Five years ago I wrote an article in my blog ” Patient’s Confidentiality and Autonomy” . It was about an article in the Malay Mail discussing on the issue of doctors posting confidential informations of patients being treated in hospital and using it to make remarks against certain group of people on Facebook etc. I wrote in detail my opinions on these matters and did warn the doctors that every patient has the right to choose what they want. Our job is to educate and advise, period. I wrote this same article in my books that was published in June 2016 (Chapter 9, page 185). Along the way I had written numerous articles on issues of doctors and social media. Interestingly, the exact issue that I spoke about in 2015 has taken a centre stage again, over the past 1 week.
We as doctors should learn to control our emotions. The public look at us as a highly educated person and we should not tarnish our names by making mocking or defamatory statement to any particular individuals, especially if we do not know the exact details of a case or never involved in it etc. Making general statements are fine. The issue that has been circulating around over the past 1 week started in early 2018, almost 3 years after i wrote my article. The court has decided that the said doctor has made defamatory statement against an individual and was asked to pay RM 230K in total, as damages and legal cost. I do not want to discuss in detail about this court case unless I have the detail judgement, which may only be released at a much later date.
What I want to talk about are comments made by many medical practitioners claiming that doctors have now lost the ability to advise people on quack practitioners, medical notes are neglected as evidence in courts etc. Some even gone to the extend of saying that doctors should be protected from being sued by member of the public for trying to protect the public from quack practitioners.
Firstly, let me explain that a defamation case is NOT a medico-legal case. In a medico-legal case, your case notes becomes a hardcore evidence against a negligent suit. Medico-legal cases/notes are only applicable from the time the patient seeks your treatment till the time the so-called negligence happens and so forth. The court will take the medical notes as evidence. So, if the patient has lied to you, they cannot turn the case against you as our management plan depends on what patient informs you. The legal test used to determine negligence is way different than a defamatory case.
In a defamation case, you need to proof that the accusation you have levelled against an individual is, on a balance of probabilities, true and proven. The legal test used is totally different than a medico-legal suit. So, when a doctor accuses a member of public of something serious, like causing death of a baby etc, she need to proof this statement in court. Can the medical note be used as an evidence?
My answer is NO, especially if you are not even involved personally in this case. Anything that happened outside a hospital/medical facility is hearsay. That’s the reason when a patient comes to emergency department and says that she/he met with an accident, we say ” Alleged MVA”. This is because we don’t know whether what the patient tells you is the truth and nothing but the truth, as proclaimed in court of law. No such proclamation is made when a patient comes to hospital. That’s also the reason why we always say ” claimed by patient” in our history taking. I hope the medical schools are still teaching this, as I learned it when I was a medical student.
Now, let’s go back to this particular case in general. The case revolves around a doctor who supposedly made remarks on FB against another “complimentary medicine” practitioner, accusing that the said practitioner caused the death of a child. I can vaguely remember the hot issue that was circulating at that time in regards to this case. The doctor made direct accusation and thus, it can definitely be deemed defamatory. No two way about it. If it was a general advisory statement without pointing to any particular person directly or indirectly, then it is not an issue and cannot be deemed defamatory.
Anything that happens outside of an hospital have to be reported to the relevant authorities to investigate. For example, if we suspect child abuse, we need to report to the police and social welfare department. It is up to these departments to take further actions. Just because the child said that she has been abused to you, it does not mean she is telling the truth and we should not depend on that story to throw accusation to anyone. Our job is to report. If we accuse so and so as responsible based on what the child said but subsequent investigations by police showed otherwise, you are liable for defamation and you can never win. Similarly, if any patients makes public accusation against a doctor in social media etc, you have every right to sue them. However, if the patient makes a report to MMC and MMC finds you not guilty, you can’t sue the patient, as she has made the right move. This is similar of us making a police report when we suspect something. The person cannot sue you for making the report.
In this particular case, police reports were made by both MOH and the person being accused of killing the child (directly or indirectly), who is the plaintiff in this case. Unfortunately, police investigations found no evidence that the plaintiff was responsible for the death of the child. This alone is enough to proof that the statement made by the doctor is defamatory. Some said that the mother lied in court and changed her statement, comparing to what was recorded in medical notes. Again, what the mother told the doctor is considered hearsay as it happened outside the hospital. In my 24 years of medical practise, I have seen countless number of patients not telling the truth. Many at times, they make up stories so that you don’t scold them or find them stupid. In the court of law, it is up to the defence lawyers to proof that the person is a liar and to expunge the entire witness statement. Till the judgement details are out, we would not know what happened in the court. I understand the said plaintiff in this case has also won another case in Shah Alam against a doctor as well, who supposedly did not turn up in court to defend himself.
