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Archive for the ‘Education’ Category

It has been a while since I last updated this blog. In my last article, I promised that I will be writing a series of article in relation to the changing world of medicine but unfortunately I met with a small accident in September while going to work. While I was OK and only hit a divider on the highway, my car was damaged and currently still in workshop. It is really frustrating when you don’t have your own car to travel around. This entire fiasco kept me busy for the last 3 months with Deepavali early this month and some travelling to do.

Medicine is or “was” a noble profession. It started as a science to help humans, to discover diseases and ways to treat them. Early doctors were trained purely by apprenticeship with no formal training or degrees. They did their own research at the back yard and came up with new techniques, findings and even treatments. In the 19th century, our ancestors believed that doctors need some form of self regulation and proper training modules. Thus, registration and regulation of doctors started. General Medical Council began in 1858.

Doctors are the only people on the planet given the rights to collect and record clinical history and confidential informations of a person. It is the only profession which can take detail information about a person which include certain intimate or sensitive details and social circumstances. You need to know every detail about a patient, from travelling history, problems at home, social history, sexual history etc etc. Only then we can formulate a diagnosis and provide treatment plans. The patient trust us to keep these informations as tight as possible and not to release the information to a 3rd party or even to his/her relatives which may even include his/her partner without the patient’s consent. This is where medical records safe keeping and confidentiality comes into the picture. Every medical council in the world has guidelines on these issues. Every doctor should read and understand these guidelines as not to breach ethical and professional bounderies.

Doctor-patient relationship is a unique relationship. We should keep professional boundaries at all times. This is the main reason why we should not be treating our own family members and close friends. Emotion would not allow us to provide the best standard of care to our loved ones. We will be in denial and would not give the best advise. On the other end, patients can become a vulnerable victim to a doctor. Only a doctor knows sensitive information of a patient and thus can easily be blackmailed by a doctor. This is one of the reason why professional boundaries are important to be maintained. This is also the reason why we must be regulated!

The advent of social media has created a totally new set of problems. Many doctors do not realise that social media can blur their professional boundaries. Facebook, Twitter, WhatsApp and many other messaging platforms have created new problems in the medical profession. Let’s look at WhatsApp. Doctors nowadays easily give their phone numbers to their patients, send confidential informations such as blood results etc via WhatsApp to the patient and even discuss their problems via WhatsApp. The doctor believes that he is tying to help the patient but forgets the fact that it can be construed as blurring professional boundaries! Imagine if you message the patient at 11pm at night and the patient is a married lady with some social issues, like problem with her husband etc. Imagine if the patient starts to communicate with you via WhatsApp for her personal matters, presumably seeking advise in relation to her relationship issues etc. This can definitely lead to something more serious like the case over HERE and  HERE. Furthermore any confidential information send via WhatsApp etc can be considered as a breach of confidentiality as it is leaving your premise. You got no idea who can see those messages even though the phone number can be the patient’s. It is always advisable to ask the patient to come back to your clinic for any discussion or issues. Never discuss any issues over the phone or via text messages. In India, a reason court ruling determined that telephonic consultation without seeing a patient that lead to death can be considered as culpable negligence which leads to being charged as culpable homicide!

Another issue is Facebook(FB)! Many doctors have FB profiles and some of us are active on Facebook, posting various personal matters and views. Way back in 2011 , BMA (British Medical Association) had already issued warning in the UK that interacting with patients at social networking sites such as FB can lead to blurring of professional boundaries. WE must, at all times maintain the doctor-patient relationship status. Making a patient a “friend” on FB blurs this boundary. Once you become a friend of a patient on FB, the patient can access many personal information regarding yourself, they can probably see your family members photos, your political and religious inclination and even comments that you might have made regarding a patient that you just saw in your clinic. IN fact, I have seen many doctors posting and discussing patient’s history and details in FB. While you may not mention the patient’s name but if that patient is your friend on FB, he will definitely know who you are talking about. Many Medical councils and boards in the world have produced “social media guidelines” and the common advise has always been ” never friend a patient on social media including FB, Twitter etc”. To my knowledge, MMC is yet to issue any guideline on this. KKM did issue a minor guideline 2 years ago after the labour room picture fiasco. Not only a patient can see the “life” of a doctor but the doctor can also “spy” on the life of his/her patient. In 2017 there was even an uproar in Pakistan when a doctor requested a patient to become a friend in FB! It was deemed as a form of sexual harassment and the doctor lost his job!

Whenever I talk to younger doctors in regards to this, I see a shocking face! Many doctors out there do not even know their own ethical boundaries with patients. Some even attend patient’s personal family function and interact with patients as though they are family friends. Yes, you may think that it is nothing wrong BUT as a doctor treating such patient, you should never cross the line. If the patient becomes your family friend then you should politely decline to be their doctor, to safe-guard the medical profession and doctor-patient relationship. THIS is a good article to read “Unhealthy relationship with patients”. I reproduce one of the excerpt here:

Maintaining professional boundaries

 

Avoid situations that may be misconstrued by the patient – for example:

  • Giving a patient a lift home in the car
  • Seeing patients outside the surgery without a clinical reason
  • Telephoning the patient without a clinical reason
  • Having personal transactions with patients, such as lending money
  • Conducting non-emergency consultations outside normal surgery hours
  • Having conversations with patients of a personal nature.

Medical examinations can be misinterpreted by patients, and they can be left feeling that proper boundaries have been crossed so when conducting examinations:

  • Explain if an intimate examination needs to be conducted and why
  • Explain to the patient what the examination will involve
  • Obtain the patient’s permission before commencing
  • Give the patient privacy to undress and dress
  • Keep discussion relevant and avoid unnecessary personal comments
  • Encourage questions and discussion
  • If you can sense that the patient feels uneasy, offer a chaperone or invite the patient to bring a relative or friend.

