My last article attracted a lot of debate in Facebook as well as a lot of “emotional” rants in the comment section. I will leave the emotional rant alone as people always get carried away with emotions and do not think rationally. Atrocities in this world will go on as long as people are emotional and do not use their brains to think and reason out.
One of the debate that took place in Facebook was about “Visiting Consultant” status in private hospitals. I wrote that Visiting consultants are not allowed to admit inpatients in any private hospitals anymore. This was told to me when we applied for our hospital’s license renewal 2 months ago. Following this, our central management had a meeting with CKAPS unit of MOH and we were informed of the following, which is still rather confusing at times.:
1) Visiting Consultants cannot be appointed for INPATIENT services if there is no resident specialist of the same speciality e.g: you can’t appoint a Visiting Urologist if you do not have a resident Urologist etc
2) However, Visiting consultants can run outpatient and daycare services
3) Visiting Consultants can see inpatients if the patient is referred by a resident consultant aka co-managed e.g: resident orthopaedic surgeon referring to visiting plastic surgeon etc
4) Even if a Visiting consultant is appointed for INPATIENT services where there are resident consultants: the hospital MUST make sure that the consultant is “readily available” at all time! The definition of “readily available” is not clear. It basically means that the consultant must be able to attend the case as soon as possible when called.
5) The hospital MUST clearly differentiate between Visiting and Resident Consultants! From the conversation that I had with a ministry official, a resident consultant is defined based on their “Tempat Amalan Utama” in their APC. BUT hospitals may have different way of defining a “resident” consultant. Thus, it is still not clear.
6) Maternity centres must have Resident Paediatrician and Anaesthetist.
Basically, the ministry is concerned about patient safety as what happened a hospital in Seremban. Under the PHFSA, MOH can come up with regulations which they think is important in protecting the public. Many will argue that time taken for a visiting consultant and resident consultant in attending to the patients will be almost the same, especially after office hours. Yes, I must agree that after office hours, it might be the same but it does make a difference during office hours. A resident is always there during office hours from at least 8am-6pm. The resident is also committed to the hospital (as he does not practise anywhere else)and have to take the responsibility and can always ask for help from another resident consultant/colleague if he is held up in OT etc. However, a Visiting consultant may be running his “busy” clinic outside or even doing a surgery in another visiting hospital when the hospital calls for an emergency involving his inpatient. He won’t be able to attend immediately and the resident usually do not help out either (internal politics and medico-legal issue!), especially if you do not have a resident of same speciality. Thus, I feel that the MOH concern is reasonably valid.
Let me give you an example of a case that was settled out of court for an amount close to RM 3million, recently. A patient came to a hospital in preterm labour. The patient is being followed up by a consultant in his clinic outside. He was a visiting consultant in that hospital. The MO sees the patient in the emergency department and calls the consultant. The consultant was awaiting delivery of another patient in another hospital about 1 hour away. Thus, he asked the patient to be sent to that hospital. The resident consultants definitely will not take the case as they have never seen this patient before. Patient delivered along the way and the child ended up as CP. The case was brought to court and while awaiting a verdict which was definitely going for the patient, they decided to settle it out of court, worrying that the compensation amount might be higher.
So, the ministry is now putting the pressure on the private hospitals to fulfil these requirements. There are many ways you can go around it but “IF” anything happens, the hospital will end up being penalised. Thus, most private hospitals will take the safer approach of likely not appointing a Visiting consultant if the resident do not want to work along.
