Malaysian Medical Resources: January 2005

Monday, January 31, 2005

Feedback: Bioethics Committee?

Slyvia Lim writes:

As Malaysia is trying to build up its Biotechnology sector, I am interested to find out if there is a national Bioethics Committee that examines the ethical, social and legal issues arising from biomedical research and makes recommendations concerning such issues to the Government.

Good question Sylvia. Short answer is I don't know for sure. If anyone knows, please email me.
I am aware though that the IMR has a Medical research ethics committee under the auspices of the Ministry of Health. Their web page has meeting dates but as usual the page is out of date. I don't know if this encompasses all biomedical research.

Feedback: Looking for colleagues

Stephen Chew writes:

I am trying to locate some Malaysian doctor colleagues who worked with me in Singapore. They are : Dr Benny khaw, Dr Yeoh Chee Lim and Dr Ng Peng Wah. They are all Gynaecologists.

Hi Stephen. The MMR has links to several Doctor Search engines in the MMR Directory.
I just took a look at these links again and:
1) The MMA's locate a Doctor link does not work ("Directory Listing Denied error")
2) The Academy of Medicine has a Search for Specialist engine but somehow I could not locate any of the names you mentioned!
3) The good news is if you take the Prohighway Doctor Search link, I think you'll be able to find at least two (the latter). I am not sure about Benny Khaw but the Prohighway database has a Khaw Soo Beng listed and practising in Penang.
I am not sure whether the addresses are current.

What we can also do is also post your request in Dobbs and if any Dobbs members know their contacts, we can pass these on to you.
If anyone else knows, please send me email and I'll pass the info on to Dr. Chew.

HTH

Addendum:

Dobbs (aka Google Master) writes (in Comments):
Dr Yeoh Chee Lim is at present practising in Gleneagles Medical Centre Penang.
http://www.gleneagles-penang.com/Frames/Resident.htm
Dr Ng Peng Wah is in Lam Wah Ee Hospital.
http://www.hlwe.com.my/WESTERN/panel.html
Dr. Khaw Soo Beng, Benny has his own private practice.
http://www.malaysiayellowpages.net/pakarwanita/

Sunday, January 30, 2005

MPF/MERCY Charity Sale 1 Feb

from Bernama

Muslim Professionals Forum Bhd (MPF) is organising a fund-raising sale and forum in aid of the tsunami victims in the region.
Its media coordinator, Zainurah Abdul Rahman, said that the fund-raising programme is in collaboration with the Malaysian Medical Relief Society (Mercy Malaysia).
All contributions would be channelled to the victims via Mercy Malaysia, she said.
The fund-raising sale will be held on Feb 1 (Federal Territory Day) at the Plaza Mont Kiara courtyard from 10 am to 4 pm.

Detailed Program:

10.00 a.m. Sale begins
10 – 12 noon Harley Davidson Joy Rides
10.30 a.m. 10 minute personal account by Bernama reporter, Mohd Razman
11.00 a.m. Announcement of Hourly Specials
Arrival of DYMM Sultanah Hajjah Kalsom Sultanah Pahang

11.15 a.m. Introduction of MPF by Dr. Musa Nordin
11.30 a.m. Quiz. Prizes to be given away by DYMM Sultanah Hajjah Kalsom Sultanah Pahang
11.45 a.m. 10 minute personal account by RTM reporter Noriani Idris
12.00 noon Harley Davidison team departs
Announcement of Hourly Specials
12.30 p.m. Quiz
1.00 p.m. Announcement of Hourly Specials
1.15 p.m. Account by MERCY President, Datuk Dr. Jemilah Mahmood
Presentation of cheque to MERCY from Sunrise Mont Kiara Community by Mr. Joachim Ng, Senior Manager, Corporate Communications,Sunrise Bhd.
Presentation of RM 28,000 worth of soap to MERCY by Lam Soon
1.45 p.m. Quiz. Prizes to be given away by Sheila Majid
2.00 p.m. Arrival of Datuk Shahrizat Jalil, Women, family and Community Development Minister
Announcement of Hourly Specials
2.45 p.m. Datuk Shahrizat Jalil to say a few words
3.00 p.m. Announcement of Hourly Specials
3.15 p.m. Quiz. Datuk Shahrizat Jalil to give away Grand Prize
3.30 p.m. Note of thanks to various parties
3.45 p.m. Announcement of Special Sales
4.00 p.m. End of MPF/MERCY Charity Sale

