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I have finally reached another milestone ……… as of 13/01/2020, my blog is 10 years old! Over the past 10 years, I have written hundreds of articles and even published 2 books from these articles! I probably achieved my wawasan by educating the public on what medical field is all about and how the world is changing.

My last article was written on 24/12/2019, just before the new year started. It has been almost 5 months now and the world has changed. In just a short period of time, our lives have gone upside down and we are still looking at months down the line before everything comes back to normal. 2020 suppose to be the year where Wawasan 2020 should have been achieved, transforming Malaysia into a developed nation, but unfortunately we are in a mess with recession coming soon, if not already. We have had 5 months of political drama and a brainless RNA virus terrorising the world. Let’s start with where I left you on 24/12/2019……

Critical Allowance

Based on JPA circular dated 20/12/2019, critical allowance for all new appointments into MOH will be removed. As I mentioned in my article, it is rather unfair when those who are already in the system will continue to receive the allowance but the new ones will be without the allowance. I said unfair because everyone is doing the same job and same amount of work. It does not make any logical sense, while I did predict and expected the allowance to go one day when we have more body than post. Following this announcement, there were huge outcries from various organisation and members of the public. Thus, on 9th January 2020, this proposal was postponed for further review, scheduled to be updated by end of this year. REMEMBER, it is only postponed and not cancelled!

U41 Contract Renewal

As I have written in several articles towards the end of last year, the number of permanent appointments given out following completion of housemanship has been dwindling down from about 500 for the first batch(December 2018 cohort) to almost 0 in subsequent batch(May 2019). This is again not unexpected. KKM simply do not have enough post to offer everyone. The slides below is self explanatory…..

It is very clear that KKM do not have any post to even offer permanent positions. Thus, almost everyone will be given an extended contract which will be the final contract before you say sayonara to KKM. The issue of being offered U41 post instead of U44 has not been resolved either, despite promising to do so in November 2019 by the cabinet, KKM and JPA. The new contracts are still renewed at U41 as of April 2020. On 29th October 2019, I wrote this :

“The best is yet to come: those who receive extension of contract can remain at the same place where they were transferred as a floating officer! In another word (the way I interpret this), your life in civil service ends there within another year aka completing 4 years of compulsory service. It’s just a diplomatic way of putting it !”

Interestingly, this is now proven true when the newer contract renewals categorically says that ” this will be the last contract!” ………

So, basically whoever received the U41 contract extension of 2 years, after their 3 year initial housemen contract, have to start planning their future. I believe this clause was added after the Sarawak doctors debacle that was publicised widely in newspapers in January 2020. These were doctors who returned from overseas in 2017 and was given a 2 year contract to complete their compulsory service. Unfortunately , they were told that their contract would not be renewed. To be frank, no contract is permanent. A contract is a contract and the employer can decide not to renew your contract once it expires. It is the same in any profession including the medical profession. Even in private hospitals, the hospital can decide not to renew your contract if they feel they do not need your service anymore or simply, if they don’t like your face!. It has happened before and there is nothing you can do about it. There is a clear difference between ” termination” and “non-renewal of contract”. While the Sarawak doctor’s contract were finally renewed, to avoid any such scenarios happening again, JPA has now clearly stated the above clause in the newer contracts. So, now no one can claim ignorance.

What about those who received a permanent post? Again, they were given a U41 post! However, they were told that this is due to technical reasons. The U41 permanent post will be backdated to the day they started housemanship and soon, they will receive their promotion to U44 backdated to the day they completed housemanship. Whether this has happened with all the chaos that is going on now, I do not know! We shall wait and see.

In a sudden turn of events in April 2020, about 102 permanent post were created in Sarawak. This could be part of about 1000 post that suppose to be created over the next few years as I wrote in December 2019. So, about 102 of them were sent an urgent email early April 2020 offering them this permanent post in Sarawak and NO appeal will be entertained……..

Whether there is a political reason for this, I got no idea. Based on the report by Codeblue, about 28 of them declined the offer and decided to stay on their final contract appointments. We just have to face the fact that the government will never be able to absorb all graduates. With the current economic situation, the scenario will only get worst. No job is guaranteed in this world. What is happening in Malaysia, is also happening in many developed countries but at-least, these countries have a better control over the number of graduates being produced, unlike Bolehland.

COVID-19

The world is yet again faced with another Pandemic. I would say that this is the 4th viral outbreak I am facing in my 23 years working as a doctor. It started with SARS in 2003 followed by H1N1, MesCOV and now COVID 19. Facing these viruses or any infectious diseases are part of our occupational hazard. I know many doctors who have contracted infectious diseases and some even succumbed to the illness. So, those who think that doctor’s job is sitting in a cozy room and earning big bucks, please think again. We are not only at risk of being infected with a disease but also high litigation rate and verbal insults.

