It has been 3 months since I wrote my Part 2 of this topic where I discussed about the public healthcare system of this country. Now, I will move to the private healthcare system.
One of the first component of the private healthcare system of this country are the General Practitioners or simply known as GPs. The private hospitals started to appear in the 1980s. Thus, I will divide this topic into 2 parts: GPs and private hospitals.
General Practitioners (GPs)
In Malaysia, anyone can become a GP after completing 4 years of compulsory service with the government. GPs were the first private healthcare service providers in this country. They were highly respected by the community as almost equivalent to a specialist. In 1970s and even 1980s, specialists in various disciplines were a rare species in our healthcare system and thus the community considers GPs as their family specialist. In fact GPs did a wonderful job in providing simple primary care services to the general public as they were open till at least 10pm daily and there were not many government polyclinics then. When I was small, I still remember my father bringing me to see a GP for simple upper respiratory tract infections. Consultation and medications will just come to about RM7-10, which is quite a big amount those days!
It was quite a profitable business for doctors to become a GP then. Whatever people say about being a GP, it is still a business to earn money and a living. Almost all GPs in 1970s up to 1990s were doing very well and were earning quite a big sum of money. There were no regulations to monitor them except for professional conduct which was monitored by Malaysian Medical Council. They were also allowed to store and dispense medications without a pharmacist and trained nurses. This situation is still the same up to today. However, when more and more doctors started to open clinics in a town, competition began to set in and this has changed the scenario of GPs currently.
The competitions for GPs are not just from their fellow GPs and private hospitals but also from the government polyclinics and recently, the 1Malaysia clinics. At one point of time many doctors were leaving the civil service to start their clinic immediately after completing their 4 years compulsory service but the situation is slowing down gradually. Why is it so? Firstly, the government has come up with the Private Healthcare and Facilities Act 1998 which was implemented from 2006. This act makes sure that every private facility is built based on certain requirements, like the size of the door, toilet, consultation room etc etc. Before you can even start the clinic, you need to submit the floor plan to MOH for approval. You can only start your renovation after they had given the approval. After completing your renovation, the ministry’s unit(UKAPS) will come down to inspect your clinic to make sure that you comply with the act. Any non-compliance is punishable under the law. Only then you will be given the permit to start your practise.
Secondly, the income of many GPs is gradually dropping due to severe competitions. I know of some GPs who had closed down their clinic and doing locums instead, both privately and in government clinics. Some GPs are only earning a net profit of less than 10K per month. Remember, an income like this by working from 9am till 10pm daily is pathetic to say the least. There are many factors that will decide on whether you will be successful or not. Your location of the clinic is one of the factors. Many town areas are quite saturated. The best option will still be rural and semirural areas. Most successful GPs are from these areas as well as in housing areas which are far from government polyclinics/private hospitals. Your communication and clinical skills is the next factor.
Unfortunately, due to severe competition, some black sheep’s began to appear in this system. Many of these GPs were just interested in making money and nothing more. They refuse to upgrade their knowledge and manage their patients accordingly. In Malaysia, unlike other countries, you can renew your Annual Practising License (APC) without needing any CME points. In many other countries, you need a certain minimal number of CME points before your APC is renewed. Even Dr Mahathir and Dr Chua Soi Lek can still get their APC despite not practising as a doctor for so many years. As long as you are a doctor, you will get your APC!
I had seen many GPs mismanage common medical conditions like asthma, diabetes and hypertension. Even when they know that they can’t do anything much, no referral is made to a specialist in either public or private sector. This is because they do not want to lose the patient to another physician and thus reducing their income. I had seen patient who are diabetics for many years but not a single blood test was done for renal function, fasting blood sugar, HBA1c etc etc. Only glucometer readings are done. Many will turn out to have renal impairment. Many at times, even a diagnosis of hypertension and diabetes is not properly made. I had seen many patients presenting with hypoglycemia with treatment started by GPs and turn out to be non-diabetics. I still see obese diabetic patients being started on sulphanylureas when the standard guideline says that Metformin should the first line treatment. These are bread and butter diseases that should be managed properly by GPs but not so in this country due to poor continuous medical education and the non-existence of compulsory CME points for renewal of license. I know GPs who are selling medications including sleeping tablets over the counter, asthmatics still being managed with tablets and daily steroids etc etc.
Many years ago, I did locum in a GP clinic. For every patient, irrespective what is the complaint, 3 medications must be given including 1 antibiotic!! Even if the patient complain of headache or bodyache! If you don’t do it, the staffs in the clinic has been ordered to add the medications! How unethical! This was one of the reasons why I never did locum after that! I had only done a total of less than 30 GP locum sessions in my entire medical practise so far. It is becoming increasingly difficult to see GPs who really cares for a patient.
When the national health care financing system is introduced in the future, GPs will be forced to do postgraduate degree in family medicine like in many other developed countries. As you may be aware that in many other countries, you can’t become a GP without a postgraduate degree or proper training. Being a GP itself is a specialist.
Soon, GPs will also lose the right to dispense medications. This is already in the pipeline with full support from the Malaysian Pharmacist Association. Only MMA is still fighting against it to safeguard the lifeline of many GPs. Selling medications really brings a lot of profit for these GPs.
MOH is encouraging GPs and soon to be GPs to do Diploma in Family Medicine for a start. Academy of Family Physicians of Malaysia has started this programme since 2009 and the first batch has graduated. It is an online course. They can go on to do FRACGP for another 2 years after that.
I got nothing against GPs but many black sheep are destroying the reputation and status that these doctors had once upon a time. Once respected doctors are now going down the drain. Many, finding it difficult to survive. That’s the reason why you don’t see many new clinics opening recently or doctors leaving civil service to open GP clinics……………… Frankly speaking, government polyclinics have better facilities to manage chronic diseases then GPs but the doctors got not much time to spend with the patients and there are no proper supervision of junior doctors.
Next: Private Hospitals……………..