science such that we can no longer be sure if what we know as plausible today would or could withstand the ratification or self-correction or ‘reality’ adjustments of tomorrow’s ideas and ‘truths’.

Consider the case of post-menopausal hormone replacement therapy (HRT) which has now been found to be more harmful than what was thought to be just a few years ago—with greater risks for heart disease, stroke, breast, endometrial and ovarian cancers, etc!

Yet despite such harrowing uncertainties with the continued use of artificial hormones, a better appraisal of how we can better manage the ill-effects of the climacteric has emerged.

Stunned, gynecologists and epidemiologists have now learnt to tease apart nebulous minutiae to determine what remains beneficial and worth offering to the long-suffering woman folk of the modern world.

We can no longer be too dogmatic or sure of our ponderous wisdom to prescribe at will without being challenged anymore… This is emblematic of our current position in today’s medical practice.

So, can many or any of our medical practices withstand the onslaught of increasingly negative or uncertain evidence to the contrary, in the near future, considering that perhaps only 30% of our medical ‘truths’ is evidence-based and proven?

Are we facing our own denouement for the folly of our hitherto paternalistic arrogance, such that we must now redouble backwards into ambiguity and shaky foundations?

Yet with the onslaught of new technology and techniques, many of us doctors are rushing headlong into embracing many of these newfangled treatment regimes, technical wizardries, devices and drugs, with a vigour that defies our much vaunted dispassionate logic and rational wisdom.

It is true that with every passing day, we are being bombarded with ever-newer understanding of our human body, the mind-boggling and paradigm-shifting intricacies of its workings.

And we are devising ever-newer techniques, medications or probes to correct or modify some of these failures or perceived errors of ailment and ill health.

We have even taken to redefining what constitutes health and well-being, with a mindset driven to prolong life to near immortality as possible.

Modern lifestyle expectations and limitations are re-designated as disorders, which can be modulated—without fully comprehending what we are trying to achieve in the long run.

Most importantly, we appear to be creating and offering more and more meddlesome modifications to shape and re-shape our rapidly changing concepts of what constitutes normalcy or disorders, as well as re-conceptualizing functional vs. dysfunctional states.

Thus, the recent eruption and growth of anti-ageing medicine, use and misuse of growth and sex hormones, other poorly tested supplements and supposed youth-enhancing elixirs and concoctions, is symbolic of this allurement of creative ‘medical’ pastiche—artifacts of a modish modernist culture.

When medications do less than they should or could, cosmetic techniques are seized upon: lasers, creams, Botox, direct vitamin C injections, etc. Cosmetology and aesthetics have become big money-churning enterprises, which pander to the narcissism of ageing (and age-fearing) people worldwide by tantalizing their Dorian Gray aspirations for those elusive fountains of youth. Has modern ‘medicine’ descended into these depths of pandering to pedestrian despair and gratuitous opportunism?

Yet, many medical professionals are now turning to this niche of gray and tenuous medicine, where the demand is fastest growing in a wealthier middle-class society.

Many such doctors are happy that for once, few of their clients are demanding too much but are willing to expect less, but are happy to part with more. What better deal with Mammon can there be?

With the human genome now essentially mapped, we are also exploring genetic, proteomic and pharmacogenomic probes and technology to correct indeed to improve or replace some of our inherited genetic lapses or translational errors.

We are now struggling to find the place of human stem cell research and cloning in our search for the ultimate rejection-free tissue or organ replacement (minus their genetic defects) to treat hitherto incurable diseases.

We have still a fair way to go, but the frontiers of ethically-nebulous genetic research continue to be extended relentlessly with the promise of immortality in the biotech horizon…

Only the unknown possibly beckons: with the possible hellish island scenario of Dr Moreau’s misshapen and deformed cloned creatures! (HG Wells, The Island of Dr Moreau, 1896)

While some of these innovations have yielded promising benefits, many of these have been met with surprising mishaps and unexpected complications and miscalculations. We have simply not fully understood many of the cross talks which plague the straightforward models that we have developed—many are too simplistic and therefore incomplete…

Elsewhere, medical technological wonders have totally revolutionized many a disease landscape. Consider the field of revascularization for coronary artery disease.

When Andreas Gruentzig first proposed that using a balloon catheter to dilate the atherosclerotic plaque could improve coronary circulation in 1977, it was a paradigm shift of the very first order. Conceptually and intuitively brilliant, this technique has outgrown itself into millions of procedures carried out throughout the world—from first to third.

Currently angioplasties outnumber surgical revascularizations (CABG) by two is to one. In just a short span of less than 3 decades, interventional cardiologists have displaced and reduced the demigod status of the cardiac surgeons to highly-trained and skilled technicians scrambling and trying to minimise, micronise, and even roboticise their incisions and procedures.
But alas (sic), we still need the surgeons—they have been left with the horrendous end of the CAD stick of severe diffuse disease, poor LV function, diabetics and especially when gung-ho cardiologists screw up, etc.

Of course they are still needed for the ultimate therapy of heart transplant or ventricular assist devices… Cardiologists have even taken over pacemakers, resynchronization therapies and defibrillator implants.

Not shockingly, cardiologists have been promoted to become technology-laden pushers of new cutting-edge devices, newfangled techniques and drugs.

They have morphed into articulate exponents of a new biblical paradigm of technology-driven and costly pinhole surgery, for which their evidence bases are slim and patchy at best.

They have also hewed their hitherto hidden talents to become brilliant miniaturized technicians adept at manipulating and traversing impossibly tortuous and narrowed or occluded vessels…

Many specialists have become so one-dimensional that the expansive breadth of heart disorders has become collapsed into a humungous accretion of one stretched out system of coronary artery disease, period!

