Over the last few weeks, I have had many elderly patients with multiple co-morbidities being admitted under my care. Call me conservative, but right from those days I had always believed in informing the relatives the hard truth. I will inform them from day one itself that there is nothing much I can do and very high chance that the condition will deteriorate. I will inform them the possible options that are available. These are patients who are suffering from irreversible medical conditions and have reached their terminal event. Ventilating these patients will never be my option. You just have to put yourself as the patient and decide what would you want at that time.
There are many doctors out there who will listen to relatives than making a sound clinical decision in the best interest of the patient. I have had doctors who ventilate a terminally ill advanced cancer patients and even a patient who has been bed bound for the last 2 years due to a stroke. Will this change the outcome ? It will only prolong the suffering of the patient. In private sector, it is just a waste of money for the relatives. No matter how painful it is to say that we can’t do anything for the patient, it has to be done. Remember what this doctors said in his last speech ?
Let me give you an example. I just saw a 81-year-old frail looking lady. She was diagnosed to have Ca Head of Pancreas with biliary obstruction and liver mets 6 months ago. If I was the doctor, I would have just suggested stenting of the bile duct and go for palliative care. Unfortunately, someone out there in a neighbouring country decided to go for a major surgery (Whipple’s procedure) after subjecting the patient to ERCP, EUS and tissue biopsy. Intraoperatively, they felt that it is at an advanced stage and decided to do a triple bypass surgery instead. Logically speaking, why did they even attempt the surgery in a 81-year-old lady with the CT scans already showing metastasis ? Is it because the family requested or someone wants to be a hero? A good doctor would have just advised her to go for palliative care and symptomatic relieve. Now, the same doctor who did the surgery told the patient to go back and rest at home as nothing much can be done!! Shouldn’t this been told when the diagnosis was made? The story is just for everyone to ponder upon! The family spend huge amount of money for something that did not do any good for the patient.
The article below was circulated in Facebook and emails about a month ago. It appeared over here. Every budding doctor and doctors themselves should read this article below, written by a family physician. It is the truth and definitely I do not want someone ventilating me, putting me on a tracheostomy tube, NG tube and being bed bound for the rest of my life, if I survive. I rather die peacefully. What’s important is that my family will be taken care of by leaving behind adequate insurance and a will. As I cross halfway of general life expectancy, I have done all those.
Well, after 16 years of service as a doctor and almost 3 years of being “on-call” daily in a private hospital, for the first time (except Singapore) I am bringing my family for an overseas vacation. I could not afford to do this for a long time. Thus I will be off my blog from 30/05/2013 till 9/06/2013. It is a long trip to the Theme Park city of the world. …………………
How Doctors Die
It’s Not Like the Rest of Us, But It Should Be
by Dr Ken Murray
Years ago, Charlie, a highly respected orthopaedist and a
mentor of mine, found a lump in his stomach. He had a surgeon explore
the area, and the diagnosis was pancreatic cancer. This surgeon was
one of the best in the country. He had even invented a new procedure
for this exact cancer that could triple a patient’s five-year-survival
odds–from 5 percent to 15 percent–albeit with a poor quality of life.
Charlie was uninterested. He went home the next day, closed
his practice, and never set foot in a hospital again. He focused on
spending time with family and feeling as good as possible. Several
months later, he died at home. He got no chemotherapy, radiation, or
surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die,
too. And they don’t die like the rest of us. What’s unusual about them
is not how much treatment they get compared to most Americans, but how
little. For all the time they spend fending off the deaths of others,
they tend to be fairly serene when faced with death themselves. They
know exactly what is going to happen, they know the choices, and they
generally have access to any sort of medical care they could want. But
they go gently.
Of course, doctors don’t want to die; they want to live.
But they know enough about modern medicine to know its limits. And
they know enough about death to know what all people fear most: dying
in pain, and dying alone. They’ve talked about this with their
families. They want to be sure, when the time comes, that no heroic
measures will happen–that they will never experience, during their
last moments on earth, someone breaking their ribs in an attempt to
resuscitate them with CPR (that’s what happens if CPR is done right).