Saturday, January 29, 2005

Picking hospitals for housemanship training

eida writes:

I am filling up my HO forms and I actually have no idea where I want to apply for work. So thought that I could ask you. A lot of our MOs here gave a lot of conflicting advices on where to pick your houseman training so I just wonder what's your thought regarding this. :)

Hi eida.
Try to get a Hospital Besar not far from home ;)
I was lucky enough to do my Housemanship in my hometown - Penang. It was great since you could get out and have nice home cooked food now and then rather than rely on the stuff they serve you in the HO's quarters.

Friday, January 28, 2005

Update: Blogroll

Added Allenliau, a blog by a local Paediatrician to the MMR's medical blogroll.
Thanks to Dr. Liew for the pointer.

Feedback: Type II Diabetes Mellitus

radzli writes:

i'm a medical student in ireland.i need some info on type 2 diabetes that affect people under 20 in malaysia.i really appreciate if u could help me out since its very difficult to find them on the internet.it'd b great if u could include statistic on this topic.thnx alot!

hi radzli. i guess it's this sms thingy which makes us frgt how 2 use capital letters in our emails s well s use strng shrtcts ;)
thnks for writing in anyway.
i am afraid u hv to do it the hrd way. it was even harder during my time when we had to sift thru volumes and volumes of index medicus publications.
i am sure there must be losts of data published on niddm in malaysia and hopefully you'll find some data on young-onset niddm.
the tools i use are:
pubmed
google scholar
i did a cursory srch nd i gthr there wuz a national diabetes survey done in 1997. i don't hv the reference tho. hunt it down.

we already pointed out how hopeless malaysian medical websites are (hopefully the mmr does not fall into this category :P )
the persatuan diabetis malaysia doesn't look like it's been updated for a long long time. i was excited when i found that the national diabetes insititute has a section on "diabetes research and statistics" but lo n behold, it's blank!

hth. good luck.

P.S. You could try emailing the contacts in the above two websites and hopefully they could put you in touch with someone who knows

Thursday, January 27, 2005

Feedback: Setting up a clinic

Rezza Huzzieni writes:

I've been searching the web for procedures/criterias to setup a clinic for GP in Malaysia but have not found any. If you are able to help, below are my questions:
1. Where can I get advice?
2. Do I need to set up a company under ROC?
3. Does it require any registration with MMC/MMA?
4. Is there any other requirements to set it up?
5. What is the capital amount to start with?

Thanks for writing in Rezza. I have not setup one before so I don't really know all the details for sure. This is one thing they don't teach you in medical school!

1) I suggest you ask in Dobbs where there are lots of Malaysian doctors who can give you advice. There have been similar threads in Dobbs including a recent one on the cost of a clinic practice.
2) You don't have to
3) I don't think so
4) I think you need a business licence with the local council. You of course need a valid APC and the required capital and know-how.
5) I have no idea. Best ask in Dobbs. Commonsense would tell you though that a large part of the capital will depend on whether you are purchasing a shoplot or renting it. The latter of course would also depend on location.

Sounds like "Setting up a clinic 101" would be a good course in medical school.