Be aware of your own vulnerabilities:

  • Develop skills in saying ‘no’ whilst maintaining compassion and rapport.
  • Be aware of the impact of isolation and take steps to have as much peer interaction as possible
  • Do not to be seduced by comments that may appeal to your ego ‘you’re the only person who listens to me and understands me.’

Some of the things you need to consider include:

  • Making friends with patients or treating friends as patients can lead to unreasonable patient demands
  • Politely decline invitations from patients to be Facebook ‘friends’
  • Living and working in close rural or cultural communities means you may be invited to social and community events. You don’t need to decline every invitation you receive but do consider the nature of the event before accepting. And, you must always maintain professional boundaries if you choose to attend
  • Accessing patient records for the purpose of making social contact breaches the patient’s right to privacy.

I realise that many junior doctors and even some of my own colleagues do not understand their boundaries. They take it for granted especially doctors in private sector. These doctors feel that it is a form of marketing strategy to be friends with patients in FB, to attend functions organised by patients and make friends with patients as though they are your family friends. Some even question me when I advise them not to do so. It is ethically wrong fo a doctor to breach a doctor-patient relationship. At all times, we should maintain our professionalism and treat a patient as a patient! Never do more than that except in an emergency situation.

I see a very dangerous trend of doctors accepting patients as FB friends etc. Please be VERY careful! It can be harmful in both ways. With increasing medico-legal cases in court, it can only harm you further. We are not any different than judges who have to refrain themselves from many social events.

It has been a busy year for me. I may not be able to update another article within the next 1 month. Thus, I wish everyone a very HAPPY NEW YEAR 2019…………………

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Three years ago, I wrote an article with the above title. I thought of revisiting the title again, as there are a lot of negative publicity with the medical profession over the last few weeks. It all started on 29/07/2018 when a front page article was published by the Star.

 

The front page title was followed by an article which supposedly exposed an HOD who has been sexually harassing junior doctors. Currently KKM is conducting an enquiry into this matter and the said HOD has been asked to go on leave. While I do not want to speculate on the truth of the matters raised, I am not totally surprised either. “With Great Power, comes Great Responsibility” but unfortunately, Great Power also comes with great corruption! It is not unusual for someone in great power to abuse their position. It happens in almost every field. Even in Hollywood and Bollywood, actresses have been sexually harassed. The recent expose of Harvey Weinstein sexual harassment scandals rocked Hollywood and subsequently many more exposures came to light. Whenever someone is in a vulnerable position, the superiors with ultimate power tend to take advantage. Have I seen it happening in medical field? If I say NO, I will be a liar. However, most of what I have heard are verbal in nature. Please be also informed that there is a difference between sexual harassment, sexual abuse and assault.

On 9th May 2018, for the first time since independence we saw a change of government. What happened after that? Expose after expose showing how the country’s and the people’s money were misused and abused. I have lost track of all the exposes since 9/05/2018. Why did it happen in the first place? The answer is the same: with great power comes great corruption! Anyone who stays in power for too long will bound to misuse their position. It is human nature. That’s why politicians will never try to give up their seat. The same thing happens in any organisation. When someone becomes the HOD and remains so till retirement, he becomes untouchable. He becomes so powerful that every single thing needs his approval. From approving leaves, giving SKT marks, approval to attend courses, signing for exams, approving claims, signing off housemen etc etc, almost everything needs his/her signature! What a powerful position! On the other hand, the HOD can go missing anytime, hardly does any clinical work, goes overseas conferences under pharma sponsorship etc etc and NO ONE will ever complain or take action against him/her! I have seen HOD’s who only came to work twice a month and was sitting on a JUSA C level! The rest of the days, he/she is contactable at home! I have seen HODs who hardly does any clinical rounds but will appear in the ward everyday when a VIP gets admitted. It really fits into the term ” Makan Gaji BUTA”. How many HODs even put in their leave application forms but yet they are on-leave?

When someone is that powerful, things like sexual harassment etc bound to happen. Many years ago, I wrote in the MMA magazine that HOD’s post should be rotated! When I was doing my attachment in Singapore in 2007, it is the policy of the hospital that HODs can only hold the post for a maximum of 2 terms. One term is 3 years. So, after 6 years, the baton must be passed to the next person. This next person may be a junior to the current HOD by years BUT the rotation will still need to be done. The whole purpose of this policy is to prevent abuse and at the same time, give the junior doctors an exposure to administrative work. Somewhere in the late 2000s, there was a circular from the then DG, Tan Sri Ismail Merican suggesting that the HODs to be rotated every 5 years among the JUSA salary scale. Unfortunately, there were huge objections from the HODs themselves and the suggested plan never materialised. Human nature: power! And absolute power corrupts absolutely!

IN 2014, I wrote an article about bullying. In fact, i had written several times on the issue of bullying and thus, I would not elaborate on that matter in detail again. There is a thin line which differentiates bullying from scolding. We cannot assume that every scolding is a form of bullying. Medicine is about life and death matter. A simple twist of the pen can cause death. Thus, seniors scolding juniors will happen no matter how hard you try to prevent it. However, it should not be done in front of the patients/relatives.Bullying on the other hand has nothing to do with scolding for making mistakes.Bullying includes actions such as making threats, spreading rumours, attacking someone physically or verbally, and excluding someone from a group on purpose. Unfortunately, it looks like now, every scolding is being considered bullying. Medical life is a stressful life, both physically and mentally. When you work in such a stressful situation, scolding bound to happen. However, with increasing number of doctors, shouldn’t it get better? Where did we go wrong? Why despite having increasing number of doctors ( I heard some hospitals have close to 4 MOs in a ward!!), there seem to be worsening situation of “bullying”? BTW, real bullying do occur and it occurs in every profession and in every country. This article talks about bullying in Australia and this in NZ. Nothing unusual but the type of bullying varies from one centre to another. We can never prevent it completely as we are working in a stressful job.