Almost all medical professionals have seen what we call
“futile care” being performed on people. That’s when doctors bring the
cutting edge of technology to bear on a grievously ill person near the
end of life. The patient will get cut open, perforated with tubes,
hooked up to machines, and assaulted with drugs. All of this occurs in
the Intensive Care Unit at a cost of tens of thousands of dollars a
day. What it buys is misery we would not inflict on a terrorist. I
cannot count the number of times fellow physicians have told me, in
words that vary only slightly, “Promise me if you find me like this
that you’ll kill me.” They mean it. Some medical personnel wear
medallions stamped “NO CODE” to tell physicians not to perform CPR on
them. I have even seen it as a tattoo.
To administer medical care that makes people suffer is
anguishing. Physicians are trained to gather information without
revealing any of their own feelings, but in private, among fellow
doctors, they’ll vent. “How can anyone do that to their family
members?” they’ll ask. I suspect it’s one reason physicians have
higher rates of alcohol abuse and depression than professionals in
most other fields. I know it’s one reason I stopped participating in
hospital care for the last 10 years of my practice.
How has it come to this–that doctors administer so much
care that they wouldn’t want for themselves? The simple, or
not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in
which someone has lost consciousness and been admitted to an emergency
room. As is so often the case, no one has made a plan for this
situation, and shocked and scared family members find themselves
caught up in a maze of choices. They’re overwhelmed. When doctors ask
if they want “everything” done, they answer yes. Then the nightmare
begins. Sometimes, a family really means “do everything,” but often
they just mean “do everything that’s reasonable.” The problem is that
they may not know what’s reasonable, nor, in their confusion and
sorrow, will they ask about it or hear what a physician may be telling
them. For their part, doctors told to do “everything” will do it,
whether it is reasonable or not.
The above scenario is a common one. Feeding into the
problem are unrealistic expectations of what doctors can accomplish.
Many people think of CPR as a reliable lifesaver when, in fact, the
results are usually poor. I’ve had hundreds of people brought to me in
the emergency room after getting CPR. Exactly one, a healthy man who’d
had no heart troubles (for those who want specifics, he had a “tension
pneumothorax”), walked out of the hospital. If a patient suffers from
severe illness, old age, or a terminal disease, the odds of a good
outcome from CPR are infinitesimal, while the odds of suffering are
overwhelming. Poor knowledge and misguided expectations lead to a lot
of bad decisions.
But of course it’s not just patients making these things
happen. Doctors play an enabling role, too. The trouble is that even
doctors who hate to administer futile care must find a way to address
the wishes of patients and families. Imagine, once again, the
emergency room with those grieving, possibly hysterical, family
members. They do not know the doctor. Establishing trust and
confidence under such circumstances is a very delicate thing. People
are prepared to think the doctor is acting out of base motives, trying
to save time, or money, or effort, especially if the doctor is
advising against further treatment.
Some doctors are stronger communicators than others, and
some doctors are more adamant, but the pressures they all face are
similar. When I faced circumstances involving end-of-life choices, I
adopted the approach of laying out only the options that I thought
were reasonable (as I would in any situation) as early in the process
as possible. When patients or families brought up unreasonable
choices, I would discuss the issue in layman’s terms that portrayed
the downsides clearly. If patients or families still insisted on
treatments I considered pointless or harmful, I would offer to
transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some
of those transfers still haunt me. One of the patients of whom I was
most fond was an attorney from a famous political family. She had
severe diabetes and terrible circulation, and, at one point, she
developed a painful sore on her foot. Knowing the hazards of
hospitals, I did everything I could to keep her from resorting to
surgery. Still, she sought out outside experts with whom I had no
relationship. Not knowing as much about her as I did, they decided to
perform bypass surgery on her chronically clogged blood vessels in
both legs. This didn’t restore her circulation, and the surgical
wounds wouldn’t heal. Her feet became gangrenous, and she endured
bilateral leg amputations. Two weeks later, in the famous medical
center in which all this had occurred, she died.