What has become so alluring and mesmerizing to erstwhile proponents of the art of action-oriented physicians is the immediate gratification of producing great looking blood vessels, with the aid of balloons, stents etc.

However, nature has its way of coming around again to haunt us with their fight-back, their unpredicted relapse, the less-than-certain prognostic outcome—the restenosis bugbear!

Using the live-demonstration model to teach to a wider audience of doctors, ‘Live’ Transcatheter (Endovascular) Courses have now exploded throughout the world—with thousands of cardiologists crisscrossing the globe to teach and learn from one another, as well as to demonstrate and show-off skills and new devices which are happily supplied by the growing number of vendors and marketers.

Younger doctors and trainees can thus be exposed to how such skillful techniques can be learnt and practiced as well as to share with the experience, and hopefully to avoid the pitfalls and mistakes of the teachers, the proctors and the skilled.

It is true that many a suffering patient has benefited from these new and wonderful techniques, and immediate symptom relief has made many enthralled with the option. In acute coronary syndromes and myocardial infarction, these techniques have been clearly life-saving and prolonging.

However, the longer term benefits for less severe and more chronic forms of CAD have remained elusive or inconclusive vis-à-vis medical treatment per se. Still, this has not deterred doctors from offering more and more of these awe-inspiring technology and therapies…

What is severely lacking however, is the time-honoured tradition of trying to fully analyze what it all means to the unwitting patient out there at the other receiving end. Are we really helping our patients out there, or are we pandering to our misperceived arrogance and self-importance?

Does trying to perform every little thing to correct anatomical lesions, really benefit our patients? Have we improved their quality of life or even their longevity or are we sometimes causing more iatrogenic problems (more harm), which we then try finding other more innovative ways to combat?

Are we causing more harm than good in the long term, or have we lost sight of our Hippocratic dictum of promoting health and treating only ill health, but not creating new ones?

On the other hand, are we guilty of the modern in-thing, to create fresh and faddish disorders or fashionable medicalisation, so that we remain relevant as health care providers, as needed experts and healers?

Have we prostituted our profession to cater unthinkingly to the changing whims and fancies of our ever demanding consumers or the perverted mindsets of our procurers—our medical pharmaceutical industrial innovators? Who’s driving who?

Perhaps it is time to take some steps back and ponder. Is it simply the modern age that’s shaping our mindset, or have we allowed ourselves to lose touch with the real world out there by becoming too attached to the changing fashions of the world?

Have we become so enamoured with becoming engaged players in a ‘reality show” of our own making, so that we stay relevant, involved?

Have our increasingly synthetic world lobotomized our usually better instincts for human values and medical professionalism?

Can we or do we want to lessen or escape the stranglehold of Modernity on the practice of Medicine?


(MMA News Editorial, July 2005)

Leadership & the Medical Profession: A Call to Arms

“Capable leaders are needed in medicine to shepherd and influence continued evolution of dynamic healthcare systems. The changes we face are profound and have crept up on doctors and many professional bodies. The ‘professional bureaucracy’, characterized by disseminated power, individual autonomy and inflexible structures, has difficulty in responding nimbly to external forces. For individual doctors, the model of professional work has moved from control by individuals to constraint by systems, from flexibility to rigidity of practice, from primacy of an individual blend of art with science to management by multi-professional teams, and most importantly for many in the profession, stability has been replaced by uncertainty and ambiguity.” ~ SB Dowton, in Leadership in medicine: where are the leaders? MJA 2004;181:652-4.

“Illness is the night-side of life, a more onerous citizenship.” ~ Susan Sontag, in Illness as metaphor and AIDS and its metaphors. New York, Picador, 1990.

Once every 2 years we elect a new president to steer and lead arguably our most representative body for the medical profession in Malaysia, the MMA.

Representing some 11 thousand members (out of around 17000 MMC-registered practitioners), carries indeed an onerous if seriously responsible task.

This duty however should never be relegated to some one or any one who is faint-hearted and who might feel that his time has come to take charge, as of one chancy opportunity by being there at the right place and at the right time.

It should never be given away by default, and the aspiring leader must earn that position of trust and know full well that the membership expects nothing less than a sterling and steadfast performance.

We expect that our president must be capable of grappling with all the issues pertinent to the medical profession and our health care, and he must robustly represent the medical professional’s views vis-à-vis any agency or authority that the MMA deals with, including the Ministry of Health and its Minister and officials.

Importantly the MMA president must be totally engaged in defending our professional interests as well as those of our patients, who have placed their implicit trust in us to speak on their behalf, on such issues as appropriate access to health care, rising healthcare costs and insurance, medical systems failures, mishaps and errors. The post of president or indeed any other position of leadership should never simply be for just any ‘seat-warmer’.

Although we need the greater participation from more of our membership, we must also not be complacent or indifferent. We need more than just the staunch worker or supporter, or the solidly loyal foot-soldier—we need more cognoscenti, who have been well-apprenticed, deeply involved and experienced in the arts, the mechanics and nuances of the mission and the spirit of the Association.

We need visionary and people–focussed leaders who can take charge by showcasing their insightful knowledge and passion in wanting to further enhance our profession, not just simply in our own narrow patch of earth or in our parochial specialty fields, but much more so in the wider perspective of national health issues and concerns.