My answer is simple, which I had written since 2004! The quality of graduates had deteriorated! When quality deteriorates and graduates do not even know basic medicine, scolding aka “bullying” will become more rampant. From what I gather, the quality has deteriorated to the extend that sometimes, the consultants do not even bother to ask the HOs anything, as it is pointless! How did someone graduate when they do not even know how to take a history, examine and come to a diagnosis? It is the very basic of medicine that you go to a medical school for. How did someone even passed the final exam? Again, this is what you get when you commercialised medical education. Do you really think that the medical schools are interested in producing the best quality of graduates? All private universities are profit driven. Only profit matters. With such a low entry requirement to enrol into a medical school, we still have almost 100% passing rate! Can anyone beat that? Australia with such a stringent entry criteria, still have about 5-10% drop out rate! UK has almost similar figures. India went through the same phenomenon when they commercialised their medical education in late 1970s. Corruption, lowering entry requirement and high pass rate with dropping standards forced Medical Council of India to introduce a common entry exam! Now, every student who intend to do medicine must sit and achieve certain level of pass marks to be eligible for medical course. Only after that, you can apply to the universities: public and private.

I just hope MMC will seriously look into this matter and introduce some form of either a common entry or exit exam to maintain the standards of medical graduates. If not, we are be going backwards! Many still do not know how medicine has changed and still changing. I will continue these series of articles over the next few months. My next issue under this heading will be “doctor-patient relationship” and professional boundaries. With social media everywhere, do medical students or junior doctors know where their boundaries are?

Happy 61st Merdeka ……………

 

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It is about the time of the year when you see a sudden surge in my blog visits. It happens every year after the SPM results are announced. Once again I will get emails and comments asking me all sort of questions which has been answered many times before. I have written countless number of articles since 2010 in this blog which is still available for people to read. Somehow I feel, our current generation do not like to read much and wants quick and easy answers. I would blame the education system which never encourage students to read and explore the world. There are so many things happening in this world and the world is changing rapidly day by day. Our society is still living in cocoons.

Once again I would encourage everyone to buy and read my books before deciding whether to do medicine or not.  You can see instruction to buy my books over HERE and I can still sell it at a special price of RM 85 per-set. Do not jump into medicine just because you got 9As, your parents & relatives said so or you think you are going to make big money etc. The number of doctors/graduates quitting medicine is increasing day by day all over the world. Only the toughest and those who got real passion and willing to sacrifice, will survive.

Many people believe that medicine is the only profession where you can help people. Frankly there are many people out there who are helping people more than doctors. At the end of the day, medicine is just a profession to earn a living. It is a service for a price! The society now perceives doctors as someone who is paid to provide service and not ” helping people”.  Would you “help” and treat people if not paid? Not to mention the viral damaging remarks made against doctors and clinics being circulated in FB and Whatsapp! It is becoming a norm. The best part is , you as a doctor CANNOT reply to those comments as it is considered breach of patient confidentiality! You will be called up by MMC for disciplinary action.  Many do not know that once a disciplinary action is taken by MMC, you will not be able to even apply for a job anywhere in this world even if your degree is recognised in that country. This is because, every medical council in the world will request for ” Certificate of Good Standing (CGS)”  from the country where you are working currently. Once there is a disciplinary action taken, it will be listed in CGS. So, likely you will be disqualified from getting a job.

Not to forget doctors being assaulted in India and China! The video below shows how a doctor is being assaulted in India! It is becoming so rampant in India. It all started with commercialisation of medical education and medical business! The public now had lost trust on doctors. IN western countries, it is manslaughter charges as I had written in my last post.

Frankly, do patient really listen to you nowadays? Five out of 10 patients do not even bother to follow your instructions. They come to you with complications years later and expect you to cure them. No one bothers to take care of their health and most doctors nowadays are treating complication of life style habits. They insult you if you don’t give MC but can happily go shopping while smoking! I can write tons of examples but suffice to say that people just consider you as another person who is doing a job. Only the senior citizens in 60s and 70s seem to appreciate you nowadays. You see more older people thanking you than any young people. The young people just consider you a service provider for a fee ( I pay you, you do your job)!

What prompted the title of my article is a message that has been circulating in Facebook and WhatsApp. It is a well written piece but I got no idea who wrote it. Please see below:

WHAT IS THE DARK SIDE OF BEING A DOCTOR IN INDIA and ? MALAYSIA

“Loneliness”

Profound loneliness. You can be surrounded by friends, family and colleagues, but in reality, you are quite alone.

If your family does not consist of doctors, they hardly understand the difficulties that you go through. They sympathize with you, yet are unable to grasp the reality of your training and career. Why you must spend days and weeks and even years apart from them. Why a lot of their calls are unanswered by you, while you are busy during rounds or managing patients.

Your old school friends do not really understand how hard the years have been. Why you couldn’t attend all the weddings you were called to. Some just attribute it to arrogance. Some understand. Only a few are driven enough to maintain a relationship where you hardly meet, talk or hang out. Nobody realizes that you hardly have time for yourself, leave alone the closest of friends.

When you do meet your old buddies, from various different fields, you can feel a fence that has formed around you. You smile, and nod your head. Yet, you are some distance away. The conversations seem a bit trivial compared to what goes on everyday in your other life. It is like viewing the rerurn of a tv show you had loved at some point of time.

Your college friends don’t stay with you for too long. Forever branching and specializing fields of medicine mean everyone either ends up in a different college, City or country eventually. You do drop each other a message once in a while, especially if you can remember who it is that you are missing. Conversations do not progress beyond a few words, as both of you are busy beyond compare. Time and distances lighten the strongest of bonds.