It’s easy to find fault with both doctors and patients in
such stories, but in many ways all the parties are simply victims of a
larger system that encourages excessive treatment. In some unfortunate
cases, doctors use the fee-for-service model to do everything they
can, no matter how pointless, to make money. More commonly, though,
doctors are fearful of litigation and do whatever they’re asked, with
little feedback, to avoid getting in trouble.
Even when the right preparations have been made, the system
can still swallow people up. One of my patients was a man named Jack,
a 78-year-old who had been ill for years and undergone about 15 major
surgical procedures. He explained to me that he never, under any
circumstances, wanted to be placed on life support machines again. One
Saturday, however, Jack suffered a massive stroke and got admitted to
the emergency room unconscious, without his wife. Doctors did
everything possible to resuscitate him and put him on life support in
the ICU. This was Jack’s worst nightmare. When I arrived at the
hospital and took over Jack’s care, I spoke to his wife and to
hospital staff, bringing in my office notes with his care preferences.
Then I turned off the life support machines and sat with him. He died
two hours later.
Even with all his wishes documented, Jack hadn’t died as
he’d hoped. The system had intervened. One of the nurses, I later
found out, even reported my unplugging of Jack to the authorities as a
possible homicide. Nothing came of it, of course; Jack’s wishes had
been spelled out explicitly, and he’d left the paperwork to prove it.
But the prospect of a police investigation is terrifying for any
physician. I could far more easily have left Jack on life support
against his stated wishes, prolonging his life, and his suffering, a
few more weeks. I would even have made a little more money, and
Medicare would have ended up with an additional $500,000 bill. It’s no
wonder many doctors err on the side of overtreatment.
But doctors still don’t over-treat themselves. They see the
consequences of this constantly. Almost anyone can find a way to die
in peace at home, and pain can be managed better than ever. Hospice
care, which focuses on providing terminally ill patients with comfort
and dignity rather than on futile cures, provides most people with
much better final days. Amazingly, studies have found that people
placed in hospice care often live longer than people with the same
disease who are seeking active cures. I was struck to hear on the
radio recently that the famous reporter Tom Wicker had “died
peacefully at home, surrounded by his family.” Such stories are,
thankfully, increasingly common.
Several years ago, my older cousin Torch (born at home by
the light of a flashlight–or torch) had a seizure that turned out to
be the result of lung cancer that had gone to his brain. I arranged
for him to see various specialists, and we learned that with
aggressive treatment of his condition, including three to five
hospital visits a week for chemotherapy, he would live perhaps four
months. Ultimately, Torch decided against any treatment and simply
took pills for brain swelling. He moved in with me.
We spent the next eight months doing a bunch of things that
he enjoyed, having fun together like we hadn’t had in decades. We went
to Disneyland, his first time. We’d hang out at home. Torch was a
sports nut, and he was very happy to watch sports and eat my cooking.
He even gained a bit of weight, eating his favorite foods rather than
hospital foods. He had no serious pain, and he remained high-spirited.
One day, he didn’t wake up. He spent the next three days in a
coma-like sleep and then died. The cost of his medical care for those
eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of
quality, not just quantity. Don’t most of us? If there is a state of
the art of end-of-life care, it is this: death with dignity. As for
me, my physician has my choices. They were easy to make, as they are
for most physicians. There will be no heroics, and I will go gentle
into that good night. Like my mentor Charlie. Like my cousin Torch.
Like my fellow doctors.
Ken Murray, MD, is Clinical Assistant Professor of Family
Medicine at USC.
Pagalavan's Avatar 
Very well written Dr Paga. Unfortunately, medicine is run by pharmaceutical companies and the healthcare workers are just a part of their play. An infectious diseases physician once pointed out that pharmaceutical companies are more focused on cardiovascular and diabetic drugs, spending millions on clinical research and trials, but not on antibiotics, as antibiotics is a definite form for cure, but non-communicable diseases will never be cured, only can be controlled.