Although this may sound pompous, it is nevertheless a genuine plea for greater involvement from all of us out there who may feel challenged or belittled. I know for a fact that there are great leaders out there who have championed multifarious causes and have led or are leading great voluntary or public organizations. We need more of you to step up to the podium and be counted.

We need not just armchair critics or backseat drivers, but more drivers, action-stars even heroes to come forward and lead. We need greater numbers of committed loyal and dedicated people willing to carry the heavy burden of apprenticeship and commitment for at least 6 years—2 as president-elect, 2 as president, and another 2 as immediate past president. This is indeed a lot to ask for, but assuredly, the personal (though not the financial) rewards can be worth the while.

For the aspiring ‘young’ leader out there, the time to act is now—get interested, committed and become involved in medical professional issues which will serve as the necessary spring board for the future.

There is nothing wrong in wanting to become a leader. Develop your zeal and your ambition early by becoming an active even vocal member, and not just serve as background noises. Get recognized as a doer and a potential chief.

Weak leadership with too little preparation or ignorance, can demean the highest position of the MMA, and belittle the lofty goals and clout which the MMA has nurtured thus far. We need more people of the highest caliber to carry the flame of a strong beacon to spotlight our mission and goals.

What is required of the enlightened leadership in this new era of changing healthcare scene?
As medical professionals we need perhaps to redefine our mission and goals. Perhaps we need to articulate a better and more meaningful identity not just for the doctors but also for the community.

Leaders need to showcase more positive and successful stories of where we the medical profession has excelled or innovated.

We must highlight our effective or contributing roles in nation building, as well as in the more sanguine aspects of healthcare delivery, promotion and research.

We also need to engage more vigorously our invited input in helping to refashion some of our national health policies and redesigning some of its strategies.

We need to serve as indispensable cross bridges for disparate groups or entities which have some stake in our health care system, always anchoring on our premise as our patient’s chief advocate. Because we are directly involved in being the primary healthcare provider, we must strive to simplify and translate the complexities of the criss-crossing pulls, tugs and tensions from all interest groups.

To quote Prof. Dowton, leaders must play a vital role in advocating for “an appropriate balance between the professional needs of individuals and their collective responsibilities to the institution, system or society”.

In other words, we need to take the lead in promoting all aspects of health or medically-related issues, so that the public can understand our commitment to their causes, as well as to our own professional ones.

Among the most pressing issues must be included:

• the right of every Malaysian to have affordable and equitable access to health care;
• the right to the best treatment available especially for catastrophic and unavoidable ailments;
• the right to reasonably inexpensive medicines and therapies
• the right to be covered by some mechanism of community-rated insurance benefits which favour the insured (preferably government-owned and run) and not the insurer or the managed care organisations;
• the right to proper and evidence-based medical or health-related information (with bogus or dicey claims being properly debunked as quackery and unscientific);
• the individual’s right to be aware of the options of cost and effectiveness, and be able to choose his own physician and healthcare system of payment or reimbursement.

Our leaders must address these complex issues of uncertainties and help interpret them so that the public and other stakeholders such as third-party payers and employers can understand the nuances of health access, costs and choices.

We must learn to plan and project ahead so that whatever financing schemes we develop in trying to provide universal healthcare for all our citizens, we must not forget to inform and apprise the authorities on the escalating trends and dizzying technological leaps which can and do ‘cost an arm and a leg’.

We need to inform the public that healthcare costs money, often lots of it, and that this cannot always be subsidized forever.

We need to demonstrate the balance sheets of healthcare expenses and reality cost invoices, so that we can become better aware of the true nature of how much is needed and are spending.

We must show that what the public has been used to paying is in reality a pittance and will no longer be an affordable option for any modern government or health authority to continue to sustain.

And we must advise the government that we have to take hugely politically-unpopular measures to counteract this fiscal disparity.

We must temper the public’s demand and physicians’ enthusiasm for newfangled technical advances with a humane touch of dispassionate aloofness and rational rationing for the greater public good.

In other words, we have to practise ‘fiscal conservatism’ with regard to utilizing our finite healthcare resources. We must push towards cost-effectiveness and efficiencies, so as to make our healthcare Ringgit lasts that much longer and for better reproducible outcomes and benefits.

Because we do not live in a vacuum, we will have to deal with other professionals and other organizations which may have divergent and perhaps even diametrically opposing views from us.

Our leaders must quickly learn to walk that thin line in accommodating and creating effective linkages with such agencies and organizations, especially healthcare system managers and our health authorities.

Nevertheless, our positions of interests and policies must always be a reflection of the membership’s wishes and resolutions. Thus, our interests must always be made very clear to those who challenge us.

Our president must defend our members when their rights and rice bowls are in jeopardy.
This pertains especially to the escalating and wanton abuse of the dispensing privileges of pharmacies, of late. Pharmacists or assistants in white coats, acting or falsely purporting to be doctors are rampant and fearless—we urge the pharmacy association to restrain their wayward members, and remind them of their code of ethics and practice, lest they be charged with the full burden of the law upon them.

Yet our leaders must also frequently and repeatedly articulate our medical professional duties and ethical concerns when these are breached by our errant members or other non-member medical doctors.

We know that a minority amongst us abuse their sacred trust and duties and engage in unethical and unprofessional conduct, and they must constantly be reminded to steer clear of such short-sighted activities.

Short-term gains and quick-fix money making enterprises must be scrupulously avoided and weighed against the potential backlash of besmirching our professional status. If one wishes to dabble in ethically-ambiguous business schemes then the onus is on oneself to switch totally to that business, and perhaps leave aside medical practice…

We must always fall back on our Hippocratic Oath and our ethical compass, when ambiguous desires surface. We must learn to challenge our conscience often and seek the path of moral clarity and not of expediency, connivance or other venal interests.