Your partner/spouse/girlfriend/boyfriend understands your trials and tribulations with difficulty. A similar profession leads to conflict, ego struggles and comparisons. A different profession causes irritation and indignation at your personal priorities. You keep training and hardly find time for them.

Your patients may love you for your bedside manner and clinical acumen but neither do you form friendships nor expect any support in times of trouble. You keep a distance. Always. Proximity causes lack of objectivity. And, patients rarely come out in open support of their physician.

Your colleagues in the same branch view you as competition. So much so that they would be secretly relieved to see you fail. You colleagues in other branches form cordial, friendly relations. You meet once a year for joint conferences and sometimes discuss patients which have been referred. You can expect a bit of professional support but nothing emotional or personal.

The hospital you work in couldn’t care less about you. You are indispensable to them, until you are replaced.

Not all this is true for everyone in all scenarios, but, yes, you learn to live with this reality.

Add to this the constant fear of litigation, abuse, violence and disciplinary action.

It can get very lonely at the top for doctors sometimes. And the higher you go, the further away you are from everyone.

If this is not part of your story, being a doctor, you really are blessed.

 

Trust me, the article above is what most doctors go through in their life. At the end of the day, no patients will ever come to your defence if something happens to you. Do you see anyone coming to the defence of Dr Bawa Garba and Dr David Seelu in UK? None! Your own medical council will attack you in the name of public safety. That’s the life of a doctor. The untold story that I have been writing for the last 8 years. Only do medicine by knowing all these issues! If you think housemanship is torturing, wait till you see the real world of medicine.

I hope all SPM leavers would not just jump into medicine just because you got 9As. Read and learn to know the world and how it is changing. Do medicine only if you are willing to put up with all these struggles. If not, please do not waste your money and time.

 

May we make a right choice for GE14…………          Have a blessed Good Friday……..

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The world of medicine is changing rapidly. For those who are aware what is happening around the world, we know how the perception of public towards medical profession has changed. Unfortunately, there are many out there who are living in cocoons, do not even know that sooner or later they can be charged for manslaughter!. The recent case in UK involving Dr Bawa Garba has sent shock waves around the world. A senior trainee paediatricians were given suspended jail sentence of 2 years for gross negligence amounting to manslaughter. GMC ( the guardian of medical profession) appealed to High Court to struck off her registration despite Medical tribunal giving only 12 months suspension. Two weeks ago, the court allowed GMC to struck off DR Bawa Garba from medical registry. A detail reading of her case will remind us that what has happened to her, happens on a daily basis everywhere in this world! Unfortunately , the world is changing.

Many still believe that medical indemnity will cover their butt if and when they make any mistake. Unfortunately, any negligence leading to death can now be charged under manslaughter and no more a civil negligence case. IN Malaysia, similar case is currently ongoing involving our very own DPM’s son in law’s death. The doctor who gave sedation is now being charged for manslaughter which can carry a prison sentence of up to 10 years. If he is convicted, it will set a precedence for any other such cases in the future. Similarly, another doctor was charged in December 2017 for circumcision gone wrong. He is being charged under Section 338 of Penal code for causing grievous hurt which can give you 2 years of imprisonment.

IN the US, just 2 months ago, an anaesthetist was charged for murder, “killing” a patient undergoing plastic surgery procedure by giving overdose of an anaesthetic agent. In fact, the first time a doctor was charged for second degree murder in US was in 2015.

Doctors around the world are rallying behind DR Bawa Garba. The fact is , the case just portrays how the healthcare system has failed. She was overworked, just came back from maternity leave and covering 2 person’s job without a supervising consultant. Sounds familiar? Unfortunately, the court do not take into consideration of all those shortfalls. It just concentrates on the negligence part and sentenced her accordingly. Any gross negligence leading to death is now considered a manslaughter! Is anyone still living in dreamland thinking that doctors are “gods” in the eyes of public? You are treated similar to anyone else when you cause a death due to negligence. Nothing special.

DR David Sellu’s case in 2013 is another good example. A well renowned colorectal surgeon of 66 years old was sentenced to 2 and a half years imprisonment for causing death of a bowel perforation case. A patient who developed bowel perforation following a knee surgery, deteriorated while waiting for surgery and subsequently succumb to sepsis. This happened in a private hospital with limited facility for emergency anaesthetist and OT. Thankfully, after 15 months spending in jail, the court of appeal reversed the decision when new evidences emerged regarding the lack of facility and why he could not do the surgery immediately. Unfortunately, damage is done and he had spent 15 months in jail together with other criminals convicted of rape, murder etc! After saving lives for 40 years, at the age of 66 he was treated as a criminal and even labelled as Dr Death! He was also subsequently subjected to GMC’s suspension. This is a good article to read as well : https://health.spectator.co.uk/david-sellu-a-surgeon-wrongly-jailed/

These cases have created a new term : ” Medical Manslaughter“! The list of such cases in UK till 2014 are listed in this article and attached below.

 

Looking at those cases above, we will wonder that these are nothing unusual in day-to-day medical practice. It happens on daily basis. Sometimes complications can never be predicted. Errors do occur and it is not entirely due to the doctor’s fault but the system as a whole. There are many factors that can cause such negligence to happen or how the complications are treated. Unfortunately, the court only considers the healthcare professional’s mistake. This applies to paramedics as well. Nurses have also been charged for manslaughter. This WEBSITE has some information of other health professionals who have been charged similarly.

 

The above video made last year is worth watching. Doctors are humans and do make mistakes. However, the society is not willing to accept these mistakes anymore. I had written much about civil litigation that is increasing day by day. Criminal charges are now increasing day by day as well. As long as you are proven to make gross negligence leading to death, you can be convicted for manslaughter. This can be as simple as giving a medication !  For example, if you give IV Pethidine for pain and the patient stopped breathing and dies, you can be charged for “murder”! And subsequently, the medical council will struck you off the register!

