Moments of Madness…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Private-Public Partnership in Healthcare for Malaysia

Abstract. Malaysia has a dual-tiered system of healthcare services: a government-led and funded public sector, and a thriving private sector creating a dichotomous yet synergistic public-private model. However, we don’t have a unified system of universal access to healthcare for every citizen. The public sector caters to the bulk of the population (~65%), but is served by just 45% of all registered doctors, and even fewer specialists (25-30%).

The heavily subsidised public sector is almost entirely borne by budget allocations, with patients paying only nominal fees for access to both outpatients and hospitalisations. The private sector on the other hand, has grown tremendously over the past 25 years. However, this two-tiered system with quite different goals may be unsustainable in the longer term.

There appears to be ambivalence as to whether to adopt a market-driven healthcare system or to resort to single-payer National Health Service model where universal access to health care is guaranteed. Closer collaboration and sharing of services and personnel may be the way forward.

An integrated system of medical information and expertise access may lead to greater cohesion and efficiency of healthcare services. More cross-purchases of services should be facilitated where there are shortages. Information exchange can be made efficient through the use of a unified system of health information portability mechanisms, while safeguarding and ensuring patient confidentiality and privacy.

Full integration of private-public healthcare sectors appears unlikely, but better partnership and collaboration of services can be aspired to, where the best of each system can be harnessed for the healthcare betterment of our citizens. We should aim for a more cost-effective system. A single or easily portable system of reimbursement should also be considered.

Keywords: Healthcare Partnership, Healthcare Services Sharing, Integration, Information technology, Corporatisation


1. INTRODUCTION

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

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

On the one hand, there has always been an overarching concern for the common citizen, especially the poorer segment of Malaysian society, where there is an implied social contract and acknowledged ‘right’. There is a deep-seated commitment of the Malaysian government to eradicate poverty and develop human capital.(1)

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

On the other hand however, there appears to be a covert if unannounced shift in thinking that eventual corporatization of the public sector facilities and services should be allowed to unfold, where market forces dictates the price, extent and quality of the services offered. The ultimate aim is that the government should play only a regulatory, monitoring and facilitator role to safeguard the welfare of its citizens, while at the same time encouraging growth of the less-bureaucratic, better-run and more competitive private sector.(2)

Thus, despite public dissent, over the past 20 years or so, there have been sporadic if partially successful attempts to privatize or corporatize various components of the public health sector, e.g. the government’s drug procurement and distribution centre (to UEM’s subsidiary Southern Task, later renamed as Remedi Pharmaceuticals, then as Pharmaniaga); and the divestment of its support services (cleaning, linen, laundry, clinical waste management, biomedical engineering maintenance) to Pantai Medivest, Radicare and Faber Mediverse.(3)

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

A UNDP Human Development Report (2006) paper determined that in 2005, the Malaysian government spent just 2.2% of its gross domestic product as its contribution to the public sector healthcare funding, while some 1.6% of our health care expenditure came from the private sector.(4) The World Health Report 2006 stated that the Malaysian government spends some 6.9% of its total expenditure, on health care.(5)

Yet despite such a low level of national investment on healthcare (just 3.8% of GDP), we have achieved quite laudable health outcomes results. Our life expectancy at birth has risen from 55.8 years and 58.2 years for men and women, respectively in 1957, to 71.8 and 76.3 years, respectively for 2006.(6)

The tax-funded public healthcare sector caters for the bulk of the population (~65%), but is served by just about 45% of all registered doctors, and even fewer specialists ((25-30%).(7) The cost of these services is almost entirely borne by budget allocations from the central treasury, with patients paying paltry nominal sums for access both to outpatient clinics or admissions to hospitals. These are offered at unrealistically cheap but clearly cost-effective if heavily subsidised rates. However, this is questionably sustainable in the longer term, if we allow market forces to prevail.(8)

2. PUBLIC HEALTHCARE SECTOR

2.1 Rural Health Service
This is one of the largest sectors in the services department whereby the government provides almost all the infrastructure and the human resources. Doctors, nurses, pharmacists, dentists and other allied healthcare workers are employed and deployed by the Minister of Health to various healthcare centres: from rural clinics to district hospitals to tertiary specialist hospitals throughout the country.

The distribution of these resources to various parts of the nation is arguably based on the size, need and population of the various districts and states. However, the reality is that in the rural and more mountainous or remote (less accessible river-bound or jungle/forest) regions, the deployment of facilities as well as manpower is uneven and there remains great disparity and inequitable distribution of health care personnel, especially doctors.

Nevertheless, Malaysia boasts of having a healthcare facility within every 5 km radius, which, renders especially for the rural folk, relatively easy access to these clinics whenever the need arises. However, not all are manned with adequately trained staff—most are under the charge of a jururawat desa (or rural health nurse), with sporadic visits by a medical assistant or a doctor, ranging from weekly to monthly schedules.(3)

Deployment of medical personnel to such rural sites remains very unpopular with the better-trained and educated staff, that views the remoteness of such postings, unrewarding. There should be greater monetary and even promotional/seniority incentives such as hardship allowances or tax breaks, (such have been offered to teachers) promised preferential selection for training and development protocols and career development, to attract more doctors and personnel to such areas.(9)

The MMA (Malaysian Medical Association), through its Section Concerning House Officers, Medical Officers and Specialists (SCHOMOS) has been arguing for more structured deployment planning, such that even with these incentives, there should be detailed contractual undertakings that these personnel would be re-deployed to bigger centres of their choice, (for clearer career development programmes or pathway) once they have completed their ‘hardship’ service in the interior.(10)

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

2.2 Tertiary Healthcare Services
Notwithstanding these problems, the past 5 decades have seen the Malaysian healthcare structure remaining quite well integrated. The rural health service provides effective primary healthcare coverage, which is connected to large hospitals in each state and the capital city through a unique system of referral. For medical and surgical emergencies, these are adequately provided for, with a government-managed fleet of ambulances, including airlift capacities for more interior remote sites.