Our leaders are expected to show great transparency, integrity and authority in being able to focus on such issues and keep our membership so enlightened.

Leaders must inspire amongst us the role model to follow and adhere to. And members must be clear that they have chosen a profession which has more stringent boundaries than many others. For this singular honour, we have been bestowed upon us the prestige and trust by the public, from time immemorial. Alas, of late, some of this shine has been fluffed and lost…

We must strive to regain much of the glory and esteem of bygone times and reinvent the profession such that most if not all can admire and aspire to.

We must dispel the growing disenchantment which has been permeating the medical profession especially among our older practitioners and leaders.

We must fight the despondency from infecting our younger and more hopeful aspirant doctors and imbue them with a new generational ethos of hope, enthusiasm, excellence and mission.

Medical leaders of today and tomorrow are expected to stridently develop and advocate a set of core professional values that will help to stem the ‘current crisis of confidence’ that swirls around the medical profession.

Aside from the politics of election, we must now begin to think out of the box, and renew our commitment to serve and serve well.

Doctors, rise up to the occasion and be counted! We need all of you to be leaders.

(MMA News Editorial, March 2005)

Pondering Our Lost Art of Healing…

“Patients will not acquiesce to the ultimate alienation of being reduced to standardized objects. No one will accept for long being identified by their illness, as nothing but an assemblage of broken down biologic parts. Patients crave a partnership with their physicians who are as sensitive to their aching souls as to their malfunctioning anatomy. They yearn not for a tautly drafted business contract but for a covenant of trust between equals earned by the doctor while exercising the art of caring…
"Medicine’s profound crisis, I believe, is only partially related to ballooning costs, for the problem is far deeper than economics. In my view, the basic reason is that medicine has lost its way, if not its soul. An unwritten covenant between doctor and patient, hallowed over several millennia, is being broken.” ~ Bernard Lown, MD, Professor Emeritus, Harvard Medical School, world-renown cardiologist and Nobel Peace Laureate, in The Lost Art of Healing, Ballantine Books, 1999.

Professor Bernard Lown’s musings from more than 50 years of medical practice could not have been put more candidly. That special patient-physician relationship once the hallmark of the patient-doctor encounter, is slowly but surely dissolving into its last remaining vestiges in the acidic vat of modernity.

Has modern medicine reached its zenith and is now meeting its hubris? Have we let progress and the Knowledge economy superseded our roles by being too complacent and unprepared?

Have we been too smug in our obsolete beliefs that we are untouchable, despite the relentless “barbarians at the gate”?

Is the tenacious clinging to our paternalistic and autocratic approach too passé in today’s world? Or, have our previously paternalistic approach and superior attitude given way wholesale to the hodge-podge demands of the client, the consumer, whose every whim we must now pander to, whether it is for their ultimate benefit or otherwise?

Are we over-investigating and/or over-treating our patients for their sole benefits or for our own vested interests? Are we driven by financial and personal interests when we advocate for their choice in the best therapeutic recourse, or are we covertly perhaps subconsciously fraudulent in reshaping their decisions toward our own ends?

Have we pandered to the fashionable fads of today’s factitious wants that we dabble more and more into alternative, anti-aging and aesthetic therapies?

Indeed, are we as doctors the sole and final arbiter of what’s right and good for health these days? Sadly, the answer must be a resounding ‘No’. In this day and age, doctors have been relegated to be only one of the many bit players of an ever-expanding quagmire of our evolving health care ecosystem, which encompasses more and more players and participants.

Have patient or consumer knowledge empowerment so radically overwhelmed our sensible yet equipoise authority on what is truly best for each and every different person?

Have we surrendered en mass our balanced and well-honed judgment to the stringent inflexibility of practice guidelines of the modern era?

Has our hitherto much-vaunted physician-patient relationship expired its last breath?

Has modern medicine crossed the proverbial Rubicon, and met its overweening self-destructing conqueror—that technological disburser of ‘equal’ and one-size-fits-all health care to everyone?

Has medical practice become too scientifically or technically reductionist to the point of being all science and no art at all? Has this cold and impersonal approach driven our patients away toward other more caring practitioners of alternative systems?

Has the practice of medicine become so standardized that the 5-minute assembly-line type of patient-doctor encounter will become the norm of the future?

Have we let third party payers dictate how and what we should or could do as physicians nowadays? Do we need ‘gate-keeping’ because we could no longer be trusted to be objective and not consumed with conflicts of self-interest?

Have we floundered in our role to help everyone in need of health care, without that need to be partial to economic realities?

Have we bartered our souls to the pharmaceutical medical industrial complex, so that we are at their beck and call, as modern day drug-pushers?

Or has modern medicine favoured inequitably the rich and the powerful and those with a bigger buying power?

Are we now so enamoured with our own personal importance and well-being that we have neglected the paramount interests of our raison d’étre, our patients?

Have we debased the shifting ethics of our profession and sold our souls to the god of Mammon and the overarching supremacy of the modern consumerist? Whither our roles and place as modern day physicians?

Surprisingly, although doctors have been besieged with relentless crises after crises, many school leaving students still wish to become doctors.