As I had always said, the world of medicine is changing. Modern medicine is infected by virus of mistrust as written over HERE. Commercialisation of medicine is one of the reason behind these issues. A profession which started during ancient times as a science to help people has been systematically and gradually converted into a multi billion dollar business. A business to suck people’s money in many developing countries. Generally, countries which have a universal healthcare system will have lesser number of negligence and complains, as patients do not pay much. Unfortunately, NHS in UK is dying day by day due to lack of funds and overcrowding.

If criminal charges against doctors left unchecked, we may be seeing many doctors behind bars despite saving many lives! I wonder whether AI will come to the rescue? Can AI be charged in court for making a mistake? These are the reasons why many doctors are feeling the overwhelming stress at work(burnt out) all over the world. After years of training and money spent, a simple mistake will land you in court. What use to be civil has now become criminal offence. I can only see more and more doctors retiring early and leaving medical practice. Many do not even encourage their offsprings to do medicine.

What I foresee is that the society will dig their own grave. More and more people would not do medicine. Many doctors would not take high risk cases. Consent forms will become as thick as “Harrison’s Book of Medicine”. Finally, mistakes will be hidden and notes will be fabricated!  The art of medicine is already dying due to CBM (Cover backside medicine) but eventually medicine itself will undergo a silent death………..

Gong Xi Fa Chai everyone………

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On the eve of the official release of Star Wars Episode 8, I thought of writing something new, since I had not updated my blog over the last 3 months. Medicine has a long history, going back to the time of Hippocrates(460-370 BC). He is known as the Father of Medicine. Hippocratic oath was one of the most widely known Greek medical text. It forms the basis of medical ethics.

Medical profession is the most widely regulated profession in this world. Degree recognition, disciplinary actions and standard setting is part and parcel of medical life. Our ancestors decided that medicine can be easily misused and thus a proper regulatory body must be formed to prevent any ethical abuse. I had written enough about these issues since 2010. Unfortunately, as I had written in my previous post, the commercialisation of medical education and healthcare system had led to “prostitution” of medicine. Doctors sell their soul to businessman for profit. Some say it is a “win-win” situation but to me, the day a doctors charges a fee for service, the nobility of being a doctor disappears in the eyes of the public. The businessman uses that to do business and the private healthcare is born to squeeze the people. There are 2 things that a government should never commercialize: health and education! The day these 2 sectors are commercialised, that’s the day you will see deterioration of the system. Almost all countries that commercialised these 2 sectors are seeing the outcome of such move. That’s why most developed countries other than US maintain their healthcare and education system under their government’s control. One of the major side effects of commercialisation, is litigation! And when litigation increases, who takes the brunt of it ? Not the hospital but YOU!  The businessman will just wash his/her hands off and disavow any knowledge of your existence!

Medicine is regulated by multiple rules and regulation. It all started with the Medical Act 1971 which regulates registration of doctors, recognition of degrees and disciplinary actions against errant doctors. The Poisons Act 1952 regulate the import, possession, manufacture, compounding, storage, transportation, sale and use of Poisons. Many doctors still do not follow what the poison acts has mandated them to do, like labelling of prescribed drugs etc. Dangerous Drugs Act 1952 specifically regulates the import, export, manufacture, sale and use of opium, dangerous drugs and related materials. This act is more related to opiates and benzodiazepines. Many doctors have been caught selling these dangerous drugs over the counter.

In 1998, the infamous Private Healthcare Facilities and Services Act (PHFSA) was passed. The regulation came into effect in 2006. Prior to this act, any doctors can open any shop-lot to run their clinic/provide service. With the enforcement of the act, anyone who intend to open any medical services clinic have to comply with the rules and regulations stated. The size of the doors, mandatory equipments, storage of medicines etc all all regulated since then. Together with PHFSA Act 1998, the fee schedule was made into a law! The 13th Schedule determines the maximum fee a doctor can charge to a patient for consultations and procedures. Unfortunately, it DOES NOT control the fees charged by the hospitals! The last review of this fee was in December 2014 after 1998! Again, we lost to businessman!

IN 2012, the Medical Act 1971 was amended. The regulations came into force in July 2017 which mandates compulsory registration of specialist, compulsory CPD points for renewal of APC and NSR as well as compulsory indemnity insurance. I had written about this over HERE. The APC fee increased to RM 100/year and there is also a RM 1500 specialist registration fee every 5 years. The doctors also have to pay PHFSA fee for registration and renewal of their clinic license. Just recently, few of the local councils have mandated that clinics must also pay the business license fee to local authority which was deemed exempted before. Not to forget waste disposal fee, minimum wage for staffs etc etc. IRB on the other hand is going after all the doctors to collect more taxes. As long as you sign an agreement under your name, all payments must be declared under personal income tax and not under your company’s tax.

On the other hand, the world of medicine is changing. The beauty of medicine is in making a diagnosis via clinical examination and interviewing a patient. I use to tell my students that interviewing a patient is like a police interrogation to find evidence to charge a criminal. This will be followed by clinical examination which together, will give you a diagnosis almost 80% of the time. Investigations is just to confirm your suspicion and diagnosis. This is called the Art of Medicine. Unfortunately, with increasing use of technology and rising litigation rate has created something known as CBM: Cover Backside Medicine. Why do you need to sit and take a history of headache or cough when you can do a CT Brain and CXR is a few minutes? What is the use of auscultation of the heart when you can ECHO anyone, anytime? For matter of fact, is stethoscope really necessary in this era? Has it become a mere symbol to say “I am a doctor” and that’s it? I have seen doctors who hardly take 4 lines of history and orders a battery of test to exclude whatever diagnosis he can think of. What is the difference between you and a technician? If that is so, why do you need 5 years of medical school? We see private hospitals promoting their latest gadgets to the public to make money. The public now beliefs technology more than a doctor!