We may be considered as a hero at the moment for tirelessly facing this pandemic. But trust me, once all this is over, we will be back to square one. No one will even remember what you did. That is the reality out there. But COVID 19 also thought us a lot of other lessons. The Earth is breathing better and animals seem to be enjoying their life. We must understand that the entire ecological system on Earth lives in a balance. It evolved over millions of years keeping everything in an absolute balance. The very fact that we produce CO2 and plants converts it back to O2 proves this balance. BUT humans are always greedy. We feel we can do anything to mother earth and get away with it. I had always said this to my children ” Never play with nature, take care of it. If not, nature will always get back to you!” COVID 19 just proves how nature can get back to you. A simple brainless RNA virus can shut down everything on EARTH! Viruses have been around before humans came about. So, never play with nature. Stop destroying nature and learn to live in harmony. As Sir David Attenborough said in one of his famous documentary “ If you kill a whale in the ocean, the entire ocean ecology changes!” If there are no animals which eat insects, the world will be overrun by insects, which by the way have the highest population number in the world.

What else has this pandemic thought us? Good hygiene and social distancing keep doctors away! Many would have realised that there has been 70-80% drop in the number of cases attending private hospitals and GP clinics. Some GP clinics have even decided to close their clinic as their income has dropped drastically. It is better to close than to continue to maintain the running of the clinic. Private consultant’s income has definitely taken a beating. With lock-down, there were hardly any accidents. People were afraid to go to hospitals as they were worried of getting infected in the hospital. Social distancing, stay at home and good hygiene has drastically dropped the rate of infectious diseases like URTI, respiratory infections and gastroenteritis which generally forms the bulk of private hospitals admissions. Elective cases has also been postponed. It just shows that any job can be affected if something like this happens. It happens in all outbreaks but COVID 19 has been the worst. The only job which will continue to be not affected are civil service jobs! The government has no choice but to keep civil service running and paid. While you may end up taking a pay cut eventually, you will still get paid. In fact you will even get Raya goodies!

BTW, KKM has also offered 6 months contract jobs for those who are interested to be the frontliners. Specialist will be paid RM 12K/month and MOs will be paid RM 6K/month. I understand the offer is not available anymore. I heard some GPs did take up the offer.

Democracy

On 9th May 2018, everyone thought that Malaysia has woken up. In my article titled ” Towards Malaysia Baru?” on 4th June 2018, I wrote this

“With all the euphoria that we are having now, it is just too early to say how this new government will perform. Statistic shows that Pakatan only received 48% of the votes with BN & PAS taking 52% of the votes. Pakatan won in many areas due to split votes. PAS benefited from split votes in Kelantan and Terengganu. Personally, I feel that the Pakatan government is not really in a very stable situation. Tides can change by next election if they do not outperform the previous government by leaps and bounds.”

Again my words have come through! One of my friends told me to stop predicting anything as everything I predict seem to be happening again and again. The Sheraton move on 27/02/2020 and subsequent fall of PH is something I expected to happen sooner or later. The politics in Malaysia is as such. Everything is tied to race and religion. Whoever plays the right card, will win. Who cares about corruption and good governance? Whatever said and whatever mockery that has happened to Malaysian democracy, the country seem to be going downhill. Years of brain drain and racial politics will only take this country to the dungeon. With COVID 19, fall in oil price and dry coffers, we are surely heading into a recession and disaster. Never in world history I have heard of a 1 day Parliament sitting with nothing more than the royal address! It is the joke of the century.

After 10 years of writing this blog, I hope readers would have learnt something. My predictions are all based on facts and statistics. It is not rocket science!

Have a blessed Ramadan and SELAMAT HARI RAYA………………………. a different Raya I must say………….

11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved drug price control and currently under review for implementation. This triggered an uproar among the GPs whose consultation fee is already regulated and capped under Private Healthcare Facilities and Services Act (PHFSA) 1998. Schedule 7 which controls consultation fee for GPs has capped the maximum price at Rm 35! This has been as such since 1998 but the act came into force in 2006. The hospital doctors on the other hand had a review in 2013 and Schedule 13th was amended with roughly 15% increment, starting 2014.