Tertiary Care Hospitals have recently made its presence felt in the Malaysian public healthcare sector, beginning in the 1980s, with the expansion and privatisation of the University of Malaya Specialist Centre (Petaling Jaya), and the building of the Universiti Kebangsaan Malaysia Medical Centre (Bandar Tun Razak, Kuala Lumpur), and the renowned National Heart Institute (Institut Jantung Negara, IJN), along Jalan Tun Razak.

These have provided excellent specialist care for several highly specialized medical disciplines such as cardiology, cardiothoracic surgery, nephrology, cancer care, neurology and some infectious diseases. These however cater predominantly to our Malaysian civil servants, pensioners and their dependents (including many of our VVIPs), but due to facility constraints, long waiting times are now the norm.

In the past decade or so, several other public hospitals with tertiary specialist facilities have been developed in most major cities in the country, in Penang, Melaka, Johor Bahru, Kuching, Serdang, Selayang, Ampang, Sungai Buluh, Kota Bharu, Kuantan and Kota Kinabalu.

Although these have added to the capacity to cater to the growing demands for tertiary specialist medical care, the problems of understaffing and staff poaching continue. We seem to be unable to adequately provide enough manpower and skills development to sustain better than average care at these centres.

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

Currently, in Kota Kinabalu, Sabah, cardiology and cardiac surgical services are purchased with weekly rotations of specialists from the corporatized IJN, at hefty prices. Also being a corporatized medical centre, the IJN has been billing the government to take care of its public servants, pensioners and referrals from its MOH hospitals and clinics. This comes at a premium, with the government reimbursing some RM 31.3 to 144.5 million per year, from 1993 through 2004, respectively, for these services.(11)

However, because of higher wages and better work conditions/benefits, specialists at the IJN appear to have less rapid turnover (3% annually), and thus enjoy greater consistency and continuity of services.(12) This also makes continuing manpower and specialist training possible, too, to enable it to maintain its reputation as a centre of excellence. But obviously this comes at a higher cost—perhaps this expenditure is more realistic in terms of healthcare economics. This successful model has now made it an object for takeover by a GLC, Sime Darby Bhd.(2)

So this model of public-private partnership appears to be successful and beneficial and attempts have been made to have it emulated. However, there have been serious misgivings about this concept of healthcare reform because of its wider socio-economic implications; the Coalition Against Health Care Privatisation has been most vocal against any development toward the passing of any extra cost to the public.(13,14,15)

2.4 Full Paying Patient
In 2005, another patient fee-paying system was introduced i.e. Full Paying Patient (FPP) scheme, where part of the fees were used for physicians’ reimbursement to supplement their income/allowance. Thus, this scheme provides those who are willing to pay more, quicker access and shorter waiting times for elective surgeries and other therapies. While this is one mechanism to recover some costs for the healthcare system, it is only a minor fraction of what the system truly costs. There has been great unhappiness that this will only encourage queue jumping from those who are well-to-do, and therefore penalise the poor and less-financially endowed, and consumer pressure groups have called for their abandonment.(13,14)

Still, the sporadic but unending attrition of losing specialist to the private sector has long been the problem of the public healthcare sector, and staff and expertise retention is a perennial problem, which has yet to be resolved or tackled sensibly and judiciously. Some 300 doctors and 50 specialists leave the public sector annually.(7,14,15)

3. PRIVATE HEALTHCARE SECTOR

The private sector on the other hand, has always attracted both general and family physicians who had opted out by opening individual clinics or by joining more established group practices; while specialists join the better-paying more personalised care practices in urban private medical centres.

Private healthcare expansion began in earnest during the Mahathir premiership in the 1980s, where private hospital beds increased nearly 10-fold (from 1171 to 10405 between 1980 to 2003), and the private sector’s share of hospital beds increased from 3.9-5.8% to 23.4-26.7%.(16,17)

On average over the years depending on the economic circumstances, this private sector constitutes around 55% of all registered doctors, who look after some 25% of the population, most on a self-paying fee-for-service arrangement, and increasingly through some third party paying (e.g. health insurance) mechanisms.(18)

3.1 General Practitioner Clinics
Importantly nationwide, private clinics cater to most of the fee-for-service self-paying public, which include: private sector employees through panel doctor contract/insurance arrangement; thus relieving the already overloaded Ministry of Health’s public clinics. In general, the choice for such private clinic consultations and treatment is due to easier access, simpler registration and appointment, and shorter waiting times.

There is also possibly greater continuity of care with better personal attention from one’s own family physician or general practitioner—i.e. superior personal touches and closer encounters are the added values in private clinic visits, despite greater fees for consultation and medicines, which are frequently bundled together.

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

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

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

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

This underutilisation of many urban clinics is wasteful, and could perhaps be one mechanism to help out the overcrowded public sector outpatient clinics. Redistributing public sector patients who sometimes have to wait several hours, to a panel of urban or suburban private clinics nearer their home, can be a real option for better patient care and attention. A payment mechanism can be worked out to address this purchasing of services, which will generate a win-win scenario for all concerned.

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

However, private medical centres are not simply for emergency and/or trauma care. Most are now developed as competitive consumer-driven full-fledged healthcare facilities to cater for the more discerning public who would pay more to obtain perhaps better (perceptibly), more personalised, faster (less or no waiting time) and possibly more comfortable and/or luxurious medical care. Health insurance or maintenance organisations have also bought into this system to offer more premium benefits to their clients, particularly those of the corporate world, where risk-averse and delay-averse market-driven results are expected. Executives and staff are offered contracted quicker and direct access to possibly more expert specialised care, with faster turnaround times and earlier return to work expectations.