Our perennial woes—from too little remuneration, too much work, long backbreaking hours, extensively prolonged apprenticeship and training, compulsory national service, intemperate competition (from fellow doctors, unscrupulous but bloodthirsty retail pharmacists, sinsehs, bomohs, qi gong masters, Ayurvedic physicians, alternative pliers of dubious therapies, etc.), rising medico-legal litigation, unwanted supervision from nonphysician corporations and managed care organizations, insurers, and third party payers, may seem insurmountable and inescapable—but these do not seem to deter the steady stream of aspirants from wanting to join our teeming but beleaguered ranks…

Perception from the public has never been more challenging and negative, even sneeringly envious and distrustful. Yet, when asked pointedly which profession the public respects the most, physicians still manage to come out tops in most societies—perhaps because other professionals are deemed even more cynically ignoble.

Nonetheless, despite these many questions which should interest the thinking doctor, there remains that implicit noble precept and understated prestige which colours our profession, and emanates that subtle but wholesome whiff of sanity of what it still means to be a physician.

Shouldn’t we all try and recapture our souls so that modern medicine in its finest glory can be the best, the safest and the most beneficent to everyone—regardless of all secondary concerns—equitably accessible to all.

Let’s all ponder some moments to reignite that inner voice of why we chose to become physicians in the first instance, and let our forgotten art of healing emerge.

(MMA News Editorial, November 2005)

Equitable Access to Health Care for All

Equitable Access to Health Care for All: Is this still a Pipe Dream for Malaysians? A Medical Professional's Perspective

Dr David KL Quek, KMN, MBBS (Mal), MRCP (UK), FRCP (Lon), FAMM (Mal), FNHAM (Mal), FASCC (ASEAN), FCCP (USA), FACC (USA)
MMA representative to Suhakam's “Human Rights & Access to Equitable Healthcare” Dialogue, Kota Kinabalu, Sabah, 08 January 2008

“The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.” ~ Julian Tudor Hart: ʻThe inverse care law.' The Lancet, 1971

“The reason we don’t know that we know things is that they conflict with more powerful ideas, and so we see them but fail to recognise them. The idea that inequality is a sign of economic health and social vigour is too compelling to permit serious engagement with the idea that inequality is anti-social and a cause of illness. We need to be told what we know, instinctively, about what makes a good society.” ~Marek Kohn, in Prospect magazine, September 2005.

Malaysians in general have had a sterling achievement in terms of advancement of human capital development, for the past 50 years since independence.

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 years and 76.3 years, as of 2006. Infant and maternal mortality rates have markedly decreased to current levels, which equal those of developed nations.

Our primary health care service especially the rural health service has long been the envy and role model for other developing countries around the globe to emulate, deservedly endorsed by various agencies of the World Health Organization. I will not discuss this aspect further, but would concentrate more on the actual secondary and tertiary medical care access issues and their problems as these impinge upon the rights of the Malaysian patient.

In a recent high–level policy paper by SUHAKAM/UNDP [the Human Rights Perspective on Millennium Development Goals (MDGs)], one specific area of thrust to help move toward policy and practical goals is through improving the health status for Malaysians. These goals are articulated as follows:

Improving the health status

• Policies and programmes that provide improved health care for the poor and vulnerable groups, as well as for the growing number of older persons, need to be formulated and implemented.
• The poor must be excluded from user charges with increased privatization of health services.
• Reproductive health targets, including those for adolescents, should be set, to further improve maternal health.
• Sexual education in schools, as well as through civil society and religious organizations, should be intensified, to prevent health problems, such as the spread of the HIV/AIDS epidemic and pregnancy among youths.
• Country-specific MDG plus targets relating to mental health, heart disease, and cancer should be set and monitored.

Yet, when one turns the pages of our daily newspapers, we are invariably accosted with pleas and requests for financial help to pay for some expensive, supposedly urgent life-saving medical services—particularly heart-rending stories when they involve babies and young children. This constant ʻbegging' for alms to help defray medical therapies and surgeries is unbecoming of a nation which aspires to be a fully developed one by 2020, i.e. a mere 13 years away.

A few years ago, when such pleas became too embarrassingly shameful to bear, the Ministry of Health initiated a Medical Assistance Fund (MAF). Unfortunately, despite occasional injection of funds from public pledges and the government, the distribution of such monies have been painfully slow, pedantically bureaucratic, and sporadic—so much so that the deprived still resorted to direct pleadings via the mass media to implore some sympathetic charitable souls to help out.

From a recent press statement by our DG of Health Tan Sri Datuk Ismail Merican, this MAF is now topped up to RM 25 million, but this will only be available to requests for treatment at government and public institutions only, which effectively excludes those seeking treatment from the private sector or overseas.

Another emergency fund launched by the Ministry of Health in collaboration with the National Welfare Foundation called “D’tik YKN” has been set up recently. It has received an initial allocation of RM 5 million. (“D’tik” is an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara.) This fund 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.

Surely there must be a better mechanism to address these clangorous but pitiful entreaties for help from among the less well-to-do, the underprivileged, or simply the uninsured, or underinsured.

How is it that for so long we seemed to have weathered such demands in the past without these coming to the surface? Were there factually fewer cases requiring such special tertiary surgeries or therapies previously, say some 20-30 years ago? Or is it because we were less sophisticated then, more ignorant, and therefore less demanding of what medical treatment we are entitled to?

Perhaps over the past 2 or 3 decades we have become exposed to the stupendous advancement of medical progress, such that once desperately untreatable conditions are now given new hope of cure or palliation? Better education, improved literacy level and increasing human self-esteem and the huge explosion of information accessibility, especially via the Internet, have clearly contributed to this knowledge dissemination. Greater wealth distribution has of course also added to this new empowerment for more perceived rights and entitlement as citizens.