Wednesday, January 26, 2005

HO's pay

So for those prospective medical students - be warned. The Health Minister himself admits that the MOH pays house officers less than fast food joint employees.
From the NST

It was an embarrassing admission, but Health Minister Datuk Dr Chua Soi Lek managed to keep a straight face when he said a fast food outlet worker may actually earn more than a houseman.
Fielding questions during a dialogue with staff of the Tengku Ampuan Afzan Hospital here today, Dr Chua said the Government realised the low allowance paid to trainee doctors doing their housemanship in a government hospitals.
He said his Ministry is in the process of revising its scale.
"Please be patient, it may take some time but we are trying our best in this matter," he added.

When you read reports like Private specialists may earn between RM20,000 and RM30,000 you might think that all Malaysian doctors make tons of money and that medicine is a financially lucrative occupation.
You have to consider that perhaps you (or your parents rather, unless you are lucky enuogh to have a scholarship)) would have had to spend something like RM500,000 for a medical education overseas. After that you struggle with a salary less than a McDonald's employee for a year followed by a medical officer's salary increase of something like RM100 annually. After about 2-4 years, if you are lucky, you get into a specialist training programme (Masters course locally) which takes another 4 years. So by the time you become a specialist, it my be like 8 years post graduation. Even then you still need another 5 years at least post-specialisation to be proficient and considered "experienced" enough so that would mean something like 12-15 years post-graduation. By that time, you would still not have recovered the RM500,000 investment!

I think if it's money one is interested in, don't do medicine. Go into business, property development or something more lucrative. Do medicine because you genuinely want to help people and be a healer, teacher or scientist.

Tuesday, January 25, 2005

Feedback: Bioinformatics

MP Ng wrote in:

I am a bioinformatics student in University Malaya. Bioinformatics is still a very new major in Malaysia. Some people are wondering what is all about.
Bioinformatics can be say a combination of information technology and biology. We learn about dna sequencing,dna matching,bio molecular modeling and programming language. We handle databases like genbank, ncbi, ebi and etc.
This major can help a lot in pharmaceutical and health care especially in medicine.
I hope can get a chance to learn more practically.

Thanks for writing in MP. I am not sure what the job market in Malaysia is like for Bioinformatics but I can imagine this will be a field with potential given the increasing importance of Research in molecular biology, genomics and proteomics in Medicine and the Healthcare industry in general. I think Malaysia in very keen to promote it's "Biovalley" concept and I certainly hope we succeed. But I think we face stiff competition especially from our neighbours south of the causeway. Talented researchers will be attracted to places where there isn't too much bureaucratic red-tape and where investors will be more than willing to go.
If anyone knows more about the Bioinformatics job market here in particular, please send in feedback or post a comment here.

Link:
National Biotechnology and Bioinformatics Network

Monday, January 24, 2005

Dengue fever: herbal warning

I spotted this thread in the USJ-SJ Forum where someone by the nick of RolyPoly claims that Pegaga Juice can "cure" Dengue fever.

The scientific name for Pegaga is Centella asiatica (also known as gotu kola, hydrocotyle). There is quite a lot of information on Centella asiatica from HerbMed. Traditional folk medicine use is primarily in "keloids, leg ulcers, phlebitis, slow-healing wounds, leprosy, surgical lesions, striae distensae and cellulitis". There is no evidence there is any benefit in dengue fever. There are also no studies on the potential adverse effects if given during dengue fever, particularly if there are any anti-platelet or "blood thinning" effects so we do not know of any potential problems in this area. However, in addition to the link above, here are some theoretical precautions and contraindications of Centella asiatica (source: Lexidrugs Natural Products database):
- contraindicated during pregancy (abortificant in animal studies)
- large doses may be sedating : additive effect if given with CNS depressants
- high doses elevate cholesterol levels

The main clinical features of dengue are fever which will last approximately 1 week (no matter what treatment you give), associated with bodyaches, headache and a rash which appears around the fifth day. There are variable gatrointestinal symptoms including nausea, vomiting and diarrhoea.
The main dangers of dengue are fluid losses and the risk of bleeding as a result of dropping platelets (small blood cells important for clotting) and deranged clotting function. The most important aspect of treatment is to ensure adequate hydration - intravenous hydration may be required if patients cannot drink adequately due to vomiting. Platelet and plasma transfusions may be necessary if the platelet counts fall to dangerously low levels.