Of late, the entry of different national and transnational capital flow into the private healthcare system has further developed the service capacities of this sector. Healthcare industry players such as the state-owned KPJ group (Johor State Development Board), Parkway Holdings (Singapore-based, American-invested), and latterly Khazanah National Berhad (a Ministry of Finance Malaysian GLC) have greatly influenced the direction and expansion of these private services, while at the same time inflating the cost of private health care services by offering more sophisticated amenities and newer technology-driven expert care. Together with the Association of Private Hospitals (APHM), there has been a move to expand the services toward attracting foreign medical tourists, which is targeted to grow to 30% in 2008, and nearly 1 billion ringgit as of 2005.(17,19)

3.3 Private Healthcare Facilities and Services Act/Regulations
Currently, the Private Health Care Facilities and Services Act (PHCFSA)(20) and Regulations (PHCFSR)(21) have prodded the private sector to transform for the better, purportedly for safeguarding the safety of patients. But forced administrative micro-management, stiff fines and restrictions have angered many private medical practitioners.(22)

Many are unhappy with the highhanded tone and manner of the regulations, inspections and implementation, which have been construed as trying to criminalise doctors.(23) At least one physician had been jailed for technical non-registration, and a few have been fined heavily because of technical breaches of these new regulations. Some clinics have been inspected with disdain and rudeness.(24)

4. HEALTHCARE SPENDING & ACCESS ISSUES(2)

Healthcare spending is still suboptimum in Malaysia, the government spending just 6.9% of its total expenditure on health care services (i.e. 2.2% of the GDP). In 2003, Malaysians spend just USD 374 in total (Purchasing Power Parity) per person per year on healthcare expenditure, with the government contributing USD 218.(5)

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

Out-of-pocket spending as a percentage of private expenditure on health takes up about 75% of the total costs, with some form of private prepaid plans (e.g. insurance) contributing 11.9 to 14.2% over the years from 1999 to 2003. Social security expenditure as a percentage of general government spending on health hovers around 0.8% only, mostly from requested withdrawals from the specific allowable account within the Employee Providence Fund savings (EPF).(5)

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

There has been flip-flopping ambiguity from the MOH, as whether to allow market forces to dictate healthcare costs, but overall, there has been no public will to enact what could be unpopular.(2) Suggestions to end free treatment at public hospitals and highlighting that rising healthcare cost is too heavy a burden for the government, had not been too well-received by the citizens.(25,26)

This strategy seemed to have disappeared following the recent electoral setbacks of the incumbent government. In a recent interview for internet media Malaysiakini, the new health minister Dato’ Liow admitted that the public hospital services are heavily subsidised by the government: RM12.9 billion or 98% of the entire budget, while patients paid only 2%! But, Dato’ Liow reiterated his views that government subsidies for patients utilising public healthcare facilities would continue (RM1 for outpatients clinic visits, RM5 for specialist clinic visits, and maximum RM50 for third-class ward hospitalisation costs), and pledged the populist view that such a quantum would continue, despite this being unchanged since the 1970s!(27)

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

4.2 Access Failure & Medical Assistance Fund
But concerns as to failures in access continue to pop up sporadically in the mass media.(28) Poorer patients have resorted to the mass media appealing for financial assistance to help defray medical costs, especially for some costly or tertiary specialist care—e.g. in one week alone in October 2007, there were at least 3 appeals for help.(29,30,31)

Thus, this has prompted some stopgap measures such as setting up a Medical Assistance Fund (MAF) of RM 25 million, by the Ministry of Health. However, this fund can only be utilised at public or quasi-governmental healthcare facilities, and appeals have to be vetted stringently to ensure need and priority, which had drawn sharp criticisms of this being too bureaucratic and slow, even unfair.(32)

Yet another Emergency Fund (D’tik, an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara) has been set up. This fund of RM5 million, provides critically ill patients access to treatment within 24 to 72 hours, but is currently only available at Kuala Lumpur Hospital as its pilot medical facility to kick-start the programme.(8,26)

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

4.3 Corporatisation / Privatisation Controversy
Earlier hints that the public sector health services should be restructured into a government-owned non-profit entity, made economic sense in its first offering. This ‘corporatisation’ model implied converting most of the larger public hospitals into operating as quasi-private entities. This would avoid creating a two-tier system, and would facilitate disbursement of funds when a single payer health insurance scheme was introduced.(33)

At least that is what had been planned. However, many are still quite in the dark as to when or if these would be enacted, and serious doubts and anxiety have been raised. This ambivalence is now quite understandable because earlier attempts to corporatize these public hospitals and facilities were scuttled after news leaks prompted severe backlashes from some consumer and pressure groups and opposition politicians.(12,13,14, 34)

4.4 Skim Insurans Kesihatan Kebangsaan (SIKK)
This brings us to the question of having a single payer system, which has been earlier mooted as the preferred system for encouraging or implementing universal access to health for all.(7)
The much-awaited National Healthcare Financing Scheme, now rebranded as the National Health Insurance Scheme (Skim Insurans Kesihatan Kebangsaan, or SIKK), appears to be a political deadweight. Following the formation of the new government, this has once again been deferred for fears of public disavowal and protests. Perhaps, there are just too many variables inherent in the Malaysian system, which renders such a scheme too politically incorrect, too inexpedient to implement.(35,36,37)

Interestingly, when it was raised earlier, the MOH tried to allay public fears by announcing that civil servants (which number 1.2 million people, including military and police personnel) and their dependants, 200,000 disabled persons, 435,000 pensioners, 250,000 hardcore poor and an unknown number of unemployed individuals, would be exempt from the SIKK. What is not clear is whether the government would pay the premiums for these people or that they will continue under the present system of healthcare. The latter option would defeat the purpose, because this would undermine the community-rated concept of the SIKK.(13)

Also considering the fact that only 1.2 million Malaysians pay any taxes, collection of such a mandatory ‘health tax’ would be a struggle and challenge. It has been calculated that based on an estimated 4.63 million families in Malaysia (25 million population, average family size 5.4), this sharing of the burden (RM13 billion as of 2003) would encumber each family household around RM2,808 per year or RM235 per month.(13)

Clearly, many would not be able to pay, because more than 58% of Malaysians earn less than RM2000 per month, per family; and paying more than 10% of the salary on healthcare premiums would be too high! Besides, the government would still have to cough up possibly billions of ringgit to sustain the shortfalls and other preventive health care measures. This scheme has been criticised and rejected by the Coalition Against Healthcare Privatisation, as putting the onus of premium paying on the lower- and middle-income private sector employees and citizens.(13, 14)

So, for the foreseeable future into the next 4-5 years at least, it is very unlikely that there will be any attempts to resurrect such a tendentious issue as a national health insurance mechanism. Our current system which has been described by Chee H. L.(18) as segmented, polarising and eventually untenable, is therefore likely to be the status quo for the time being, and making this work better for our citizens should be the way forward, at least for the interim.

