MEDICAL FACILITIES: Rethink 1Malaysia clinic move

2009/12/24

DR DAVID K.L. QUEK, President, Malaysian Medical Association

WHEN the government announced in the 2010 Budget the setting up of 50 1Malaysia clinics in urban areas, the Malaysian Medical Association was perplexed. That these clinics are to be be set up at all is perhaps a good move by the government that must have genuinely felt the need to offer some much-needed goodwill to the urban folk, especially the poor and the marginalised.

However, what is disturbing is the plan to have these clinics run by medical assistants and nurses, which in effect places the standard of these clinics at the level of Third World countries, where there is a real shortage of registered physicians.

The MMA is gravely concerned that such a major shift in policy with regard to public sector healthcare should be implemented without sufficient input from and discourse with stakeholders, such as medical practitioners and perhaps even Health Ministry officials.

It has been suggested that even some health officials were taken aback by this announcement, but they have been instructed to implement the decision next month.

Firstly, let me reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also concerned about our patients, that is, the rakyat who are our reason to exist, our raison d'etre.

We welcome the government's concern about the health needs of the people. We also recognise that for many urban poor, the only recourse to healthcare is that offered by the ministry's overcrowded and understaffed outpatient clinics. That there has been much queuing and long waiting times is regrettable and wasteful in terms of productivity. Certainly, we should do better.

We also know that new ministry directives have been employed to shorten waiting time to less than 30 minutes: this has been included as part of the Key Performance Indicators or Key Result Areas announced by the government.

Perhaps this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution, has prompted this new approach.

But we also urge the government to recognise that throughout the country, there are many general practitio-ner (GP) clinics available in almost every urban block of shophouses and business complexes.

There is a severe glut of GPs in urban areas, such as Klang Valley, Penang, Johor Baru, Malacca, Ipoh and other major towns. In these cities, the ratio of doctor to population is 1:400 -- better than the World Health Organisation's recommended ratio of 1:600.

While some GPs have been successful, the great majority of them simply eke out a mediocre living. Most GPs see less than 20 patients per day and are, therefore, under-utilised. This is grossly unproductive and wasteful.

The problem is learning how to manage the distribution of the doctor-patient function more efficiently.

It is with this in mind that for several years now, the MMA and the ministry have been seeking an efficient public-private partnership in shaping a better healthcare system for the country.

Unfortunately, because of the differential system of fee and/or payment mechanisms, it is proving to be rather tricky to bring about a cohesive transferable system.

Thus, there have been talks about integrating the public-private sector for primary care medical services.

This will hopefully integrate all the GPs into a primary care medical service, whereby the public can seek treatment at either the public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will, undoubtedly, be the way forward.

Of course, quite a few discrepancies need to be addressed, for example, differing expectations and amenities available. But this can be worked out and we are establishing common areas of standardisation which will ensure that the public can be assured of as high a standard of healthcare as possible.

In this context, the establishment of the new 1Malaysia clinics appears to be unnecessary. If the government feels that these clinics should be set up despite the protests of the medical profession, then the least it should do is to ensure that these clinics are manned by registered medical doctors.

The standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is unbecoming to offer a lesser level of care to citizens just because they cannot afford to pay to see a doctor.

Employing medical assistants and nurses to do a doctor's job is called task-shifting, a practice employed mainly in Third World countries, where there is a severe shortage of doctors. To do so in this country would be a major step backwards and, in the MMA's view, unnecessary.

Do we have enough doctors? Of course, we do. It is just the poor distribution and logistics that need to be addressed.

Recently, more than 2,500 new doctors joined the public service as house officers. It is learnt that many of them are under-employed in various government hospitals.

Owing to the mushrooming of medical schools (23 as of this year) in Malaysia and medical graduates returning from abroad, we will have some 2,000 to 3,000 new doctors returning to our shores annually.

We can certainly tap into this resource to help run our public clinics more efficiently. At the very least, the public will be better served by registered medical doctors.

Although they may only have a probationary medical licence, the fact remains that they have had sufficient training and knowledge. Medical officers, registrars and specialists can supervise these doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioners?