My fear of herbal advocates is that people may not seek proper medical care until things are too late thinking something like Pegaga juice may miraculously cure their dengue.
Please note too that in dengue, herbs or "supplements" which affect platelet function or promote "circulation" may actually increase the tendency to bleed which is already high in dengue patients. They MUST NOT be given to patients with dengue.
These include:
Ginseng products
Gingko
Ling Zhi
Spirulina
Large doses of garlic

I don't know how people can conclude that Pegaga "cures" dengue. Anything given during the tail end of an illness may seem to miraculously cure it. So if I give some mysterious concoction to a dengue patient around the 6th day of illness and the next day the fever subsides, is it correct for me to say I have "cured" the patient of dengue? Come on people. I am sure you have more sense than that....

Sunday, January 23, 2005

Hypertension revisited

The Malaysian Society of Hypertension is holding it's 2nd Scientific Meeting January 21-23 in Kuala Lumpur. The theme is Confronting Hypertension: an Integrated approach. The Health Minister, Dato' Dr. Chua Soi Lek officiated the meeting and he was reported to say that 3 million young M’sians suffer from hypertension

A staggering three million Malaysians, mostly young men, have become victims of hypertension — all due to their unhealthy lifestyle and eating habits.
And Health Minister Datuk Dr Chua Soi Lek has described it as “a major disease but badly controlled”.
This, he said, was due a lack of commitment by people to get proper medication.
He pointed out that young adults were now dying prematurely or and becoming disabled because of the silent killer.
If preventive measures were not put in place the figure would double in 30 years, with the disease killing many young people, Chua said.
He added that said studies had revealed that 30 per cent of Malaysian adults above the age of 30 were now possibly hypertensive.
“We believe that 53 per cent of them are were possibly undiagnosed and unaware of their disease,” he said after opening the second scientific meeting of the Malaysian Society of Hypertension themed ‘Confronting Hypertension: An Integrated Approach” at the KL Hilton.
“Our study also indicated a higher prevalence of possible hypertension in the rural population, especially among women aged 50 years and above.”

Scary statistics indeed.

The most common misconception I encounter in the clinic is that people quite often think they can rely on symptoms to "detect" if their blood pressure is elevated or not. This is simply NOT correct. You cannot rely on symptoms as far as blood pressure is concerned. The symptoms could come on only when the BP is very high or may be totally unrelated to the blood pressure or there may be no symptoms at all.

Some informative links:
Hypertension Tutorial (Flash required)
High Blood Pressure (from the National Library of Medicine)
High Blood Pressure (from MayoClinic)

Saturday, January 22, 2005

Dengue : A neverending war

From Bernama,

January 22, 2005 15:49 PM
Dengue: Cabinet Orders Health Ministry To Fine Errant Local Councils

KUALA LUMPUR, Jan 22 (Bernama) -- The local councils must rid areas under their jurisdiction of mosquito breeding grounds or face being fined, Health Minister Datuk Dr Chua Soi Lek said Saturday.

He said the Cabinet last Wednesday directed his ministry to strictly impose the penalty on errant local councils.

The ruling extended beyond the local councils' compounds to include vacant lands, playgrounds and landfills, he said.

Speaking to reporters after opening the Malaysian Society of Hypertension's second scientific meeting here, he said no local council has been fined as yet.

A total of 2,465 suspected dengue cases with three deaths had been reported in the country since Jan 1 but Dr Chua said the number could increase in the coming two weeks before tapering off just before the Chinese New Year on Feb 9.