Health expenditure still low
However, Malaysia's health expenditure remains contentiously low. A total of 3.8% of the nation's GDP is spent on health care, with the public sector (i.e. government spending) accounting for 2.2% and private funding 1.6%. On average per capita, we spent only 374 PPP-USD for health in 2003, and we have 70 physicians per 100,000 population (i.e. one doctor for every 1428 citizens).

What is peculiar to Malaysia is that we have always had a rather mature dual system of health care service sectors—an incongruous dichotomy of private versus public health care sectors. There have been several papers presented to try and assimilate and integrate these two sectors so that they complement rather than duplicate each other, but so far, little has been achieved despite common thoughts on sharing patient information and talk of portable (IT-savvy electronic) personal health records.

The public healthcare sector is heavily subsidized by the government, and caters to the huge civil service employees, as well as to the less well-of (it is almost free from co-payments), such that some 70% (perhaps as high as 75%) of the population actually utilize these services almost exclusively; because for most, this is all what many perceive that they can afford to access any form of health care services, for themselves and their families.

One ringgit for consultation and medicines as an outpatient is clearly an economic anomaly, if any, to be considered as a co-payment for any health care service available anywhere in the world. Yet, our Malaysian public has been made so accustomed to this paltry sum (this cannot even pay for a bus fare or a canned drink) that it would appear politically inexpedient if any such fee adjustments were to be made or suggested.

So the government has to continue to appease the public and the electorate by staying this unsustainable course. Of course one can argue that for basic and emergency health care even the poorest can have access to treatment in most if not all of Malaysia's public health care sector.

It is true that there are sporadic attempts to offer affordable health services for the poor, but these are often fraught with uncertainties and limited scopes for the actual service rendered—it is not enough to simply offer advice and information—what is more important is that patients should also have access to what can be done—what treatment or surgery can be offered, without having to seek other alternative avenues of assistance.

However, Malaysians also expect modernization and better amenities of their health care services. Thus, huge amounts are allocated and have been spent on bringing up-to-date state-of-the-art equipment and facilities to nearly all of the major hospitals of every state or towns.

While such expenditure is laudable, there is a growing sense among the more discerning public, of possible wastage, less than spectacular structural excellence— from the outset many facilities are beset (some before being launched, even!) with ceiling leakages, mouldy infestations, structural defects, questionable fitness-to-operate certification, etc. These together with other dubious turn-key acquisition of costly equipment and beds, arguably make these hugely expensive facilities appear less than the best that they can be managed and/or run. We appear not to have achieved a bigger bang for the buck, so to speak.

State-of-the-Art Hospitals and Co-payments
When new modern state-of-the-art hospitals (built and equipped to the tune of hundreds of millions of ringgit, e.g. Selayang and PutraJaya Hospitals) are restructured so that full-paying patients can be charged for first class treatment—many protests were made, due to fears that the marginalized would once again be shortchanged and possibly neglected. It is not unreasonably feared that those who cannot pay may be made to wait unfairly long for therapies or surgeries which they need—that they might be preferentially sidelined by those who could afford to pay.

The Ministry of Health clearly views this option very differently, with the Minister Dato' Seri Dr Chua stating recently that patients are already enjoying the benefits, with some 103 patients paying some RM 116,000 as full-paying patients, with a small portion being disbursed to doctors.

Also another recent opinion piece commended the Ministry's move, stating that allowing this practice at these private wings might help retain some senior specialists from either resigning to join the private sector or even to practice as locum outside the public domain. In turn, these medical specialists can help remain in the MOH and still contribute to looking after the poorer patients in the respective hospitals.

However, some other critics are less sanguine about this practice. There have been examples bandied about that certain private wings of university medical centres are already practicing such preferential favoritism when dealing with fee-paying versus subsidized patients—that specialist medical treatments are offered fee-paying patients almost without any waiting time, whereas the poor have been made to queue, which can run into months, perhaps even years!

The uncomfortable truth is that, many of those in the queue have been told that they can always expedite their case when and once they have the requisite funds! Hence, the resorting to pleas for financial assistance from the public via the mass media, demeaning as this may be.

There is another problem—that of specialists and experienced staff leaving the public for the private sector. The usual cause for this ʻsenior staff hemorrhaging' is the financial ʻpull' factor.

Rightly or wrongly, the private sector is perceived of as being far more worthwhile, certainly more financially rewarding than the meagre public wages paid for slogging through the humdrum drudgery and thankless services for the masses.

Bureaucratic and office politics are other ʻpush' factors for this migration to so-called greener pastures of the private health care sector. This has led to the incongruity where some 60% of all the nation's physicians (in the private sector) are looking after some ʻprivileged' 30% of the population, and vice-versa! The depleted public sector doctors (some 40%) have to manage the greater 70% of population!

The perceived discrepancy between the public and private sector doctors' wages remain an unresolved bone of contention. Being part and parcel of the public services, only special allowances can be allocated to improve the final take-home pay for doctors. Of course this has been made more attractive lately with the abolishing of taxes on some of these allowances.

Still, some attrition to the private sector continues, and public sector shortages and congestion remain problems—which can affect timely and free access for poorer patients, using the system. The nearly-free treatment provided may sometimes be too much for the government to afford.

Yet, despite these misgivings, our Malaysian public has also been led to believe that health care costs in Malaysia are exorbitant, i.e. the private sector is charging too much; that doctors are profiting unfairly at the expense of the unfortunate public.

Surprisingly but not always obviously exposed, when we compare private medical practice fees and medical costs in Malaysia, we are actually modestly inexpensive—largely because our doctor's professional fees are consistently lower than those in neighbouring countries.