Many young doctors out there do not understand the field of medicine. Defamation and medical negligent cases are 2 different entity. Medical notes evidence is only valid for something that happened within the medical facility, aka from the time the patient come to you. It is only applicable for treatment related issues. Secondly, what patient tells you is confidential and cannot be made public. A doctor who accuses someone publicly of wrongdoing by using this case notes has technically breached patient confidentiality. He or she can be reported to MMC. So, be very careful when you make emotional post on social media on certain issues when it involves specific patient etc. I have written an article on this in 2018.
Some doctors have said that they will stop advising the public against going to traditional practitioners to prevent being sued. Again, many don’t understand the scenario. You can always advise and educate the public in general terms. But what you can’t do is directly accusing someone of doing something. That is defamatory unless you have solid proof. Please do not forget that despite all the advise and education, it is every patient’s right to follow or not to follow. You can’t push your ideas into anyone even if it is based on solid evidence. Always remember your medical ethics: patient’s autonomy. My article in 2015 had explained this in detail.
Our country is in a mess right now and the world is in recession. I know this year’s Deepavali would be uneventful to many. However, I would still like to wish ” Happy Deepavali” for all those who are celebrating at home.
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Totally agree with you Dr Paga. Medical indemnity insurance will also not assist in a defamation suit.
A very costly lesson indeed.
Very long article but absolutely informative.Clearly the first step is to differentiate between medical negligence and defamation.Second step, never be emotional. Rationality must be the priority as professionalism is the key word.
Patients autonomy is over rated. People dont know whats good for them and make bad choices if left to their own devices.
It is entirely up to them. We can’t force anyone. We just advise and educate.
very informative article, thanks for the enlightenment Dr Paga. May u and family have a blessed Deepavali 2020.
Autonomy prevails, thank you for standing up for that Dr, have a blessed Deepavali.
Well, if you know what she actually said and wrote, you will know what i mean. Happy Deepavali to you too.
Hi Dr, I have been reading your posts and and following them. I searched up some of your posts regarding the USMLE exam. How is the current situation right now, I can only assume it if getting harder for people to be admitted despite excellent test scores?
I think the issue now is visa and also the fact that the number of graduates from US itself is increasing over the last 5 years.
that does sound tough, i recall in your previous blog posts you mentioned how even those with high scores get no matches, do you think that still applies to this day and age? and what are your thoughts on job opportunities for graduates in UK and Australia?
Yes, high score does not mean you will get the discipline that you request. Many end up taking the least popular fields. UK is having shortage at the moment but you need to sit and pass the PLASB exams. Australia have enough internship post for their graduates. Many who sat for AMC could not get any post to complete their internship. So passing AMC does not mean you will get a job. However, vacancies are still available in unpopular places like in Northern territory etc.
thank you for this, it further reinforces your statement that medicine is a trap if you want to migrate.i have just been curious as i know of many people studying in malaysia right now who claim they want to do housemanship/ residency in countries like Aus, Uk and Us and they are so certain they are going to get spots. but from my research i have realised that even for US graduates they find it hard to get places in their own country. Thank you for clarifying this, many people go into the profession without researching only to find themselves in a dead end. Take care and have a great Deepavali!
yes, most do not understand anything about medicine. They have this false impression that ” doctors are needed everywhere” without realising the fact on degree recognition, registration, internship etc.I get emails almost on weekly basis!
yes, its very sad indeed, we see time and time again, people not getting jobs even back here in MY, but the new generation of medical students still think life will be a breeze for them in terms of getting medical residencies abroad. these students i am talking about just joined med school, thus graduating in 5 years. the situation then would most likely be worse. i hope they realise soon!
people will only learn through the hard way! They will never listen to you.
very true! have told so many people that its so hard to get a job now, they are in denial. thank you for this blog, it educates so many.