As you have mentioned, there are many relatives out there who will listen to doctors than making a sound clinical decision in the best interest of the patient. But there are some doctors who are only here for the money only sadly.
Have a good time with your family. You deserve the rest and time off with your family.
An Australian doctor once said to me,” if you’re in it for the money, patients will notice it sooner or later”.
Have a great family vacation, doc. Well deserved!
Have a good holiday Dr Paga!
The reality is that our health care system is still a medical care system. What that means is that health care providers are incentivized to give treatment and not preventing the need of it in the first place. So, patients only seek treatment (medical care) when they are really sick because they had no idea the disease was already building up in them for years prior to it’s symptomatic presentation.
This is nothing new and is certainly not rocket science. In fact, everyone out there knows prevention is the best form of health care; esp primary and secondary prevention.
How can you stop the diabesity epidemic when our country is known for its fantastic (fattening) food and people don’t have access to parks and running tracks esp in the rural areas? GLCs are running fast food chains (KFC and McDs) while gyms are being run by steroid-raged youths?
When I tell people with a BP of 140/90 that they better start doing exercise 3x a week they give me this shock of a look and ask me “where got time?? mana ada masa?” In the nordic countries people are given time off during their working hours to have a quick workout during the day.
Instead of debating and politicizing healthcare outcomes, in the last general elections the race and religion was the main problems highlighted. This is what we call a ‘mentality’ issue.
If we want to be developed, its time we take health care outcomes seriously, right from the policy and execution level. This starts by having awareness and pushing our politicians to fight for a better people serving health care system and not a businessman enriching medical care system. This is where I hope Dato Subra turns around our healthcare system into one which epitomizes and enshrines the importance of Preventive Care and Health Promotion.
Yup, preventive medicine is the way forward but no one seem to be interested in it! NO ROI mah!
I had a patient with end stage renal failure. Fistula failure plus plus, end up needed to do graft. Despite graft, it also fails. Came in with pneumonia and 3 monyhs of bed ridden. I counsel the family for conservative and stop hd. Guess what the next thing they did was went to the higher level and start to compliant about me.
Yes, it does happen. Sometimes, they don’t understand but most of the time, it is not the person you spoke to who makes the complaint! Some joker from somewhere will come and try to act that he knows the best!
You are going to Disney Land California? Not many of us can go there for lack of time and distance. Keep us posted as to your holiday experience
Nope, Orlando
Theme Park capital of the world is actually Orlando, Florida. The greater LA area comes 2nd. Disneyland California is actually in Anaheim.
Yup
Made this trip in 2002, went to 8 theme parks (including Kennedy Space Center) in 2 weeks and fried my vestibular apparatus! But the kids enjoyed themselves tremendously.
Have a good time!
Well deserved holiday forPaga. Which cities do you have to fly to to get to Orlando?
Singapore – Dubai – New York then domestic to Orlando
Wow the plane will probably be A380 airbus! Spacious and comfortable. Enjoy your trip sir!
I used the a380 in summer 2012 with emirates. Was fun..lol
It’s a big aircraft, but the seats are the same, and the leg room is also the same, and there will be a lot more people.
We went the other way, with United to LA via Tokyo, and then anther 5 hrs to Orlando. It was a full 24 hrs journey, and we needed a day to recover!
You wrote here you were working in Singapore. Were you self-employed or employed ( by Singapore hospital ) ? how much was your salary ? is Singaporean patients more fussy the Malay ones ?
I was doing attachment for 2 years. No pay but their doctors are paid well. BUT the patients are definitely more fussy and demanding.
Hello everyone!
I am a student with a few queries with regards to studying medicine. I hope you wouldn’t mind taking some of your precious time to answer them.
1) Houseman-ship : For malaysian students studying medicine overseas, in the event of limited vacancy for houseman-ship, will priority be given to students studying locally ?