-- BERNAMA

A good move by the Cabinet. The emergence of epidemics require all to work hand in hand. From individual properties to state owned estates, a move to eradicate mosquito breeding sites is warranted. Dengue has been an endemic disease in Malaysia and total eradication is close to impossible. For now, our concern is to lower the number of dengue cases and to avoid dengue-related deaths. Achieving this requires the participation of all Malaysians. Upholding cleanliness must be our forte. We must change our ways. The war against dengue will never end. We just have to take the battles as they come. The more we let our guard down, the stronger the enemy gets.

Current efforts in controlling dengue must be a continuous one. We have little in way of defences against dengue, thus it is just a matter of "damage control" by keeping mosquitoes away from populated areas where they thrive. It is a gigantic task for a growing and sprawling city like Kuala Lumpur which is well known for its filth. Perhaps we should swallow our pride and learn from our little neighbour about social dicipline. ;)

Who's apathetic?

Pak Lah says Surge in dengue cases due to public apathy

Prime Minister Datuk Seri Abdullah Ahmad Badawi says public apathy in keeping their surroundings clean has led to the recent surge in dengue cases in the country.
He said the people still clog their drains with rubbish and dirty their surroundings, making these places ideal for the aedes mosquito to breed.
“We have organised numerous cleanliness campaigns, urging people to keep their environment clean at all times.
“But, if they still do not listen and keep on asking what to do when plagued by such diseases, I do not know what else can be done,” he said after performing Friday prayers at Masjid Kampung Permatang Bendahari in Penaga here yesterday.

I'm sorry Pak Lah but I beg to differ. Don't know what else can be done?
I am sure you and I know that you can't rely on Joe Public. The epitome of apathy, true. The answer lies in getting the councils to be vigilant and enforcement - FINE the apathetic construction companies, households etc. for breeding the mosquitoes.
Take any councils to task if they themselves do not do the job of upkeeping their jurisdiction - drains, park maintenance and the like.
No more soft soft appraoch. Wield the hard stick. That's what else you can do!!

Friday, January 21, 2005

Keeping an eye on bird flu

From the Star,

Bird flu claims seventh life in three weeks in Vietnam

HANOI, Vietnam (AP) - A 47-year-old man from northern Vietnam became the latest bird flu victim, bringing the human death toll to seven in three weeks, officials said Friday.

The man from northern Thai Binh province died at Hanoi's Bach Mai Hospital on Jan. 10, about 10 days after developing a high fever and coughing, said Pham Van Diu, director of Thai Binh Preventive Medicine Center.

Initial tests came back negative for the H5N1 strain of bird flu, but the third test was positive, an official at the Ministry of Health's Preventative Medicine Department said on condition of anonymity.

The man's younger brother, who cared for him in the hospital, also tested positive for bird flu and remains hospitalized in a stable in condition.

Diu said a week before the older brother developed a high fever and coughing, the family slaughtered a duck and ate it. - AP

As we battle dengue on our shores, perhaps it may be prudent to keep an eye on the bird flu outbreak in Vietnam. It must be prevented from reaching Malaysian shores at all cost. The bird population in Vietnam is suspect in this case and thus importation of poultry or any other exotic birds, must be halted. Tighter health screening procedures need to be continuously in place especially for travellers from Vietnam. This is essential as we still cannot fully comprehend the dangers of this virus and its capabilities for man to man transmission. We must not rest on our laurels despite recently declaring ourselves as a bird flu-free country.

The current spotlight is evidently not on bird flu for several reasons. First, we have a dengue outbreak which will require our immediate and complete attention. Secondly, our government has always been very prudent about news regarding bird flu so as not to create panic and chaos among Malaysians. News of the epidemic of bird flu can be blown out of proportion by rumour mongers and irresponsible individuals. This can disrupt and possibly destroy the poultry industry. This rumour spreading is evident from the recent tsunami disaster and the perils of ingesting fish from the Indian Ocean.

However, the Government must be serious in implementing steps to prevent bird flu from reaching our shores lest we succumb to this equally deadly virus.