As for dispensing rights mentioned in my earlier article, Dato Kuljit wrote a letter to NST on 28/07/2014. IT was a well written letter about higher cost and inconvenience to patients if dispensing right are taken away from doctors. However, 3 subsequent letters in NST(HERE , HERE and HERE) rebuking his letter shows how much the pharmacist are pushing for it. I must admit that pharmacist are more united than doctors. I had given talks during their state AGM and I see a lot of them attending their AGM. How many attends MMA AGM, whether state or national level? How many are even members of an association, be it MMA (the official rep) or MPCN etc. Everyone just want to take care of themselves and their business and not bothered to stay together and fight. I have been active in MMA since I was a Housemen in Ipoh Hospital. We had fought for many issues concerning government service. Many do not know how MMA/SCHOMOS fought for whatever they are enjoying now but yet they just sit back and complain that MMA is doing nothing. I do not want to say how many trips I had to make to Putrajaya in submitting the paper on promotional pathway for doctors way back in 2005/2006(after a SCHOMOS workshop), something which I wrote on my ACER desktop computer with a floppy disc! I am happy it became a reality 4 years after I submitted it and I myself leaving the service. As a first step in improving the system, please join MMA and voice out your issues through the proper channel. The next step is to get involved actively in all activities of MMA and contribute effectively. If not, we are fighting a loosing battle!
Dr Krishna Kumar, our current MMA president also appeared in the press recently. You can read over HERE (below). He has also mentioned some of the issue that I had written in my earlier post.
Someone asked me about ASEAN trade agreement. For a start, you can read this agreement attached HERE. Basically, anyone from ASEAN countries can practise medicine here as long as he fulfils MMC registration criteria.
A heavy responsibility for Dr H. Krishna Kumar
The newly appointed president of the Malaysian Medical Association is keen to see the organisation maintain its principal aim of not compromising when it comes to the care of patients and the way doctors work.
Dr H. Krishna Kumar is a home-grown and trained doctor. He graduated from Universiti Malaya and has worked in two countries, five Malaysian states and many hospitals.
He is currently a maternal and foetal medicine specialist, and trains undergraduates, postgraduate and sub-specialty doctors.
Although he had worked as a consultant in the United Kingdom and was offered a permanent job there, he chose to come back to serve his country.
Dr Krishna, who hails from Seremban, is a proud alumnus of St Paul’s Institution.
He is quick to point out that his parents were his bedrock. They were both teachers who ingrained in him the importance of education.
“The Malaysian Medical Association (MMA) is the largest organisation that represents doctors in the country, thus, we have the largest voice among doctors in Malaysia.
“One of our core purposes is to ensure that health fees do not compromise the care of patients or doctors’ work quality.
“In order to build upon this principle, we lobby with the government to ensure that any policies that may affect doctors are addressed.
“The Health Ministry is more or less like our partner as they have similar principles,” explains Dr Krishna.
“For instance, the Malaysian Communications And Multimedia Commission with its Personal Data Protection Act (PDPA) – we are the only country that puts the health sector under this Act, while in Western countries like the UK, the health sector is excluded.
“The appearance of a third party and a new Act may in fact result in a breach of some of our ethical practices and affect the way we manage our patients.
“This is the reason why we do not support the PDPA and are in the midst of discussions with various ministers to try to get the health sector excluded.
“After all, data collected by the health sector is governed by our Medical Council and the Private Healthcare Act,” he says.
Dr Krishna also raised concerns over the current scenario where only doctors’ fees are being closely regulated, whereas there is little to no regulation of hospital fees.
“Unfortunately, this scenario is likely to go on indefinitely.
“If you look at the itemised bill from any hospital, you will find that the bulk of the bill comes from miscellaneous hospital charges while the professional charges (i.e. doctor’s fees) will only take up a small portion of it. Why this huge disparity?” he questions.
“As I do not work in the private sector, I have no vested interest in this, yet I am moved to take action because of my conscience,” he says.
Medicine is becoming a business
“If you look around, you will find that businessmen have realised that the healthcare industry is a highly profitable business.
“That is why you will find a lot of such clinics, as nowadays it’s all about making money,” Dr Krishna says.
“Gone are the days when the family doctor is in control. It has become increasingly difficult for family doctors to survive, especially in the face of numerous rules, regulations and acts that are being introduced that specifically target the health sector.
“All these are deterring independent practices as the family doctor will now have to contend with so many new conditions and administrative details that are necessary to ensure that they are not in violation of any of these new rules, regulations, and acts. They are slowly dying out as they have been squeezed at every turn,” he says.
“Every time a new ruling or law emerges, there will be a fee charged. Take the Personal Data Protection Act as an example – they would be charged RM600 a year for this. When there is an inspection of your clinic, it will cost between RM1,500-RM3,500.