Because under the Medical Act 1971, this is illegal. Because doctors who employ such unregistered persons have been charged and penalised for unprofessional conduct. Because medical assistants cannot prescribe any more than some simple medicines, cannot sign any medical leave chits or write any reports, and would become subject to medico-legal challenges with no precedents.

There should not be one law for some and another for others, even if it is approved by the government or the ministry. The MMA believes that setting up 1Malaysia clinics in urban locales is redundant, wasteful and shortchanges the rakyat. Utilising the existing GP clinics would be the better way forward.

Furthermore, the manning of these clinics by non-registered medical doctors is wrong and undermines the healthcare service, leading to a possibly poorer standard of care and many uncharted legal problems.

We urge a rethink on this project, and for the ministry to seriously look into the implications of this poorly advised move. The MMA will strive to work with the ministry to help raise the standard of healthcare for Malaysians, but not by compromising on the quality of care.

NST Online

Housemen lack basic know-how

Housemen lack basic know-how

By : Annie Freeda Cruez

NST, 31st January 2009

KUALA LUMPUR: Some medical universities, both local and overseas, are churning out doctors who cannot carry out common medical procedures, have no proper clinical exposure, cannot communicate effectively and cannot even take down the history of patients properly for diagnosis and treatment.

Senior medical consultants in government hospitals are now saddled with the task of having to retrain these people to ensure they meet the country's standard of medical practice.

Some of these fresh doctors are retained in their houseman training postings for years, some even up to six years, because they cannot meet the standards. The compulsory housemanship is two years.

In view of this problem, the Malaysian Medical Council has issued letters to all heads of department in government hospitals where housemen are posted to open a file on each of them, containing information on the university they graduated from, their performance and shortcomings.

It is learnt that by the end of the year, the MMC and Health Ministry will nail down the sub-standard medical universities and tell them to buck up.
Kuala Lumpur Hospital's Medical Department head, Datuk Dr Jeyaindran Sinnadurai, said housemen come from 300 medical colleges all over the world. These colleges churn out 1,200 doctors a year and this number is expected to increase to almost 2,000 next year.

"When they come back to work in Malaysia we have been forced to extend the period of housemanship from one year to two years in order to ensure the standard of medical practice is maintained in this country for the safety of our patients," he told the New Straits Times.

Dr Jeyaindran handles about 140 housemen a year and he noticed that some 15 per cent of them do not have enough experience to take down the medical history of patients.

"When they are taught to take the history properly and put the findings and various symptoms in a sequential order they can come to a proper diagnosis very rapidly," he said.

However, he added, this was seriously lacking in many new doctors because they have not been trained during their years in clinical exposure. Thus, during their housemanship training programme they needed to be retrained to do this properly.

"Because they have to be retrained, some of their postings are extended," he said.

Dr Jeyaindran has come up with a syllabus where a house officer must have core knowledge and experience before he leaves for his next posting.

"A houseman who comes in for training should be able to manage hypertension, asthma, diabetes and common medical emergencies appropriately based on current clinical practice guidelines, besides acquiring adequate generic skills," he added.

He said some were never taught this properly during their years in medical school and hence they were taught and assessed in a fair and objective manner during their training.

"We want doctors to examine patients properly and not take notes from the nurses' chart.

"We also do not want doctors to be over-dependent on investigative procedures which is time-consuming and expensive.

"One loses the ability to use clinical acumen to make judgment when he becomes too dependent on procedures for a result and diagnosis," said Dr Jeyaindran.

He also expressed great concern that some house officers were not able to perform even the most common procedures such as setting up an intravenous line, central line, and inserting a chest tube.

There have been complaints from patients that there were housemen who cannot even draw blood for a blood test and had to seek the help of nurses.

"Miscommunication with patients can also lead to a lot of problem and this we have encountered with housemen," he said.

"To be a good doctor it is not how much knowledge you have... it is clinical acumen and the skills developed in treating a patient.

"Medicine is not black and white but lots of grey in between and in order to identify the grey areas the only way is the more you see, the more you do, the more you understand," he added.

Dr Jeyaindran said housemen have become something like a production line.

"They come, they take some history of patients and go away.

"They never come back to check whether their diagnosis of the patient was correct or wrong," he added.