Site update: NHAM

Added the National Heart Association of Malaysia (NHAM)'s website to the MMR's Professional Associations and Societies Page
Thanks for the tip, Dr TE Cheah.
I agree with Dr Cheah's sentiment that alot of Malaysian Medical Websites lack quality. Association websites are meant to to inform members - of meetings, events, contacts etc. It is meaningless if the website is hardly updated and not current. The NHAM website may turn out to be just another pretty face if it is not updated. I notice that their site has details of the Annual Scientific Meeting for 2003 (so was there no meeting in 2004?) and the Council members are those valid for 2002-2004.
The heart of the matter is we need to take websites and the Internet seriously. No point having a website just for the sake of having one. It must be functional and be up-to-date.
Similarly, I detest it when there are people who have email addresses but don't bother to check their email!

Lack of quality Malaysian Medical Sites

Being one that surfs regularly online, one cannot help noticing the paucity of quality Malaysian medical websites. Most of the sites that shine originate from abroad in particular the United States. Sadly, many Malaysian sites are poorly constructed and not well maintained.

Many doctors have yet to embrace the wonders and inevitable integration of digital technology into daily medical practice. The fault also lies partly with academicians who themselves are oblivious and quite resistant to digital technology. Within the premises of University Malaya, one can count the number of available computers for use. This hardly reflects a country that is striving hard to be at the forefront of information technology.

It would be ideal if Malaysia had its own medical portal similar to that of Medscape. One that can publicise local researches and provide medical news that is relevant to our own country. Indeed it takes a lot of hardwork and commitment to start such a venture but I believe that it is a necessary step forward. Current available sites are disappointingly lacklustre. Sites like profizham.com is sorely missed.

Continuing medical education sites of Malaysian origin is also lacking. Developing materials for continuing medical education programmes is important especially for doctors serving in more remote areas where access to important up-to-date information may be difficult. Grand round presentations can be put online for the perusal of doctors at their leisure time. Take for example the numerous presentations at UM grounds. Medical officers can sometimes hardly find the time to sit in and listen due to other work commitments. These presentations should be recorded digitally and made available to the doctors online for viewing.

Hospitals should also upgrade their information systems where patient information can be retrieved wirelessly without the need to travel down the hallway to access information through desktop computers. These technologies may not be all that expensive as many doctors already have PDAs with wireless capabilities on hand. It is the sorting out of security issues that need attention.

The need to make Malaysian presence online in the medical field is grave.It is an area that cannot be ignored.

Thursday, January 20, 2005

Dengue Scourge : Our Folies

From The Star,

Wipe out dengue, give priority to safeguarding people’s health

MY FAMILY and I recently returned to Kuala Lumpur for our annual Christmas holiday. As usual, we put up with my in-laws in a Chinese new village in Cheras.

One thing that stood out this year was the number of people infected with dengue fever in our area.

We decided to cut short our trip because we were afraid that we, including our two boys, might be prone to the dengue infection.

In fact I was down with fever for two continuous days in Kuala Lumpur. Luckily, it was not dengue.

The following are some of our observations which the authorities may want to consider in their policy deliberations:

1. Not enough resources are devoted to prevent and combat the current outbreak. When we were there, there were more than 16 cases of serious infection within a 100m radius of where we lived within four weeks.

Not once did we see any health or district officer come around to spray insecticide in our area (I was told repeated calls to the Health Department and the District Office were met with lukewarm response.).

2. Owing to the abundant rainfall and the sunny weather, overgrown shrubs and vegetation can be seen everywhere, even in the backyards of our neighbouring houses.

Also, the drainage system in Kuala Lumpur is normally blocked by debris and water tends to remain stagnant for a long time, becoming breeding grounds for mosquitoes.

The authorities should step up their efforts to educate the people regarding cleanliness, failing which stern action should be taken against non-compliance after a grace period.

3. Taking into account the fact that Malaysia is still a developing country and the rainy/tropical weather we are in, it is impossible to rid dengue fever infection altogether.