Let me give you an example in Australia. The passing rate for AMC Part 2 exams is about 20-30%. Even after passing AMC, the chances of getting an intern job is not that great either. So many will try to do the alternative route to Part 2 which is WBA (12 months ward based assessment). You need to find a 12 months full time contract job in an accredited hospital to complete your WBA. In one of the regional hospital in WA, accredited for WBA, there was a vacancy for MO post. You know how many applied for the job? 253 candidates, almost all requesting for a WBA position! I also know many consultants who are not able to get a full time job in Australia. They work in several hospitals on part time basis.
Wow! Thank you for providing that data, the sad thing is many dont understand and analyse the data. They float around on the idea that there is a demand everywhere without understanding the thorough numbers behind it. Only simple research is needed to be done to know the impact. As per a study online, medical school enrollment in the US has grown by 52% since 2002, but their residency slots have only grown by 1% per year. If accommodating their own medical graduates is a struggle, it certainly will be hard as a foreigner to get a job there. https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30
Also do not forget that many hospitals prefer hiring nurse specialist rather than doctors nowadays, to do the same job!
exactly!
also just learnt that the “shortage of doctors” in the US is apparently due to Residency caps and not shortage of medical graduates! https://www.ucop.edu/federal-governmental-relations/_files/fact-sheets/fgr-health-factsheet-gme-f1.pdf
Yes, it is all about money.
indeed it is! thank you for trying to educate people on this matter and it is unfortunate people dont listen
There is an article on Joy for contract doctors as govt announces salary upgrade published by FMT on Nov 7. It is stated that plans are underway to absorb contract staff into permanent staff . Furthermore plans are being made for local Medical Officers to serve in England. Are these statements really possible?
When it comes from our great minister of health, i don’t trust anything! As for the upgrade, that should be the case. But as for absorbing into permanent post , we shall wait and see. As for working in england, how can you work when your degree is not recognised? Either he is confused with subspeciality training or he is talking crap.
What are the latest methods of assessment during the 2 years housemanship training? Are they done after each 2-3 months posting? Written Tests? Oral Examination? Have the methods changed over the years due to the large number of houseman and the need to weed out the non performers?
I always had the perception (most likely false) that like most training courses , a graduate just has to undertake the training and be awarded a certificate of completion after the 2 years. Any feedback , positive or negative is welcome.
As far as I know, the assessment is still not standardised but there are assessments, that will be conducted at the end of each posting.
Thank you Dr Pagavalan for this enlightening article. I had followed the defamation case sparingly because I sometimes read the Malaysian Medical Mythbuster’s FB page occasionally. All the information I obtained about the case is from reading online sources, which as you put it unless personally involved, should be assessed with care. I may not be a supporter of home birth methods and I sympathize with the doctor who lost the suit, but hearsay, acting on emotions and defamation is a serious thing.
Hi Dr. Pagavalan. I’m currently taking A-level in the process of taking medicine as a profession. The issue is that I’m not certain if I would be able to become a physician because most people told me to just give up because the field is oversaturated especially housemanship. I’m really scared, but I do know that I will not be happy with other career options. I’ve been reading about medicine as much as I could and it has gotten me very interested. I’m still thinking if I should just graduate locally or abroad and are the opportunities for a doctor to work abroad will be better in Malaysia? What is your advice?
You should spend some time reading my blog from A to Z. All the answers are here in this blog. The situation is the same everywhere.
Yesterday, an article at Codeblue Galencentre claimed 16 JPA scholars broke their contracts by leaving their compulsory housemanship service for Australia. Is that true? Will they be let go scot-free?
Did you finish reading the news? The medical graduates are “encouraged” to do housemanship overseas.
There is also one Codeblue article “JPA, MARA Scholarships Don’t Guarantee Permanent Posts For Doctors, Dentists”. Looks like the situation is even worse for self sponsored medical students.
“encouraged” to do housemanship overseas is an oxymoronic statement by our leaders. Firstly, other than NUMED and Monash graduates, no other degrees are recognised overseas for you to be able to do housemanship overseas. Secondly, if you are going to do housemanship overseas in developed countries, who will ever come back?
Firstly, these are Monash graduates as it is recognised in Australia. Not all who applies get an internship post in Australia. If they do get, I am very sure they will take up the offer. Since the government does not guarantee a job for anyone, including JPA scholars, I would not blame these students taking up the offer for internship post in Australia. Whether JPA will come up with any penalty, that is up to them.
Hi Dr.. I have a question about the contract MO’s. Apologies for the wrong section.