We are attracting foreign healthcare tourists because of our perceived modern facilities, greater technical and expert skills as well as affordability and cost-effectiveness. However, some people are unhappy as to this lopsided push for more tourist health dollars, which they feel may further disadvantage the poor.

But it is true that by and large, those who are uninsured and who are not civil servants, can find it expensive and in some cases unaffordable, when they seek private medical health care. Thus, their access to health care can be curtailed and they may resort to self-delays or seek alternative therapies, which in the long run may endanger their health even further. Others sometimes think that they can afford private health care initially, only to be burdened by high charges which accrue when complications set it unexpectedly or when unforeseen.

Unfortunately, there is no mechanism to assist such patients caught in such quandaries. However, most private medical facilities would offer discounts and even waive most of the extra charges, when they can after assessing the socioeconomic background of the patients and their families. But some also had legal demands dumped on them to reimburse these hospital charges, which can bankrupt the unwary.

What do modern patients want in health care?
In a recent report (A Clinical Vision of a reformed NHS, 2007) by the Joint Medical Consultative Council (JMCC) and the NHS, it was reported that the following are what patients want from their health care experience:

• Fast access to reliable health advice
• Effective treatment delivered by trusted professionals
• Participation in decisions and respect for preferences
• Clear, comprehensive information and support for self-care
• Attention to physical and environmental needs
• Emotional support, empathy and respect
• Involvement of, and support for family and carers
• Continuity of care and smooth transitions

The public as citizens may be concerned with abstract notions of good service such as affordability—free at the point of care; universality and equity; safety and quality; and health protection and disease prevention.

Although we do not have a similar survey conducted in Malaysia, I believe that many among the public would agree that the above-mentioned features are what they too aspire our health care service to be. Most importantly, everyone expects to have ʻreasonable' access to reliable effective and safe health care and advice. The problem is what is considered as ʻreasonable'?

Which model is sustainable?
This concept of universal access to health care is not easy to define or to delimit or more optimistically what it should embrace. Can it be a ʻbe all' and free for all comers? Clearly this is not a feasible nor reasonable option unless of course, we have command economy where every aspect of healthcare services is state-controlled and delivered via a system of one all-inclusive integrated services—there being no private sector or third party insurer or payer.

Unless we adopt such a radical or revolutionary change, as that practiced by communist Cuba, then we have to find an alternative approach—one that melds the two divergent arms of the private and public sector into a coherent complementary system.

Although many nations are increasingly looking toward the model of the NHS in UK, many are fully aware of its severe shortcomings and its rapidly evolving and chameleon-like shifts in practices and approaches.

The laissez faire free-for-all system as now practiced by the United States is clearly flawed and far too expensive (15% of the national GDP!) and leave too many disadvantaged groups fully neglected or uninsured (some 46 million people!) including many children and elderly (although the latter is assisted by Medicaid).

Other highly dependent state-insured nations such as the Netherlands, New Zealand are smaller populated but richer nations which spend an inordinately high portion of their social taxes on health, social and individual taxes can reach 50 percent or more—something that our country simply cannot match as of this juncture.

Germany for example, has a statutory health insurance system where 78% of the population contributes, the remainder being voluntary members or pay private insurance; in 2003 88% of the population has social health insurance.

However, it is estimated that only 30% (1.1 million tax-payers only!) of our adult population is paying any form of income tax or provident fund savings—how then can we raise sufficient community-rated premiums to help defray the enormous cost of health care for all?

Modified single insurer states such as Taiwan are facing serious financial crunches after grappling with an erstwhile successful model for the initial years—spiralling costs from more and more advanced treatment options are exhausting whatever reserves or spread of risks for its rapidly-ageing public. End-of-year credit squeezes and fund exhaustion (from DRG disbursements) are hampering high-cost surgical or medical procedures and therapies, thus elective procedural deferment and waiting times are increasing once again…

Co-payments are now being suggested as are rationing of certain forms of less than urgent or life-saving forms of therapies. In Germany, a physician fee of 10 euros is charged for a first visit to either GP or specialist, but free for other contacts within a quarter-year, if referred, to prevent doctor-hopping.

Our current model of private and public sector health care dichotomy is not without flaws, but is one that has provided reasonable access to health care for nearly everyone, with the public sector facilities serving as a fall-back safety net, whenever, higher costs therapies and surgeries preclude the patient from affording them.

This model may be sufficiently robust as to be tweaked and adapted so that we have a system which can work more efficiently with less wastage, despite our paltry expenditure as a whole. Although the health care budget is touted as some 5% of the GDP, actual government spending on health care and services amount to at most 2.6 to 3%, which is way below the number suggested by WHO and most health care advocates (which is around 8% of a nation's GDP).

Imagine if we can allocate another 5% into the healthcare budget, we can clearly achieve so much more and provide even better care and hopefully more access to cover more of the population, rather than the recurrent hiccups we encounter almost daily, these days.

A New National Health Care Financing Scheme and Authority
For a long time the MMA through its National Health Policy and Planning Committee headed previously by past president Dato RS McCoy have advocated a single-payer National Health Plan, which was presented to the government in a comprehensive monograph titled “Health for All”. We understand that large sections of our single-payer initiative proposal have been incorporated into the proposed scheme by the MOH in the National Health Care Financing Scheme (NHCFS).

Although in the beginning the MMA was enthusiastic about this development of the NHCFS, over the past few years, the very many alterations and distortions which have crept into the scheme, have created many concerns and doubts among those who had earlier favoured this approach.