The authorities should not be complacent and should take proper town planning into consideration in approving residential development so as to avoid over-population of certain pockets to reduce the risk of mass infections.

4. Health should be given more priority under the 9th Malaysia Plan. After all, we have been independent now for close to 50 years and if we were to achieve anywhere close to a developed country status, public health should be the Number 1 issue.

Again, this brings us back to the issue of population control. Big in population may not necessarily be a good thing as the bigger the population, the more complicated the social issues the government would face. For example, increased health cost and more spending on infrastructure.

It is the quality of people we have that counts.

KEITH SAW,

Melbourne,

Frequently in the press, we have heard of how we could get fined for giving the Aedes aegypti mosquito breeding space. The public is also often chastised for not upholding a high standard of cleanliness. However, this is only part of the story and on many occasions mosquito breeding sites lie in areas under the jurisdiction of respective city councils. The letter writer above have several valid points.

Resources are indeed limited from manpower to the availability of proper equipments. The priority of at this moment, as reflected in the latest Budget, is certainly not health related, as our spending in Health still does not reflect that of a developed country. Not only that, this country continues to riddled with corruption and a lazy workforce. On many occasions during my tenure as a Medical & Health Officer, vector control units did not perform fogging activities despite being instructed to do so. However, they would sign papers saying that such activities were done. So on paper things look in order. Any attempts at hauling such individuals to the diciplinary board would be resisted by bureaucracy and red tape.

Clogged drains are ideal places for breeding mosquitoes. Other than rubbish and made-made debris, drains are often clogged by fallen leaves and branches. Unfortunately, our City Council officers are not vigilant enough to clean up such mess. They in turn put blame on the public for not maintaining cleanliness. I do acknowledge that many individuals are still irresponsibly disposing rubbish in drains but in the interim period, such drains need to be cleared. Education of our current generation may be futile unless strict measures similar to those taken in Singapore is implemented.

Town planning has never been the forte of our planners. Look at our road systems. They lack proper planning and at many areas even promote traffic congestion. Contruction sites should be thoroughly checked for mosquito breeding grounds. Strict guidelines on housing developments should be in place. Ultimately corruption should be eradicated, which in my opinion is the main culprit in promoting unsatisfactory development projects.

I agree that Public Health need more attention under the 9th Malaysia Plan. We are constantly being challenged with public health issues, from the bird flu saga to the current dengue epidemic. More money is needed to beef up the current workforce. We need to equip them with the proper and necessary equipments. The medical fraternity should view Public Health as an important specialty in Medicine and more emphasis put in medical school curriculums. Ultimately we need to crush the disease of corruption which is the cancer of our society.

Who's selling medicines now?

It seems like even property companies are getting into the act!
From the Daily Express:

A director representing a company primarily dealing in landed property was fined RM5,000 or three months' jail for possession of six cartons of an unregistered health product for sale.
"Carasinar Sdn Bhd is a company registered under the Companies Commission of Malaysia 'to purchase or acquire for investments, lands, houses, buildings, plantations and other property'.
"It has no Health Ministry authorisation in the supply of health products," submitted Prosecuting Officer, Joseph Oyol Modili, from the Health Department's (Pharmacy) enforcement division.
Pressing for a deterrent sentence, "to send a strong message to other similar business establishments", he stressed on the use of unregistered products as posing a health risk to the general public.
"As such, the public needs to be protected from such establishments that have no respect for law, public health and wellbeing."
He also impressed on the court that possession for sale of unregistered products under the Control of Drugs and Cosmetics Regulations 1984, under the Sale of Drugs Act 1952 is an emerging problem in the State.
According to the facts of the case, a pharmacy enforcement team led by Dzafarullah Daud inspected a consignment at a shipping and forwarding agency, Koh Han Ming, in Kolombong on May 8, 2003 at 11.25am.
In the presence of one Koh Tze Chean, the team found 696 boxes of 'Simei Antiseptic Cream' which were later confirmed to have no registration record under the Sale of Drugs Act as required under the Control of Drugs and Cosmetics Regulations.
During mitigation, the director who pleaded for leniency told the court that the company was fined RM6,000 in Kuala Lumpur for a similar offence earlier, when one such consignment they were expecting from Taiwan was intercepted there.
"Unfortunately, it was too late for us to stop this particular consignment which was by then, already on its way here. We do not want to repeat the offence," he explained.
Nevertheless, Sessions Judge Ravinthran Paramaguru, in imposing the fine, said he viewed the offence as very serious, "that may not just cause people to become sick but maybe even paralysis."