2) Houseman-ship : In the event of limited vacancy, will private hospitals be another avenue for housemanship?
3) Is MBBS from Monash ,Manipal, Segi, MSU in Malaysia, recognised worldwide?
4) If one has become a doctor with medical license from Malaysia (i.e. through the MBBS course), in which countries would this doctor be able to work in?
Thank you so much for your time and advice.
All of these questions have been answered before in my various articles.
1) yes
2) NO, to do housemanship, the hospital has to be gazetted by MMC. At the moment, NO private hospitals are allowed to take housemen. However, it may happen when the government runs out of post.
3) Monash is recognised in Australia/NZ/Sri Lanka/Mauritus. The rest NIL
4) No where except UM/UKM in Singapore and Monash as above
Which universities in Malaysia do you reckon is the best Medical university?
UM, UKM, USM, IMU, PMC, Monash
I have my reservations about PMC, in view of their intake policy. They accept people with as low as ATAR80 for their 6 year programme. That is no better than these new local med schools. Or Russia.
Didn’t know that they have detriorated!
Hello there Dr Pagan,
Let say if a malaysian student would finish his/her medical degree in Australia and able to get a year of internship in Australia. Subsequently able to get register with the Auatralia Medical Council to practise in Australia.
If that person decides to come back to Malaysia, does he or she needs to go through the two years of housemanship before he can apply to register with the Malaysian Medical Council and subsequently serve the two years compulsory service with the government ???
If it is yes, then those who goes thru this process get the best of both world with just one year of internship/housemanship, he or she can practice in Australia or Malaysia anytime.
If she/he comes back immediately after internship in Australia, then he will need to do the remaining postings in Malaysia as per housemanship rotation here.
And , yes, she has to do 4 years compulsory training.
If she comes back as a specialist or more than 5 years of service in Australia, she can be exempted from housemanship.
The entry requirement for IMU 5 years program is ATAR 85. Will this make you have reservation on IMU as well?
Was this a recent “revision” ? Oh dear.
For IMU, I understand that this may be just one of their standard entry requirement, but MOST of its students are straight As students. My sister is in IMU now, she told me almost all students from Taylor and Help who went to IMU are straight As. Yeah, She was one of the straight A students from Help too. She always thinks she was very smart (always top in her class), but now she realises that many in IMU are better than her. sigh for her!!
The reason being these straight As students could not make it to the public universities because they did not sit for STPM, so they have no choice but go to private universities, and most of their families can afford to pay the RM 400 thousands tuition fee too! Nowadays, most students do not like to do STPM’, because it sounds very ‘out-dated’ to be still in ‘school’, they prefer ‘college’. Parents have no choice but to fork out a huge sum to let them do medicine in private medical school instead of telling them to sit for STPM trying their luck to get a place at public U.
Yes, most students in IMU are straight A’s students because there are just simply too many of them nowadays. My premed class of 30 had produced 10 students with 4As and above, and that was 6 years back! Can’t imagine how much the number has gone up now. Having straight As in A level does promise a certain level of academic capability, but it does not mean that every straight As scorer is “very good”. Try comparing the STPM syllabus to A levels and you will know what I mean.
Don’t confuse between minimum requirement, and actual requirement for acceptance. The minimum for all universities is the same, as required by MMC, ie BBB or ATAR80 etc.
In recent years, the number of student achieving AAA or better in Malaysia is increasing. Overall, 18% of candidates worldwide sitting for A-Levels achieve AAA or better, and if you look carefully at some private colleges in Malaysia, they exceed that.
Basically, it means AAA is equivalent to better than ATAR82. 4% get 3A*, ie better than ATAR96. Extrapolating between these two, you get an idea about the equivalence.
Since 5 years ago, IMU-PMS entry is minimum ATAR95/AAA. On the other hand, the 6 year PMC stream in designed for people who failed to qualify for the 5 year stream, and I know people who got in with ATAR83.