Gone were the days when a doctor can palpate an abdomen and diagnose Appendicitis. Now, we need to prove to the patient that it is appendicitis. So, every patient gets a CT scan! If CT scan is normal, insurance may decline the case and patient may refuse the surgery. Interestingly, the Radiologist get pressured and reports it as appendicitis! It is a “win-win” situation I guess. The day medicine was commercialised which in turn caused litigation to rise freely, the pressure builds up for the doctors to prove everything. Unfortunately, in medicine, not everything can be proven by blood test or radiological investigations. At the end, doctors become technicians who orders investigations no matter how accurate his diagnosis is.  The trust is gone. Matters are made worst by article such as THIS. All these issues are affecting doctors all over the world. Depression among doctors, burnt out phenomenon are common in many countries. A recent article in BMJ ” Why has Medicine become such a miserable profession?” says it all!  ” The Dark Side of Doctoring” by DR Eric is also worth reading on how doctors are being used by businessman for profit and why he feels miserable. We have become a glorified prostitute to sell ourselves to businessman. Even US hospitals are feeling the pain of physician burnout. Probably we should also come up with a  “Drop Out Club” like HERE.

Will AI take over medicine one day? My answer is YES. Technology is going into healthcare. I predict radiologist will be the first to extinct. Already Ultrasounds are being done by ultrasonographers in many countries. THIS article talks about the 3 latest advancement in AI. The rise of the machines is coming! THIS article on “AI vs MD” is a long and interesting read. We will one day become like Star Trek and Star Wars where AI will diagnose the condition and even administer the medications. Doctors will merely become a technician. IBM Watson is already revolutionising the oncology treatments.

As Episode 8 of the Star Wars saga (The Last Jedi)  opens tomorrow, it may be the end of the Jedis. The title of the Movie reminds me of the fate of physicians. The Art of Medicine is dying. The beauty of medicine is dead. What is there left in medicine for everyone to be screaming to do medicine? Do people really need us when even now, most do not even listen to our advise? Most do not trust what you say and rather buy thousands of ringgit of supplements, but refuse to pay RM 90 for a consultation?

May the Force be with us……………………… Are we the remaining Jedis who will surely go extinct one day, not long from now………..

 

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It has been a hectic 2 months for me with too many holidays and personal matters to take care of. It has been 8 years since I started blogging and almost everything that I had said and predicted has become a reality. As I had predicted as well, in the end no one takes responsibility and blames each other. IN a typical Malaysia Boleh style, we chase after the numbers and forget about the quality. Many do medicine without being well-informed. Many do medicine without knowing where they are putting their foot into. I had written enough in this blog and even published 2 books to explain all these issues. Despite that, I still get young school leavers who keep asking the same question again and again. I wonder what they are actually learning in schools. Our education system has messed up the student’s brains well enough for most students not to know what the hell is going on in this world. Do you know that most SPM students do not even know who is Abraham Lincoln and why is he famous for? Do you know that they do not know anything about American and European history and history of the World Wars? Ask them who is Mahatma Gandhi! You will be surprised and shocked to the amount of knowledge these students have despite scoring strings of “A”s in their exams! Oh, BTW, according to TITAS textbook which is a compulsory subject for 1st year public university degree program, Mahatma Gandhi is “Tokoh Tamadun India” !! I give up!

With all the hoo-haa that has been going on in KKM regarding the HO issues, one thing for sure is the fact that almost 50% of graduates will not be offered a permanent civil service post after 4 years of compulsory service. Recently, MOH claim they will be introducing a “tagging” for those graduates who are waiting for posting. MOH claim that the waiting period should not be more than 6 months since the introduction of contract post which do not need an interview. However, I am not sure whether they had taken into consideration the increasing number of graduates since 2016 as few more medical schools have started to produce graduates and the final list of recognised medical schools will be out this year when the last few medical schools which started in 2012 becomes recognised by MMC. The number of graduates produced by these universities will subsequently increase over the next few years. Can MOH cope? The answer is obviously NO. One more interesting thing about the “pre housemanship tagging” as proposed by MOH is that it will be done in hospitals without housemen. These hospitals are technically district hospitals without specialist. So, who is going to guide who? Will it become a story of ” blind leading the blind……”? UM has also started a similar program for their own graduates as mentioned HERE but this is done in their hospital

Recently, there was a post in Facebook from a specialist asking a questions on why many doctors are discouraging their children from doing medicine. He claim that despite the increase in litigation, rules and regulation , it is still a noble profession. I do agree it is a noble profession BUT saying that medicine is the only noble profession is wrong. WE must move away from the notion that medicine is the only noble profession in the world. The world has changed. The day a doctor started to charge a fee for service, medicine as a noble profession has died. If you still believe medicine is a noble profession, than you should go back to government service and serve the people. Anyone in private sector cannot claim it is a noble profession as without money, you would not be able to treat a patient. It is a business and nobility takes a back seat or probably not existent. There are so many jobs out there which is also noble. I have an engineering friend of mine who is actively promoting greening of earth and promoting clean environment. Isn’t his job noble? Let’s take Mark Zuckerberg. He created Facebook without charging a single fee to anyone and connected the entire world! Long lost friend became close within seconds! Isn’t what he did noble? What about “Whatsapp” and many other social networking apps which is free? If you say charging a fee for service is noble than a mamak shop which charges a fee for food is also noble as he is providing food to everyone, without which people can die as well. Almost all philanthropist that I know are not doctors. Are they not being noble by donating to charity and foundation to help people? Are they not providing scholarship to needy students to pursue their education? What about teachers? WE should stop saying that we are the only noble profession in this world. A senior consultant friend of mine once told me that Tan Sri T J Danaraj, the founding dean of UM medical faculty once said ” The day  medical education is commercialised and medical practise is commercialised, that’s the day prostitution of medicine starts How true! At the end of the day it is all about money and survival.