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

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

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

The recent suggestion by Sime Darby Healthcare to acquire a stake in IJN (now a corporatized entity 99.99% owned by the Ministry of Finance) has already brought a swift and negative dissident response from a newspaper editor.(38) Gunasegaram P. has stated his dismay that “for large sections of the Malaysian public, the very idea of privatising IJN is shocking because charges will rise to astronomical levels.” He questioned whether there is any net benefit to the public or government, and that if there were any reasonable doubt, this privatisation should not be undertaken. He alluded to past experiences that previous privatisation exercise of other services had not brought down costs for the public or government. He concluded that “(t)here are some things that should not be up for sale at any price. Affordable health care for the general public is one of them.”(39)

In another article in The Edge Daily, it was reported that the health minister and his ministry is not too happy with this divestment, either.(40) However, the Prime Minster and his deputy appears to have already endorsed the plan, just cautioning the GLC against forgetting its social responsibility to the poor, and they seem to imply that this exercise would allow the private healthcare sector to grow even more.(41)

Latest reports suggest that this takeover bid by Sime Darby has been deferred indefinitely due to public outcry, and possible political fallout.(42, 43) The former Health Minister Datuk Seri Chua Soi Lek has also condemned this sell-off bid, which he said has put paid the good will of the government, despite it costing the government just a ‘paltry’ RM 200 million a year (about 2.5% of the national health budget) to run the IJN.(44) Thus, there is this incessant tussle for public need/good versus free-trade market-driven practices from administrative or financial/budgetary realities points of view.

5.2 ‘Rentier Capital’ Divestment Concerns
There are of course, also worries about ‘rentier capital’ economics where state assets are divested to politically well-connected private entities through a system of political patronage, perpetuating mutual dependence between the business elite and the political rulers, i.e. the ‘crony capitalist’ model that supervenes the true nature of this form of take-over. Most economists believe that this form of rentier capitalist model unfairly enriches these business elites at the expense of costlier services and goods to the public at large, and is therefore, wasteful and counterintuitive toward better productivity.(45)

5.3 Toward a More Efficient System
In his book on ‘Good and Bad Power’, Geoff Mulgan (a British political scientist) discusses that while most governments provide the structure, it is the more comprehensive, well thought-of infrastructure provisions that lead to transformative services—that “much of the recent thinking about service… has adopted models from the private sector… largely drawn on industrial… models favouring speed, standardization, flow and efficiency.” He went on to describe: “(t)hese services are human, immediate, personalized and rich in communication, anticipating need rather than just meeting it and ‘going the extra step.’ In the case of therapeutic services the servant’s job is to change the master, to make him healthier, fitter, and happier.”(46)

In a paper on the Singapore model of public-private partnership, Dr MK Lim identifies 3 key questions which should be answered: (a) how to raise revenues to pay for health care; (b) how to pool risks and resources; and (c) how to organise and deliver health care in the most efficient and cost-effective manner. It is clear that there is no foolproof system anywhere on the globe. Some of the more successful models involve a mix of safety nets with monitored privatization/corporatization of services and allowing ‘coopetition’ (competition and cooperation) to thrive.(47)

He further argues that “even in Europe, the sustainability of health care systems founded on egalitarian welfarism is increasingly being challenged as growth in demand outstrips supply. The debate is no longer about ‘who should pay?’ or ‘who should provide?’ but ‘who can do the job more efficiently?’”

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

Where too much bureaucracy bogs down the better productivity and efficiency, these should be dismantled and restructured in ways that encourage best practices, and which empowers and benefits the patient ultimately. Practice issues such as difficulty in cross-referring patients between private and public sectors should be eliminated; data and medical information portability and sharing should be facilitated and unified. Where there is excess of amenities on either side, these should be shared with crossovers of public to private sector and vice-versa. Conversely, more cross-purchases of services should be facilitated where there are shortages. Arbitrary turf protectionist methods to deny either patient or physician access to information or services of either sector should be removed.

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

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

While corporatisation/privatisation is still much feared, as a model of divesting central control of unavoidable rising costs and developmental constraints, this might be the way to go, if the model for market-driven healthcare is adopted. This is the model practiced by Singapore, with its well-tried and tested schemes that can be tweaked to respond to the many diverse facets of healthcare peculiarities.(43)

Or conversely, a single-payer (and/or single insurance) National Health Service mechanism could be introduced, learning from the examples of say, Taiwan, Canada or the UK.(48,49)

Whatever the decision, the government must make greater efforts to engage and explain to the public the policy directions that it wants the country to advance with regards healthcare services. This is especially urgent because by 2013, when trade and services liberalisation is set to take place in ASEAN (Association of South East Asian Nations), with the roll-out of the AFTA/WTO (ASEAN Free Trade Area/World Trade Organisation) agreements, there will be other considerations of foreign participation and entry into this economically important sector.

ACKNOWLEDGEMENT
Thanks to the MMA secretariat for support in obtaining some references and research data.

REFERENCES
1. Economic Planning Unit. Prime Minister’s Department. Malaysia: 30 years of poverty reduction, growth, and racial harmony. A case study report. Scaling Up Poverty Reduction: A Global Learning Process and Conference, Shanghai, May 25-27, 2004. A World Bank report.

2. Teoh S. PM wants Sime Darby to guarantee treatment for poor if it takes over IJN. The Malaysian Insider, 18 Dec. 2008.
(Accessed 18 Dec 2008.)

3. Gomez E.T. & Jomo K.S. (1999) Malaysia’s political economy: politics, patronage and profits. Cambridge. Cambridge University Press.