This plan was earlier mooted as a single community-rated insurance scheme, which will provide mandatory and statutory cover for every Malaysian, through a central-collection and distribution system. Regional trust authorities were to be formed which act as gatekeepers as well as disbursers of funds and allocation of resources, so that healthcare costs can be contained; and excesses, wastage and duplication of services and testing are prevented or reduced.

A shared provident-insurance premium contribution is supposed to have been made by both employer and employee. What has not been agreed to, is the quantum of contribution, and whether this now dispenses with other health insurance incentives/benefits which employers now offer to many of their workers.

Furthermore, additional coverage premiums for family members remain uncertain, and factoring in this additional deduction based on the number of
dependents can clearly be difficult for a large segment of the public. What about the self-employed and the unemployed?

Then, there is the question of civil servants, the police and military personnel which the government has indicated that they would be provided for from the existing system, and that they would remain outside this new NHCFS. This has drawn huge criticism that a large proportion of the population (including their not unsizeable dependents) would therefore not be participating in this so-called ʻnational' health care financing scheme. Thus, this could unfairly burden the private sector with a disproportionate burden of the community-rated insurance scheme.

There is fear that there might be cross-subsidies to the public healthcare sector because the available public sector healthcare facilities would still be offering their services to privately-insured citizens, and hence be receiving reimbursement from this same financing authority. Separation of costs and services would become an unmanageable reality, and privately-insured citizens paying such additional insurance premiums could be paying far more than his or her fair share.

Therefore, although the NHCFS has been suggested as an all-embracing model, the manner of implementation appears fragmentary and less than convincing towards a health care system which offers universal access for all Malaysians. Interestingly after some review and counter-proposals from yet another Health Care Commission (Karol), the implementation of this NHCFS has been deferred to the next 10th Malaysia Plan.

I don't pretend to have all the answers, but clearly if we are to revamp our health care services so drastically as to have a “National Health Care Financing Scheme” then clearly this should be one that encompasses every citizen, and not piecemeal adaptation which only helps to complicate the practical issues on the ground. The very large segment of the population that comprises the civil services, must also fall under this category, otherwise the system would fail, as costs cross-coverage would surely be unavoidable and difficult to control.

Rather perhaps we could instill a newer mandated approach where each employed person be given incentives to insure himself and his family, and that a reasonable raft of healthcare services available should always be made accessible—either through some co-payment (Medicare model) or Medicaid when even the most indigent cannot afford. This must cover some regulated and specified diseases or ailments, and must include catastrophic illnesses which can often bankrupt even the most modestly middle-class of the citizens.

Which health care services should be readily accessible/available to everyone?
This sounds clichéd but becomes the lynch pin of any health care service in the world. Most would agree that all medical emergencies should fall under this category, where any ill person should have and must have access to life-saving or limb-salvaging care at the most urgent and timely manner as possible.

Still medical experts and regulators must identify specifically what should be the type and extent of health care which can be offered without due consideration as to costs and reimbursement. Clearly too, such often costly medical care must be insured upon (a central insurance mechanism or financing authority to reimburse claims to these cases) so that total coverage of an acceptable quantum can be disbursed to whichever sector is handling these emergencies—so that these would not bankrupt the system.

Would the DRG (Diagnosis-Related Groups) model work, and if so, have sufficient means testing been done to determine what the actual average costs are? Clearly in many countries where this is practiced, constant revision and meticulous attention to constantly shifting details and changes (socioeconomic, medical advances and newer techniques and technology costs and skills development, etc.), are a must. Still having said this, most DRG models utilize their allocated funds within shorter periods than have been projected, with unavoidable delays and deferments toward the end of each fiscal year.

Another very pressing issue of very great public concern, is that of catastrophic ailments such as major heart and brain affectations, critical infections (HIV/AIDS; SARS, Nipah, Enterovirus-Coxsackie, Meningitis, poliomyelitis, etc) and cancers. These must also be very clearly enunciated and itemized so that they are covered for the ordinary citizen.

How much coverage and to which extent would also have to be delineated. Then there is the question of prioritization and rationing—invariably there would be some degree of waiting and queuing and the question of how long, and triaging sicker patients who need treatment more urgently than others.

How can we make our public understand that these are necessary evils, which takes place in a finite system of services with finite limited resources, no matter the allocation?

If we allow a free-for-all access to all-comers whenever and wherever, then clearly costs will balloon and easily reach stratospheric levels of exorbitance and wastes. Perhaps the role of the National Health Care Financing Scheme would be able to encompass all such concerns and address these in models, which are not too bureaucratic or doctrinaire, where access can be stymied.

However, there must be some common ground for which to agree upon a system that works for Malaysia. We believe the government and the Ministry of Health must engage all interested parties to fully dialogue on this very pressing issue, so that everyone's interests can be represented.

A cut-and-paste approach behind several layers of closed doors and OSA dictates will only stifle rigorous and fair debate on this issue which involves and affects everyone. Ultimately there will have to be concessions and compromises. But, a user-friendly cost-effective and sustainable system beckons.

“First, let us embrace market economics - yes - but also recognize that free market economics are passé. We need an active role of the state, to help the poorest to break free of the poverty trap, and to help narrow the inequalities of a high-income market society… Let us understand that economic solidarity is insurance for all, the poor and the rich… Let us resolve to honor our commitments in the fight against poverty, hunger, and disease. Our commitments are small compared with our vast wealth, and the benefits will be vast.” —Jeffrey Sachs, Economics Professor, Columbia University, New York, in the BBC World Service Reith Lecture, 2007.