Some will say that I will sacrifice my life for humanity and serve mankind till I die. For them, I have the story below:

A Dr graduated to be the best and finest surgeon in the world. At age 30, he got married.
The joy of marrying a surgeon attracted his wife to him.Few weeks after marriage leave he got back to work, thereafter he hardly spent some quality time with his wife.Their relationship began to go sour.

Not that he’s flirting around with other ladies. Not that he now had a bad company. But, at his work place, he was seen as TOO IMPORTANT.Every patient wanted him. The nurses loved him to handle all the surgeries at hand.

One day, he got home very early from work. The wife was glad that he was at least early today. Just as he was dropping his briefcase, his phone rang and the following conversation went on.

Nurse: Sir, we need you now at the hospital. We have an emergency.

He said : I’m on my way.

The wife was angry with him. As usual, he told her, “Sorry”.

This went on for so long.

But one unfortunate day, he had an accident. And….

He died! 

The other doctors and surgeons mourned him. They gave his wife cash to take care of herself.

But, can money replace love? Can some one ‘ replace a whole man?

You know the answer…

Not too long after, the wife went to that same hospital for some check up.

She was shocked to see someone in her husband’s former post. Not only that, she heard someone calling the new surgeon as the best in that town.

She wept bitterly…

Do you know you are replaceable?

Do you know you are NOT too important?

Do you know someone else can do better than what you are doing or what you can do?

Do you know you are cherished now just because you can still perform your right?

Do you know you are celebrated because you are available and useful?

No one’s saying you should not help out. No one’s saying you should not be a celebrity. No one’s saying you should not help others. No one’s saying you should be not punctual

BUT,

Take time to rest. Take time to relax. Spend time with yourself.

As bitter as those truths, many of you fail to accept that…

Tread softly… Go gently…

Your family Values YOU

Only they miss the presence of you not the rest of the world.

 

The above story is the reality out there. In the end, family comes first, unless you decide to live a single life till death. No one appreciate what you had done once you are gone. They will talk about you for one day and that’s the story.

Recently, there was another sad story in our neighbouring country(see below).  Dr Leslie Lam’s story is exactly what is happening out there. These are the side effects of “prostitution of medicine”. The day medicine was commercialised, that’s the day patients start seeing doctors as leeches who are out to suck their bloods/money. You could have saved hundreds of life but a single patient can bring you to hell! The number of complains in each hospital is increasing by leaps and bounds and almost always it is about money. They want their money back because their wound got infected! They want their money back because your surgery was not succesful and had complication etc. If you admit your mistake, they sue you to glory. If you don’t admit, they sue you anyway! BTW, I was informed that the patient who was responsible for Dr Leslie’s ordeal is a Malaysian.

The world has changed. Artificial intelligence and technology is taking over a lot of jobs. Medicine will not be spared. What you see in Star Trek and Star Wars is not far away. Skynet is not far away………….

Are these the jobs of the future(below) ?……… You can ponder upon…….

For those who are sitting for SPM 2017, Good Luck and choose wisely…………

 

Heart doctor Leslie Lam’s ordeal: Three decades to build a name… then ‘gone to bits’

Dr Leslie Lam has been completely cleared of all the allegations made by a patient who claimed the cardiologist performed an unnecessary procedure on him in 2011 for monetary gain.

Leslie Lam, cleared by Court of Three Judges, says his clinic never does things just for money

To this day, he still charges them the same rate of $25 for each consultation. At the same time, he counts among his patients Bruneian royalty who are willing to pay to have him close his Mount Elizabeth clinic for an entire day so that he can attend to them.

“I like to play a bit of Robin Hood,” said the 75-year-old grandfather of three, who has been doing volunteer work in countries such as Myanmar for more than 12 years.

That was why it came as a shock when he learnt in 2012 that a patient had gone to the Singapore Medical Council (SMC) to complain that Dr Lam had performed an unnecessary procedure on him in 2011 for monetary gain.

To Dr Lam, who was completely cleared of all the allegations last Friday, the accusations levelled at him were just “crazy”

After all, his first lesson to medical students doing their internships at his clinic has always been: “You don’t do anything for the patient unless the patient benefits from it.”

THE RELIEF

Today is one of the best days of my life, because suddenly I feel I’m completely free from this unnecessary complaint.

DR LESLIE LAM, in a phone interview after he was cleared.

Dr Lam, one of the pioneers of coronary angioplasty – a procedure in which a balloon is used to open up blocked heart arteries – said he cannot remember ever doing an unnecessary procedure.

He stressed that he often agreed to requests for discounts from less well-off Singaporean patients.

Registered nurse Siti Sundari, 61, who has been working with Dr Lam since 1988, described him as “kind”.

In 2015, after selling the premises that his clinic – The Cardiac Centre – occupies for $10 million, he distributed 5 per cent of the proceeds to his staff. He now rents the space.

He said the complaint weighed on him, resulting in many sleepless nights. His family said that he even became ill-tempered.

“It took me 30 years to build up a name like this, and (for it) to be just gone to bits over something so small, it’s crazy,” said Dr Lam, whose wife is a general practitioner. They have two daughters – one is a housewife and the other a branding consultancy owner.

Good friends advised him to appeal all the way, telling him that his name was worth everything.

Dr Lam, who has had 17,000 patients under his care, said he had had three full consultations with the patient from Malaysia.

In 2006, the patient had undergone a percutaneous coronary intervention (PCI) with three stents at Raffles Hospital. PCI is another name for coronary angioplasty.

Then in 2011, the patient consulted Dr Lam for the first time.

Dr Lam recalled that the patient had argued with him, insisting on doing a CT scan even though the specialist told him it was a waste of money because the scan would not capture the lumen, or the inside of the arteries.

Seven days after the CT scan results, the patient returned to Dr Lam and consented to a coronary angiogram – a type of X-ray used to examine blood vessels.