One of the new Drs that my clinic group is planning to hire has finished her housemanship and few months into her contract MO life in Sarawak and wants to resign from KKM and join us. [all in all 2 years and 3 months since started housemanship]
I remember back in 2015 when I resigned from KKM, the rule was that, I have to complete 4 years of compulsory service in order to be able to renew my APC in the future. Is it the same now, or has that changed with the contract system nowadays?
I’m hearing conflicting things from various sources and would like to clarify.
Thanks Dr.
The rule is still the same but they can ask for the last 6 months exception, meaning after 3 and a half years of their compulsory service. However, the approval must come from MMC before they resign.
If a medical graduate completes the 2 year Foundation Year programme in the UK (or Australia), would this experience exempt the graduate from the local 2 yr housemanship.? is there any circular on this?
See the circular in 2017. It is available in my blog as well and on MMC website.
Thanks
Has the time come for medical graduates to seriously consider alternative career pathways ? Will such a decision be embarrassing and be accepted by society? There have been suggestions along this path.
If there are no jobs available to those medical graduates, they of course have to consider alternative jobs. They can join their parents’ businesses, insurance consultants etc.
Being unemployed is actually more embarrassing. Those medical graduates should have studied job market and have done some research such as reading Dr Paga’s blog. Dr Paga has made the prediction about the oversupply many years ago. This prediction is free of charge. Unfortunately, people don’t want to listen to hard truths.
You can choose whatever field you want. It is nothing new. Few of my doctor friends are not practising doctors. The issue is the money you have spent!
Ex Trainee doctor allegedly commits suicide according to posts on MMI website and press release from the Penang medical authorities. Is the situation that bad?
We still do not know the actual reason for the suicide. It is not always related to housemanship etc, it could also be personal issues.
News reports indicate that the Covid 19 situation is here to stay and pressure is on the government to create more permanent post and increase houseman intake.
The question in mind is that does the pandemic at present translate into demand for doctors?The Malaysian economy is badly hurt and can the government really afford to sustain a growing medical workforce? It is better not to give false hopes to medical graduates and tell the reality of the situation.
As I had said for many years, the issue is distribution of doctors . Yes, we still need more doctors in public sector but if it is not well distributed, then the scenario will not change. To solve this problem, we need an integrated healthcare system with national health financing scheme as I have written many times. The government may still need to create some new permanent post but the numbers will never match the production. That is the reality.
Hi Dr, I came across your wonderful blog yesterday and I have been reading some of your older posts. I am currently a “form 5” student who is due for SPM in February 2021. I have been interested in machinery and propulsions since about 10 years old and I had my mind set on Mech. Engineering. As the years past I developed a profound interest in serving others as I find it very satisfying to make someone’s life easier and better. Then I discovered the profession of being an anesthesiologist. I know it is not as simple as making the patient unconscious and relax, but I think it is an interesting job as I get to handle different cases everyday and not a specific region of the body.
My plan was to originally finish SPM, then take A-levels and then do my medical degree, but I am unsure if this is the “correct” and viable path for me? I am of Chinese descent so I’m not getting my hopes too high for matriculation, so what would be the ideal path to end up as an anesthesiologist? I will be the first to admit that I come from a pretty well-off family but would still prefer to be able to save my parents some money. I wouldn’t mind working either locally or overseas, but it seems like since 2011 you have predicted that there will be a overflow of supply for doctors in Malaysia? Is that true for anesthesiologists? From what I gathered online, CRNAs are able to do 90% of the job in the US but they are still not recognized here in Malaysia. So what would be your plan/path for me in the next 10 years?
To be frank I am intimidated by the medicine field after reading your posts as I feel like I would not be good enough for med school or not being able to cope with the immense pressure. As of now I have more interest in physics, but on the other hand I love serving others and helping them. I understand that at my age it is normal to be uncertain about the future but I would greatly appreciate some advise from a guru like you. Thank you for your time Dr., I wish to hear from you soon.
please spend time to read my blog from A-Z, all the posts under For Future Doctors page. All the answers are there. FYI, anaesthesiologist do not see different cases everyday. Their job is just to put a person to sleep and watch Facebook! The rest are handled by surgeons and physicians. As for helping people etc, it is a myth that people tell you. Read my blog from the beginning and ALL the answers are there. You can also buy my books (details are available in this blog)
I see, thanks
Happy Thaipusam doc! Waiting for your next blog post 🙂
Thank you forr writing this