4. UNDP Human Development Report 2006. The Human Development Index ranks Malaysia 61st, with a literacy rate of 88.7%, Education index of 0.84, life expectancy index 0.81 and PPP GDP of USD 10,276. Malaysia spent some 8% of the GDP on education with the government spending some 28% of the total budget on education alone with 36.5% for tertiary education. http://hdr.undp.org/hdr2006/pdfs/report/HDR06-complet.pdf. Pgs. 302, 320. Accessed 21 October 2008.

5. The World Health Report 2006: Working together for health. WHO, Geneva.

6. Merican M. I. Medicine and Healthcare in 2020. Berita Academi, 2007, Vol 16;3, Pg.2.

7. Malaysian Medical Association, MMA. Health for All: Reforming Health Care in Malaysia. Academe Art & Printing Services, Selangor, 1999

8. Quek D. K. L. Equitable Access to Health Care for All: Is this still a Pipe Dream for Malaysians? A Medical Professional’s Perspective. Paper presented at Suhakam’s “Human Rights & Access to Equitable Healthcare” Dialogue, Kota Kinabalu, Sabah, 08 January 2008

9. Mastura Ismail. The New Team for Nationals SCHOMOS 2008/2009. MMA News, 2008 (June), Vol. 38 (5):pg 13-14.

10. Mastura Ismail. Budget 2009: Increment of Specialist Allowance. MMA News, 2008 (October), Vol. 38 (9):pg14.

11. Chua SL. Speech by YB Dato Dr. Chua Soi Lek, Minister of Health Malaysia, At The Annual Scientific Meeting 2005 of the National Heart Association, Hotel Hilton, Kuala Lumpur, 15 April 2005. Text obtained from (Accessed 15.12.2008)

12. IJN doctors: Don’t make us scapegoats. The Star online. 19 December 2008. (Accessed 19 December 2008)

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

14. Subramaniam Pillay. (for Coalition Against Health Care Privatisation) Can we afford to fall sick? Aliran Monthly Vol. 25 (2005): Issue 4 Accessed 15.12.2008

15. Citizens’ Health Manifesto for Malaysians. (Accessed 15.12.2008)

16. Ministry of Health (MOH) (various years). Annual report.

17. Ministry of Health (MOH) (2003b, 2004). Indicators for monitoring and evaluation of strategy for health for all.

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

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

20. Private Health Care Facilities and Services Act 1998 (Act 586). PCNB, Malaysia, 1998.

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

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

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

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

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

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

27. Ong A. Private and public health can grow in tandem. Malaysiakini June 28, 2008. (Accessed 17 Dec 2008)

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

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

30. Single mum needs aid for kidney transplant in China, The Star, Friday 19 October 2007, p N26

31. In need of aid to treat his burns, The New Straits Times, Monday, 22 October 2007, p N17

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

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

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

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

36. National healthcare not an insurance scheme: Chua. Sun2Surf, 15 April 2005.

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

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

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

40. Lim S-L. Sime Darby eyes IJN. The Edge Daily, 17 December 2008 (Accessed 18.12.2008)

41. Teoh S. Najib: Sime Darby must commit to poor in takeover of IJN. The Malaysian Insider, 18 Dec 2008. (Accessed 18.12.2008)

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

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

44. Chua S. L. IJN Dollars and Cents.
(Accessed 30 December 2008.)

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

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

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

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

49. Physicians for a National Health Program. International Health systems. PNHP, 2008. (Accessed 15 December 2008.)




[Paper presented at The International Conference on Public-Private Partnership in Development, Jan 15-16, 2009; Organised by the Faculty of Economics & Administration, University of Malaya, Kuala Lumpur, Malaysia.]

Physician Apology, Saying it Sooner than Later

(see also myhealth-matters.blogspot.com/)

Recently a New York Times article ‘Doctors say "I'm Sorry" before "See you in Court"’ and a follow-up editorial ‘Doctors Who Say They're Sorry’ addressed the uncomfortable issue of medical errors, especially those associated with having caused harm to patients.

For most practising medical practitioners out there, medical errors are considered a near-taboo subject: one, which is best left behind the radar screens of scrutiny.

Yet we are aware that medical errors, especially those which are inadvertent or which result from unexpected patient/individual reactions or peculiarities, do happen, albeit not too frequently.

Being honest and direct with the patients involved can, safely diffuse many of these potential patient-relative complaints. Careful and candid explanation as to why these had happened and why they should not have, and that they would not be allowed to recur, will also help lower the temperature of annoyance and anger.

Most importantly, these types of errors should be treated as high priority and with empathetic sensitivity. Affected patients must be given every avenue to resolve or lessen the harm with the least incurring of pain, suffering or costs.

Of course, medical centres and hospitals must work together with doctors to address these so that cost sharing or waiver/compensation can be implemented expediently and efficiently. The patient should leave the facility satisfied that all that could have been done had been done.

More egregious are those errors due to diagnostic inaccuracy or therapeutic misadventure, incompetency or careless negligence. These are often deviously obfuscated, with blame deflected, or simply denied a full hearing or explanation to the harmed patients.

It is this group which when finally exposed, that oftentimes cause much anger and demand for compensation, or even calls to reprimand or to punish the erring doctor or facility. Hence, the resultant litigation process which every doctor dreads.

But, admitting to medical mistakes is easier said than done. Besides, in most medical cultures, it is not permissible or safe to do so. Yet, we know that more can and should be done.

Although some 10 years ago, when Lucian Leape's group from the Institute of Medicine reported that as many as 98,000 patients died as a result of medical errors in the United States ("To Err is Human")—many are adamant that this was exaggerated. Many still denied the actual enormity of the problem.

Then some time in the early 2000s, when the Consumer Association of Penang (CAP) president, SM Idris alluded to a similar state of unrecognised medical errors in Malaysia, as the then editor of the Berita MMA, I objected quite vehemently that to extrapolate based on the experience in the US was wrong and unacceptable.