“There is another charge for waste disposal; obviously, a clinic cannot throw its rubbish away in the ‘normal’ way.
“There is a charge for business practice registration, clinics that have radioactive materials orX-ray machines need to pay a fee, and employees at the clinic must also be qualified personnel.
“The cost of the fees and the increased salaries of hiring at least two to three qualified staff per shift would add to the running cost of owning and operating a clinic,” adds Dr Krishna.
“Take maternity centres as an example. In the past, you would have the option of going to a government hospital, private hospital or private maternity centres. The private maternity centre was more affordable than private hospitals, but the new rules now state that there must be a resident anaesthetist and a paediatrician.
“Since the majority of such maternity centres do not have a large volume of patients, they cannot comply with this new ruling, thus, many are forced to close down.
This new ruling also adds to the cost of having a baby as the charges will rise since there are now three professionals involved with delivering a baby instead of just the obstetrician (especially for normal deliveries),” shares Dr Krishna.
Modern challenges
Looking back over the years, Dr Krishna notes that there have been many changes in the medical practice. For one thing, medicine has become increasingly complex, with technology taking over many aspects.
Prices of drugs have also increased, and all these factors have led to an unfortunate increase in the cost of healthcare.
“The most obvious thing that has gone up is the expectations of our patients. For instance, in the past, deaths in the wards were often taken in stride, whereas nowadays, any death (even if it is a 90-year-old with all kinds of health complications) are often greeted in an accusatory manner,” states Dr Krishna.
“The Internet has also been both a boon and a bane for the health sector. Many patients often self-diagnose by surfing the Internet for information about their condition.
“The problem we often face is when they seek information from unreliable online sources as they will then approach their doctor with this dubious information and challenge them with it.
“This is a worrying trend as many patients often visit unreliable online sources, become convinced by it, visit a doctor, challenge their doctor, and refuse to believe their doctor even when asked to do their own research (but using reliable online sources that their doctor provides). Many such patients will ‘doctor-hop’ until they find one who will give them the diagnosis that they expect to hear,” he says.
Unhealthy developments
There are other problems that need to be addressed as well, including the shortage of places for new graduates who wish to do their housemanship.
This situation is not confined to just doctors, but is occurring across all the various disciplines in the healthcare industry, such as dietitians, radiographers, and so on.
“They are all affected because there has been a gross increase in the number of colleges providing the training. Unfortunately, there is also a shortage of good teachers, which has led to many universities or colleges producing inadequately trained professionals.
“This situation is especially bad as many of these graduates are then unable to find employment due to their inadequate training,” says Dr Krishna.
“This is the reason why at one time there was a shortage of nurses, yet at the same time there were 30,000 unemployed nurses, all of whom graduated from certain universities or colleges.
“In contrast, nurses that were trained by the Health Ministry can easily find a job anywhere, even in the Middle East. Similarly, I anticipate that this scenario will be repeated with the current batch of doctors who have graduated and/or are graduating,” he says.
President for a year
Dr Krishna is quick to admit that as the president of MMA, he has to shoulder a heavy responsibility.
He comments: “For most of us, this is not our primary job, rather it is a voluntary position. For an individual to take time off to run the association for a year is enough. To bear this burden for more than a year is difficult.
“Although a year may not sound like enough time, bear in mind that before becoming president, one has to spend a year as president-elect, followed by a year after one’s term as president serving as past president, so in total, one year will be around three years.
“Just as it is for any other post in MMA, you may finish what someone else has started and someone else will finish what you have started. While the focus may change from president to president, the principles will remain the same.
“This has helped ensure that there is a continuity of purpose within the association, and this ensures that the direction of MMA remains constant, although how it is approached may be different,” he says.
“It is my fervent hope that I will be able to achieve positive changes in how healthcare is practised in this country, and to do so in a manner that benefits both patient and doctor.
“After all, if the doctors are not taken care of, how will they take care of their patients? Similarly, if our patients are not cared for, it will have negative repercussions for doctors too,” he concludes.