After the angiogram, Dr Lam advised the patient to undergo a PCI with stenting. During the procedure, the first stent slipped, requiring a second stent to be deployed.

Dr Lam said that in hindsight, perhaps he was too honest in telling the patient what had transpired. “If I had not mentioned it, if I had been dishonest, no one would ever see it.”

He revealed that after the procedure, the patient wanted his money back even though his condition improved. Dr Lam had charged the patient $1,500 for the angiogram and $7,500 for the angioplasty, which he said are considered low.

The SMC brought three charges against Dr Lam: leading the patient to believe he needed to undergo the procedure when there was insufficient basis; failing to perform the procedure with skill and care; and failing to obtain informed consent.

The first two major charges were thrown out by a disciplinary tribunal, which was satisfied that Dr Lam had carried out the correct course of action. Last Friday, the Court of Three Judges cleared him of the third charge.

The ordeal has underscored the importance of documentation and keeping good notes, he said. The brochures in his clinic are now more detailed than before, listing all the possible risks and complications.

Dr Lam said he now goes through the list with patients, ticks off each one, signs and then gets the patient to countersign with the date stated.

During the interview after he was cleared, his phone rang non-stop with calls from colleagues and patients. “Today is one of the best days of my life, because suddenly I feel I’m completely free from this unnecessary complaint,” he said.

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Finally, over the last 1 week, a Malay local newspaper had published several articles regarding the issues concerning medical graduates. This is when the blame game starts. Each authority will blame the other and finally no one will take responsibility. Eventually, it will be blamed on the previous administration and probably we need a RCI to investigate this, 10 years down the line!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Let me put it this way. For years, many in the medical profession had voiced out their concerns regarding medical school’s approval. I first talked about this in 2006 and wrote an article in MMA magazine. Many accused me of over exaggerating. Dato Dr Chua Soi Lek realised it and issued a moratorium in 2005 which was subsequently lifted in 2008 when the new government got elected. NO one did anything! Tons of new medical schools were approved between 2008 and 2011 till the new moratorium was announced in May 2011. By that time, it is too late. Too many schools were already approved which no one can order to be terminated without legal repercussions.

Who gives the approval? Everyone seems to be washing off their dirty hands. All licensing and the need for an educational program is under the jurisdiction of Ministry of Higher Education. This is governed by Private Higher Education Act 1996. MOHE treats medical education as any other educational program. MMC do not have any authority in approving/terminating any medical program.  The role of MMC is only in 2 matters: assisting MQA in accreditation process of a medical program and recognition of a medical degree. Under Medical Act (Amended 2012), MMC is the only authority who can recognise a degree which enables a graduate to be registered as a doctor. Accreditation comes under MQA Act 2007. Only MQA can issue certificate of accreditation. However, for professional programs, under section 51 and 52 of the act, MQA will work with the relevant professional body in recommendation of accreditation of a program. As far as medical program is concerned, MMC will work with MQA in the process of accreditation. A Joint Technical Committee(JTC) is formed under MQA act, consisting of 5 government bodies(headed by MMC Chairman) who will then undertake the accreditation process. The recommendation of the JTC will then be forwarded to MMC for approval at each stage of accreditation.

No where along this line, MMC can either revoke or terminate a program. If at all, they can only advise MQA or MOHE to terminate the program. This advise may or may not be entertained. For example, even the minimum entry requirement suggested by MMC have to be approved by MOHE. When MMC/MOH suggested the minimum entry requirement to be increased to 5As last year, MOHE did not agree and thus it was never implemented! The only other area where MMC is involved is in the allocation of total student intake of each batch. However, JTC allocates the intake based on accreditation guideline. As long as the college can prove the capability of having adequate lecturers(full + part-time + sessional) and facilities , JTC cannot deny the requested number of intake. On what basis can JTC/MMC allocate lower number of student intake? Legally they can’t do that unless during their accreditation process they find that the college is not ready to take the requested number of students. And if finally MMC refuse to recognise a degree, we will see the politicians and parents standing in front of MMC’s office demanding fairness!

This is not the first or the last time we will see such issues. It has happened in almost every field that we know. Unfortunately, no one in our government will take responsibility or commit hara-kiri. It is a culture of “tidak-apa” attitude. No one thinks long-term. It is always a knee jerk reaction. We can talk till the cows come home but no one listens. Their KPI is making the country an Educational Hub to generate income for the country. Who cares whether there are job opportunities or not? Who cares whether our graduate’s qualities are declining or not? As long as we can produce a graduate with a certificate , it is good enough! Numbers more important than quality.

We are only seeing the tip of the iceberg at the moment. When the first batch of contract housemen, which started in December 2016 finishes their 4 years contract in 2020, we will be seeing almost 2000-3000 doctors being released to private sector every year!. This will average out to about 200 doctors/month being jobless! This is assuming that 50% of the graduates will continue in civil service. However, we must also realise that the permanent MO post are also almost full! Can the government create 3000 MO post every year from 2020? Personally I don’t think so. Thus, the number of MOs getting into a permanent post will decline over the years as the number of post declines. So, the actual number of doctors being released into private sector will be much higher than expected. The GP field will be flooded……..If even now, clinics are closing, what more in next few years. The entire health care structure has to change to accommodate this tsunami.

One of my friend told me the other day that I probably had a crystal ball in my house. Another friend told me that it is scary to see whatever I predicted happening right in front of our eyes. Well, I did not have any crystal ball and I am no Nostradamus. It is just simple mathematics and statistics. Something that we learn in school. Unfortunately, some people never use their brains when they do something for this country. Once a mess is created, it is difficult to turn back. History teaches us that. But then, who learns the real world history anymore? Our school history books have become a political propaganda book rather that teaching the future generations what we can learn from world History!

God Bless this country…………

 

 

 

 

 

 

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