Then, I had called instead for more in-depth study and urge our health community to research this by gathering more accurate data, so that we can get a clearer picture as to the scale and the scope of this serious problem. I also called for pre-emptive attention to detail and a systemic overhaul of procedures and processes to help reduce these possible errors from taking place.

Perhaps CAP's statement to the press was too artless and seemed to denigrate the overall goodness of the medical care experience that I had felt duty-bound to defend.

As an MMC councillor, however, I have had the privilege of listening to increasing number of complaints brought to the attention of the Malaysian Medical Council (MMC).

Most of these complaints are about unexpected adverse outcomes resulting from some medical therapeutic choices or decisions, which have gone awry, and/or unhappiness with the patient-doctor communication, or implied physician dishonesty.

Many of these MMC complaints are however, not ethical in nature and does not impute serious professional misconduct.

This is not to say that there have not been medical errors or misadventures having taken place, but that the MMC is not the board or forum for resolving disputes related to negligence or incompetence, unless there is a recurrent pattern of egregious conduct, which can endanger other patients. Unfortunately many among the public has mistaken the latter as the role of the MMC.

Quite often, disgruntled patients or their relatives complain of inadequate information provided to them, some even claim that none were offered at all. At other instances, when untoward bad outcomes result, not enough information or explanations were given. Too many delaying tactics or perceived deflection or excuses to very legitimate queries, often create unresolved feelings that the doctor and the hospital are hiding something.

It is this need to have closure and/or meaning that many aggrieved parties seek out the MMC or worse the courts to prove medical negligence, and ultimately seek retribution and recompense.

Of course, there are many lawyers out there who are quite ready for such pro bono work to litigate against such incompetent doctors or hospitals, and so the problem escalates.

Thus, many medical centres and doctor groups have begun experimenting with the new deal of becoming more forthcoming, and saying sorry first and early too.

Some 30 states in the US have enacted laws to protect the admissibility of such apology-related disclosure from medical malpractice challenges. And it appears that it is working. In some medical centres, early resolution with smaller compensation claims have already resulted, with some medicolegal costs falling by as much as two-thirds!

Thus perhaps for Malaysians too, this might be a way forward. Saying 'Sorry' and admitting candidly a medical error should not be taken as license to litigate, but as trying to resolve a bad situation from becoming worse.

Still, offering an apology to patients and their relatives is not a definite or necessarily positive reaction: some aggrieved parties would still doubt the sincerity or genuineness of the apology, and cynically view these as attempts to underplay the severity of the mishap, and a business tactic to secure patients/relatives into accepting a bad outcome.

A discussion with a renowned dispute resolution advocate, Dr R. Veerapan, suggests that genuine apologising “can be difficult for doctors who have been trained in a system where admitting error has the odour of moral failure.”

“'Apology' by healthcare professionals has wide ranging implications and it is very important for potential 'apologizers' to have a very clear understanding about what these may be.

“Individual institutional policies and procedures should be defined. Doctors should know for sure what the policy of their medical indemnifier is regarding apology.

“And of course there is the fine but critical difference between expressing regret and empathy for a poor outcome, and actually apologizing for making a medical mistake of some form. Not easy, apologising! Yet so important under carefully understood conditions!” adds Dr Veerapan.

I agree that apologies are such difficult and scary animals for most of us doctors because it implies a ‘moral failure’ on our part. More than that, it also exposes our lesser than perfect image that we have acculturated into our profession.

Perhaps we have to work towards a better modus operandi to make medical apologies more systematic and acceptable—while ensuring that legal barriers are reduced if not eliminated.

Dr Veerapan suggests that “one of the obstacles besides the medical invincibility factor is inherent in the DNA of Malaysian private practice. And that is the way we are pitched in indirect financial competition with other medical practitioners. This is the undefined factor that in all likelihood contributes to the reluctance to be forthright in a variety of professional relationships in the medical or surgical field; and not just with patients and their families.”

Such personal and professional dynamics aside, it is perhaps time to move forwards. Saying sorry appears to be a way forward to help lessen the adversarial approach that seems to stifle the medical error-negligence debate.

There must be mechanisms (perhaps legislative?) to protect such apology and disclosure, and perhaps we should also enact laws to ensure that admissibility of such information is protected from medical malpractice claims.

Another approach is through a wider judicial-led Mediation process, which has already been put in place in Singapore. At one MMC meeting in mid-May, Dr Thurairatnam, (a past-president of the Malaysian Dental Association and Dental Council member) presented a short lecture on how this may be a useful alternative dispute resolution process—the MOH is considering some way to explore this option further.

"Sorry seems to be the hardest word," so sang Elton John, but perhaps we as doctors can learn to say so earlier, sooner than later, and be ready to help our patients resolve better as a result, when medical care goes wrong.

Apology is a vital component in the healing process of early intervention when conflict escalates after an adverse medical event. We must all learn to cope better with and mitigate against these increasingly challenging aspects of modern medical practice. Humbling ourselves by being genuinely sorry and saying so, rather than defensively obscuring and/or excusing unpleasant and unexpected adverse outcomes is the way forward.

(This is an expanded version of my earlier blog which is to be published in the Newsletter of the Malaysian Medical Council, July-August 2008)

Should We Tame the Political Genie in Us?

"Mankind's moral sense is not a strong beacon light, radiating outward to illuminate in sharp outline all that it touches. It is, rather, a small candle flame, casting vague and multiple shadows, flickering and sputtering in the strong winds of power and passion, greed and ideology. But brought close to the heart and cupped in one's hands, it dispels the darkness and warms the soul."
~ James Q Wilson, in The Moral Sense, 1997, p251. Free Press Paperbacks, NY.

Once again, the issue of political incorrectness in our MMA News has been raised. I have again been urged to steer clear of discursive political meanderings, which appear seemingly out of place with the aspirations of the Association and the medical profession.

If members had been following the rigorous debates since September 1997, in the various MMA News, you would no doubt have got an inkling as to my trenchant views and position as editor of this newsmagazine.