What are my views and take on these issues? Well, my comments, even in the past, had created a lot of negative feedbacks from fellow doctors. But as I had always said, I call a spade , a spade! Just look at the public feedback in Facebook etc when the above town hall meeting was reported. Videos of our GP colleagues venting their frustration was shown live and recorded by various media. Did you really expect the public to show sympathy? The answer is a BIG NO! For the public, doctors are sitting in a cozy air-conditioned room and earning tonnes of money! Only when their own kid ventures into becoming a doctor, hoping to live a glamorous life, they realise the actual life as a doctor! The hours of work, training, exams, risk taken, litigation etc before you can even think of earning a decent living.

Having said that, generally a doctor can still earn a living as long as they can get an internship post and complete their training. However, the era of earning tonnes of money and being “rich” is gone and going…….Our income will be similar to any other profession, allowing us to live a life. If you are still thinking that spending RM 500 000 to RM 1 million to be a doctor is going to give you a luxury life, think again! Jobless scenario is already happening in many countries.

Now, coming back to GPs. The day you open a private clinic, it is a business, period!Same goes to private specialist. In any business, there are gains and there are loss. Some businesses closes down and some businesses thrive and even become global players. Business is a business, nothing differentiates you than anyone else. Unfortunately , health is an essential service. Health and Education are 2 components in any country which should be the government’s responsibility. I have said and maintained this statement since I started this blog. Many may not know that the PHFSA 1998 was actually tabled and passed in the Parliament in anticipation of corporatisation of health care in this country. The corporatisation of healthcare aka National Health Financing Scheme was suppose to be implemented in 1999 as the last corporatisation exercise of Dr M! Everything was ready on paper.Unfortunately, the sacking of Anwar Ibrahim and subsequent reformasi etc totally shut down the plan till today.

Frankly I don’t agree with controlling of consultation fee. Let the market force decide. BUT healthcare is an essential service and thus the government need to be responsible. Thus, in Malaysia, they control it via the Malaysia Boleh way! Same goes in any other country as well. You may think that in other countries, the government do not control the consultation fee. On paper , yes but they do control it in another voluntary way. Their National Health Financing Scheme(NHFS) that pays for all the consultation/procedure fee do have a limit and standardised payment system. Anything more than that, the patient has to pay out of their own pocket. Public being public, obviously they will choose a doctor that only bills what the NHFS pays. NO one will ever want to pay out of their own pocket! In some countries, the doctors can only accept what the NHFS pays which is basically a fee control mechanism where everyone technically is a civil servant. Even in Australia, many patients prefer to visit the “bulk-billing” doctors (accepting Medicare fee) rather than cash billing doctors.

The GPs were arguing that they are only allowed to charge a maximum of RM35 for the last 21 years. Now, just look at the comments from the public in FB etc. You, me and all members of the public knows that a simple consultation and medication by a GP will cost RM 50-70 and in some cities, can even reach RM 100! Patients are smarter nowadays. Even my patients will go to a pharmacy and ask for the cost of the medications. Similarly, many cash paying patients would do that and will know the actual cost of the meds given by the GP. So, do you think they believe that you are charging only maximum of RM 35? You may argue all you want about the cost of running the clinic etc, but a business is a business! NO one cares whether you are running at a lost or not. No one believes the notion that you are providing a service to public. Didn’t you become a doctor to help man-kind and provide service (aka free service)?

I found that one of the main issue that was discussed the other day was about TPA (Third Party Administrators). Many were arguing that TPAs are only paying RM 10-15 per consultation and wants the government to make sure that they pay RM35 per consultation. Now, let’s go back to my statement above. It is a business! TPA goes around to negotiate the best deal in town. So, the person who is WILLING to take the offer will sign an agreement with the TPA. A business deal! So why are we complaining? You signed it and agreed to it but complain later? We all know that many GPs are dependent on TPAs. Almost 60-70% of a GP’s income comes from TPAs. Without TPA, many more GPs will close shop. This is similar to private hospitals. 95% of hospital admissions are medical card holders. If insurance companies go bankrupt, all private specialist will be out of jobs! That is the fact. So, TPAs can “tarik-harga” . Unless the GPs can unite and state their demands, no TPA is going to entertain your request. By 2021, the market is going to be flooded by GPs when 50-60% of doctors(roughly about 2000-3000 per year) completing their compulsory service not going to be absorbed into civil service. You think the TPA is going to symphatise you? They will be having a jolly good time of GP shopping! And don’t forget the “uberisation” of healthcare where even those who are waiting for housemanship seem to be giving “online” or phone advise!

Even if the government removes the fee schedule, how much do you think you can charge a patient? How much a patient is willing to pay out of his/her pocket? Under-cutting and bad-mouthing is going to be rampant and again TPAs will have the same modus operandi. They will continue to negotiate a deal for the cheapest possible GP. That is business and everyone wants to make the maximum profit.So, if you agreed and signed for it, you have no basis to complain. The government is not going to interfere with that.