Further,most local private U’s entry requirement for 5 years program is ATAR +/- 80,whilst PMC’s is ATAR 95. Let’s have same basis of comparison. Thanks.
The basis for comparison is how strict that list of ‘good’ medical schools above take in their students. Leaving aside the IPTA ones (it’s generally 4.0 for them anyway), IMU takes in 95 for both PMS and local streams, although to fill all local places, it does drop below 95 in some batches. PMC’s 6 years programme is suspect due to their low requirements. Monash is also disappointing, as in order to fill places, they have dropped their requirements drastically, down to 91 and ignoring the ISAT test scores.
one foreign postgraduate student says here that he sees 100+ patient per day while his Malay counterparts see only 20 patients per day
Is it true ? Why ?
and now he is doing postgraduate ( PG ) training for 6 years. Why he has been doing it for 6 years ?
if a foreigner wants to undergo PG training in, for example, Sweden, he must pass Swedish language test with flying colors ( high score)- Australia : IELTS band score 75 for speaking and listening. Why there is NO Bahasa test ? How good is foreign doctors’ ability to speak Bahasa fluently ?
Why you did attachment so long in Singapore ? why didn’t you just work there to earn a decent living ?
http://www.mcnz.org.nz/get-registered/how-to-register/english-language-requirements/
IELTS speaking and listening 7.5 each
Ielts is nothin much.just to chek ur english..jpa students hv that exam before flying. Only Their minimim is 7.0 if im not wrong. Anyway, it depends on country. Alot of them got 8-9 though
If they dun get it, they cant fly..haha
If buy ‘flying’ you mean going overseas to a foreign Medical School, then if it is for UK, Australia and NZ, it is a requirement of the respective Medical Schools. The usual requirement is minimum 7.0 for all components. Obviously if any JPA scholar failed to get this, they will not get an offer, and they cannot ‘fly’.
Don’t ask why in Malaysia!! you won’t get an answer!
Due to family reasons, I had to come back from Singapore
Hello Dr. Pagalavan. I have a few questions here that I hope you can answer:
1)What do you think about the quality of MBBS in IIUM?
2)Does specialisation in dentistry requires similar procedures as in medicine?
3)I don’t have any doctor in my family history. I am feeling that it is my responsibility to become one and it might come in handy in the future. None of my siblings are interested in medicine. I’ve always eager to do medicine before but a lot changed after reading some of your posts. I just finished asasi in IIUM and about to continue my degree this September. I have two choices here, medicine or dentistry. Do you think I should do medicine?
1) ok
2) almost similar
3) up to you.
Hi sir. I am currently applying medical school. For private university, except for IMU and Perdana University, which other medical university is the best in your opinion?
I will never put Perdana UNi in the list!
Monash, Newcastle, Aimst are ok
noted. thanks a lot for your advice
oh ya sir. what would you say about MAHSA?
can’t comment till you see their 1st batch of graduates
May want to consider Management and Science Uni in Shah Alam.
Hi Dr I am 30y.o n graduated from CSMU Ukraine n currently working as GP in melaka. I resigned from government aftet completing my compulsory service. Actually I left the job due to family n financial prob.. seriously right now I really feel like I m loss… I m keen to continue further in medical line but not just as a GP bcoz I m really keen to specialise. As I know joining back as MO in a government hospital is not a easy task.. so I m wonder is that possible for me to sit for the MRCP or any other alternative route that u can suggest coz my main goal is to specialise.. thks Dr if u can provide some information to me..
There is no other way unless you go back to government sector. You can sit for MRCP Part 1 & 2 without undergoing training but for Part 3, you need clinical training and a supervisor to be your referee.
The other option is FRACGP to become family physician. This is done via Academy of Family Physician Malaysia. Visit their website for further info
Dr Paga,
I believe MRCP part 1 and 2 also needs a proposer, often a hospital physician. Is this true?
yes, I was informed that even for Part 1, you need a proposer. This only started 3-4 years ago.