You would have noticed that over the years, I have always encouraged everyone to be more mature, more vocal and to speak out, on issues, which affects us as human beings or as a medical profession.

We can all do with more open dialogue and debate, transparency and accountability. Constructive criticism and opposing viewpoints are always encouraged and welcomed.

What then about our MMA editorials, which, some members appear to be rather rankled by the occasional, perceived political slant?

This aspect has been debated at length, in the past pages of the MMA News, and most recently at the Annual General Meeting (AGM) in Penang, where several resolutions were argued (yes, vociferously and engagingly) and finally passed and adopted by the delegates with overwhelming if not near-unanimous support (see MMA News, October 1999, p6-7, Resolutions 10-13).

At the Penang AGM, a resolution (Resolution 10) pertaining to the vote of confidence in the Editor (thereby embracing his style of editorship) and the Editorial Board, was discussed and adopted by a large majority of the delegates.

Further, in order to guide the Editor and the Board better, Datuk Dr McCoy and I, initiated a resolution (Resolution 11) on the Terms of Reference for Publications, which was again adopted. In this resolution (ibid. p7), point 6 refers: “To inform readers about the non-clinical aspects of medicine and public health, including the political, philosophical, ethical, legal, environmental, economic, historical and cultural aspects.”

Resolution 12 on Human Rights was also endorsed at the Assembly, among which are pertinent clauses which state, and I quote: “Recognising that the medical profession has unique responsibility for the health and welfare of society and therefore has a duty to articulate concern about issues that affect the health and welfare of the community, the MMA affirms its commitment to,” amongst others, the Universal Declaration of Human Rights, and the World Medical Association Declarations of 1975 and 1990 (ibid. p7). This adopted resolution also calls “upon the government of Malaysia to repeal the Internal Security Act and to legitimise the right of peaceful assembly and association.”

Therefore, the delegates and representatives of the MMA membership have in fact aprobated and endorsed our editorial stance and direction, which they saw as being fittingly appropriate and apropos with the current state of affairs. We are thus empowered to highlight, disseminate and act on the resolutions of the General Assembly.

The adopted resolution on the Terms of Reference for Publications will undoubtedly help steer us along the prescribed ethical path. Although, editorial independence has been espoused, we will endeavour to use this democratic mandate with respectful and solemn responsibility. Of course, this is not a carte blanche for us to pursue just about any whimsical or personal agenda.

In this context of freedom of expression and thoughts, any editorial or opinion piece should therefore, not be treated as sacrosanct or “holy script”. An editorial is just what it purports to be––an opinion piece which is deemed topical and important enough (in the eyes of the Editor or Board) to be highlighted for mental jousting and thought. It is never intended for the purpose of unimpeachable doctrine or infallibility––certainly not those that I have penned.

Therefore, any disingenuous query on whether a particular editorial was a personal opinion or that of the Board, sounds like the tired recurring scratches of a propagandist record to try and isolate and divide persons perceived as threats to authoritarian dictates. Nevertheless, my authorship has always been clearly stated, and whatever perceived bias is mine alone, as it should be. I have never imputed anyone else.

In general, editorials or opinion pieces are not subject to heavy vetting or censorship by the editorial board. The latter is particularly odious to me, and I have said so many times before. I am a declared and fiercely unapologetic proponent of freedom of speech and opinion, perhaps too artless for some.

Nevertheless, as I have earlier pledged at the general assembly in Penang, I would continue as editor only if I can help push the MMA News to greater heights of newsworthy excellence, editorial independence and higher ethical standards –– which includes unfettered yet responsible freedom of opinion.

But, anyone can disagree with me. Even some members of the Board have on occasion, distanced themselves from articles written by me, or others for that matter. My own editorial position on this has also been reiterated previously (MMA News, June 1999 pp 5, 15).

The recurrent suggestion that I might have been influenced by a “particular pressure group within the organization of the MMA” is of course, pure nonsense. In fact, I wish to categorically state here, that the MMA Council members are not at all involved in the editorial direction of the Berita MMA, except perhaps in the spirit of the Association's Constitution where the Berita MMA tries to conform, within the mandate of the prevailing Council.

Bill Cosby, television actor and writer, has cogently said that “I don't know the key to success, but the key to failure is trying to please everybody.” Doing what we believe in, does not imply the need to please or find universal conformity with everyone.

Neither should this always be by consensus seeking, as this also might be too restrictive and can stifle freedom of speech and opinion. Humans are just too diverse and socio-culturally different. Thus, I believe being able to discuss openly our differences is a mature and correct approach to help narrow the perceptual chasms which keep us apart.

Am I making use of the editorial column unfairly, to misrepresent the MMA? I certainly hope not, but then again, this is subject to differing perceptions and ideology.

My intention (as of everyone who chooses to write, aspires) is to be heard, and to jostle and prod the mind, the conscience, or the moral fibre of the reader, so that current issues could be debated with more openness or at least, be thought about more deeply. Being the supposedly more literate and educated professional, it is expected that we can take the lead in open intellectual discourse concerning the higher aspirations of our people and our nation.

It may even be that in due course, some could conceivably come to share with my views of social justice and the moral high ground that seemingly has become eroded in our society, of late. Clearly, I do not profess to have the know-all, and what I write may be all sanctimonious naiveté, to some.

However, I am glad that more and more doctors and members are now taking a more involved role in our society and association, by voicing their concerns one way or the other, rather than to remain the grudging and oftentimes silent majority––which had in the past been attracting partisan and inchoate impugnation.

I am saddened by the still pervasive attitude that implies that no one or any association can or should dare question the Establishment, etc. unless explicitly stated within the Constitution or for that matter only when permission was given!

This is most certainly an obsolete and antiquated denial of any citizen’s rights to question or to debate (without male fide) wrongs, injustice or whatever shortcomings that any authority or establishment commits or omits.

US president extraordinaire Abraham Lincoln has stated that “the possibility that we may fail in the struggle ought not to deter us from the support of a cause we believe to be just.” He should know better, because he went all out to defend the just but unpopular liberation of slavery, with the defining American Civil War. In the end justice prevailed and African American slavery was at last legally abolished.