I really felt that most of the arguments that were forwarded during the town hall meeting were emotional in nature. I was watching it live on FB and was putting myself as a member of the public. What I saw was just doctors arguing to make more money! And that was exactly how the public felt as seen in many comments on FB etc. Bringing politics into the picture made it even worst! Whatever political ideology we have, we should keep it among ourselves and should not display it publicly, as we are dealing with members of the public who may have different political ideology. Even more shocking and surprising for me was when one of the speakers rejected Universal Health Care! Lucky the MMA president came with a statement 2 days ago that MMA and all medical associations had signed Declaration Titiwangsa in support of Universal Health Care.

When 1Care was mooted in 2012, the GPs went against it as well, mainly because of dispensing separation. It was scheduled to be implemented in 2014 but the 2013 election results made it to be shelved indefinitely. We have to admit that it is the dispensing rights that the GPs have which is giving them the survival. With limited consultation fee, they make profit from dispensing medications. IF this is removed, more GPs will close shop and become unemployed. This was the reason why GPs were shocked and reacted when the Minister announced last month that drug price control mechanism will be implemented. To me, I support the drug price control mechanism. We have to look at the public and see what benefits them. Working in a private hospital, I very well know how the hospital mark-up the medication prices. Some are up to 100% mark-up, especially for inpatients. That’s the reason I don’t like to give generic medications to patients as the organisation that makes the most profit will be the hospital. The cheaper the drug, the higher the mark-up. I rather ask the patient to buy from a pharmacy via a prescription slip from me. As for a GP, having a price written at the box may reduce their overall charge.

Now, let’s come to the solution! WE have to change and move forward. We can’t be harping on the same model that we have been doing since the 1960s! The world is changing and many countries have moved on to new models. Whether these new models are better or worst is something to be decided later. We have to move to a win-win situation, for the GPs, doctors in general, government and the public. Our healthcare system is not sustainable. I have said this many times before. Two parallel system running concurrently, competing against each other for an essential service is doomed to fail. We have a public system totally funded by tax payers and a private system almost 80% funded by insurance (aka out of pocket). The insurance companies are also bleeding in billions and the only reason they are still providing medical cards is because it is mandatory under Bank Negara rules. If not, which company wants to continue a loss making business?

The way forward for a GP to have a lifeline is to have a National Health Financing Scheme which will integrate  public and private healthcare system. This is the only way you are going to survive and have a decent living. You may not make tonnes of money but at least you can earn a living. With the NHFS, GPs will be paid by the scheme with an agreed fee. GPs can charge extra with removal of fee capping but how many patients will be willing to pay out of pocket is something we need wait and see. Eventually, most GPs will do bulk billing! It will come with a price. Dispensing separation will become inevitable with NHFS, where subsidised or fully funded medications by the NHFS will have to go through a dedicated pharmacy. But the overall cost of running a clinic will drop as you do not need to employ staffs to dispense or to run an in-house pharmacy. GPs have to form group practices like in many other countries. The NHFS may have to pay higher fees for a specialist GP which will make more GPs to upgrade themselves. Sometimes I feel very sad when I attend CME talks to see the same GP’s faces all the time! And guess what, most of them are senior GPs! The younger ones are hardly seen as they are busy trying to run their clinic.

With the NHFS paying the consultation, procedure fee and medications, there are bound to be audits. Again, this is nothing new as most countries with NHFS do such audits. You will have feedback audits, prescription practise audits and even average consultation fee audits. The number of patients you can see a day may be limited in the context of quality care. Prescription of certain drugs like opiates, steroids , antibiotics etc will be monitored. At the moment, these are never audited and the GPs can do whatever they want. Do we even have the data of total usage of antibiotics by GPs in Malaysia? We do have data from KKM and private hospitals but not from GPs as there are no laws to mandate GPs to be audited for such usage. IN any system there should be check and balance and doctors are not or should not be exempted. Unethical practices will rise if these issues are not kept in check, as what is happening increasingly in private hospitals.

There is no point arguing with the government when it comes to essential services. A government’s duty is to provide such service to public. Just see what happened when education was privatised! We made someone rich by making the public to go into debts!While the NHFS will have to get the money from the public in the form of premiums plus funding from the government, at least it will distribute the health service to a united system. Patients can go anywhere without paying anything and the GPs will be able to get the load with lower overhead cost, enough to have a job to survive.

Either we change to live a reasonable decent life or we die a slow death……. it’s our choice.