The education and promulgation of such a premise as human rights must therefore begin in everyone’s mindset, which should be more open and receptive, and not clamped shut by parochial gridlock.

Fear and sociopolitical narrow-mindedness must not stifle the inherent nature of man to be free to think. As I have stated before, it is certainly ridiculous to limit talk or opinions on all things political, to the hallowed grounds of political platforms, only. Every man is indeed a sociopolitical animal, and politics pervades and affects every fibre of our human psyche and well-being.

Political affiliations mandate a certain degree of constraints, of policy rigidity––hence, I don't belong to any. I feel that I am not cut out for the malleable rules of political one-upmanship and other unsaid expediencies.

Yet, my choice does not mean I cannot be a concerned citizen. Neither does it imply that I am hiding behind the shield of the MMA to pontificate on things political just for the sake of doing so, or for a politically motivated agenda. I have none.

My overarching concern has been the continual assault, erosion and dismantling of our precious institutions, and the tale-spinning, fear-instilling destruction of our hitherto harmonious society and socio-cultural values. We appear to be inexorably sucked into the ensnaring Charybdis of wealth and the Scylla of power, with diminishing regard for human core values.

(For an excellent but otherwise exhaustive discourse on this, please refer to Datuk Dr Rais Yatim's book “Freedom Under Executive Power in Malaysia––A Study of Executive Supremacy” 1995. Alas, even he has now sung a different tune and has largely disavowed his past dissertation which he has called academic and passé!) Disaffection with the erosion of these human universal values rightly deserves the attention and scrutiny of every person.

There is hopefully still some universal standard of recognising what is right or wrong. Matters cannot be so easily painted grey or coloured in any way just to placate the whims and demands of any one person or persons. When some issues are clearly extraordinary and patently wrong, these should be exposed as such and hopefully they can be corrected or improved upon.

One such circumstance, which we opposed stridently, was the attempt to hurriedly corporatise our Health Services without the necessary safeguards and financial infrastructure. Happily, this has now been aborted, pending an in-depth reappraisal of the specifics.

Perhaps, the ugly truth of the matter may sound jarringly disquieting and unpalatable, especially when it seems to undermine the cozy status quo that we have become so inured with.

Disturbingly, we are becoming more and more myopic, preferring immediate and short-term gains, but appearing not to be interested in the larger picture or the longer-term consequences.

Wasn’t it Confucius who exhorted millennia ago, that “to see what is right, and not to do it, is want of courage, or of principle”? Is it not time to act?

We all have a right to our own political belief and/or attachment to certain personalities. But I dare say we all have to learn to be able to see beyond the horizon of simplistic yet parochial niceties and our all-consuming self-interest. We must be able to initiate or push for change for the better, whenever there is some other greater and more paramount “truth” out there.

Why should any man be satisfied with the oppressive weight of “more of the same”, no matter how fantastically well our society has been perceived as stably humming along? Is the fear of the unknown so terrifying that we dare not venture out of our shell?

Is the known status quo so cast in concrete that no change or improvement can be allowed to take place? Are we so content that we allow ourselves to be set in the fossilized past forever?

Or is it not our nature and responsibility to want to improve upon ourselves and our institutions?

We should all learn to look more closely at our society and dare say that while material wealth and well-being have permeated our society, other less tangible, less obvious executive transgressions have gotten out of hand.

The genie is out of the lamp, and it is wreaking unthinkable turmoil in our society’s sanity and sociopolitical well-being. Or are we still in closeted denial that everything thus far has been hunky-dory?

Perceptions of truth have been slanted this way and that, so much so, that we no longer are sure of our moral bearings.

Is it really that much easier for us to set our blinkers on and behave like the proverbial ostriches who simply bury our heads in the sand, when misdeeds or unpleasant happenings abound all around us?

Are some of us––the so-called intellectual elite––so caught up in our own ivory towers, that we fail to appreciate the nationalistic aspirations and bountiful largesse of our masterful leaders?

Have some of us been unfairly prejudiced by the entire world’s foreign press, so that we have failed to see the greatness of our own jingoistic society?

Or, have our chanting shibboleth of Malaysia Boleh so blindsided us, that we have become impervious to any contrarian criticism, except for sycophantic praises?

Are we so hemmed in by our overpowering feel-good mindset that we no longer care, so long as our bread-and-butter issues are left well alone?

Have we elected to become stunted at the lower rungs of our hierarchy of needs? Abram Maslow would have been disappointed!

Are our Asian values so different, that we can accept less tolerance for individual freedom and human rights aspirations?

Or, have we simply abdicated or vacated our conscience for political expediency?
I choose to believe that ultimately some semblance of sanity and poetic justice will prevail, and that the growing destructive forces of Machiavellian sectarianism, unbridled power-plays and petty interests will be contained and returned into the genie’s bottle, for keeps.

That said, whatever happens, whichever victory would have been a Pyrrhic and hollow one. Our Greek-like tragedian dramas have yet to fully reach their final denouement. Somehow, as helpless as we are, we still owe this to ourselves to want and to help make some good happen, and shape the outcome of our collective choice––one way or the other...

Should the MMA or the Berita MMA, be embroiled in this quagmire of contention? Perhaps, because I believe as responsible professionals with reasonable respectable voices and conscience, perhaps we can serve a wider and higher good.

Moreover, I do believe that our professional lives and society are much too intricately intertwined to be so sharply compartmentalized in deciding what anyone can say or do or think.

Shouldn’t any concerned citizen speak out, so that the deafening silence can be broken, for the betterment of the society at large, sans political repercussions, sans public censure, because of self-interest, fear, intimidation and/or a cowering insular mindset?

Or, should we simply stifle the political genie within us from escaping, forevermore?

"Lead me from the unreal to the real!
Lead me from darkness to light!
Lead me from death to immortality!"
~ Brihadharanyaka, Upanishad 1.3.28

[Previously written as an MMA News Editorial 25 Nov 1999]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


(MMA News Editorial, July 2002)