I can't believe the audacity of the director to plead for leniency just because he was "fined for a similar offence earlier". Repeat offenders should be fined even more and RM5000 seems to me like a slap on the wrist!
What is going on here in Bolehland? I suspect this is only the tip of the iceberg. There may be much more illegal importation of "health products" and dubious medicines. The health of our citizens is at stake here.....

OTC marketing of statins

I think it is ridiculous that pharmaceutical companies can even consider this! There are potential serious interactions of statins (cholesterol lowering drugs) that consumers may not be aware of apart from knowing when to initiate statins etc.
Luckily in the USA< the FDA has put it's foot down. From Consumer Healthwatch:

FDA advisors oppose OTC marketing of cholesterol-lowering drug.

Two FDA advisory committees have recommended against permitting Merck to market its cholesterol-lowering drug Mevacor (lovastatin) without a prescription. Members from FDA's Nonprescription Drugs and Endocrinologic & Metabolic Drugs Advisory Committees felt that under current marketing conditions, most patients will be unable to make an appropriate independent assessment about whether or not they would need long-term use of a cholesterol-lowering drug. [Mevacor daily OTC switch rejected based on patient inability to self select. FDAAdvisoryCommittee.com, Jan 14, 2005]
"Elevated cholesterol is not associated with symptoms. Before using Mevacor OTC, consumers will be required to make several judgments regarding age, the level of LDL-cholesterol (LDL-C), risk factors for cardiovascular disease and relative contraindications to appropriately select to use the product. . . . Regardless of whether they do this correctly or not, they will also have to make decisions regarding continuation of therapy. . . . There is no positive feedback related to symptomatic improvement. Positive feedback will have to come from a lower LDL-C level, which will require motivation . . . to educate themselves and continue to get cholesterol testing. Unlike other OTC drug products, Mevacor OTC should be a chronic therapy with the duration of use determined by the response to therapy and the development of relative contraindications during use. This clearly puts a burden on users unparalleled by any currently marketed OTC product. Any person choosing to use Mevacor OTC will have to be highly motivated in order to use it according to labeled instructions." [Ganley CJ. Consumer behavior issues related to the marketing of Mevacor OTC. Memo, Dec 13, 2004] http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4086B1_02_J-FDA-TAB5.htm

On another note, the pharmacists (here especially) keep saying that they should be doing the dispensing since they will have more time to provide drug information to patients. I really wonder how true this is? Do you more often see the post-Form V qualified dispenser or the Pharmacist at the counter? What are your experiences here?

Wednesday, January 19, 2005

Feedback: DBC

Edmund from DBC wrote in at length on DBC and Evidence based care:

Evidence-based medicine (EBM) is an approach that promotes the integration of valid and applicable clinical and research-derived evidence in health care. The best available evidence, moderated by individual patient circumstances and preferences, is
applied to improve the quality of clinical judgments. In the past, diagnostic and treatment procedures remained largely the same over time.
Now the increasing number of scientific publications questioning the past approaches is rapidly changing many treatment strategies today. For example, bed rest was the
method-of-choice in the treatment of acute low back pain (LBP) only a decade ago.
Now more or less all doctors are, at least should be, aware of the harmful effects of bed rest in the treatment of acute LBP.

Thanks for writing in Edmund. Your feedback was too long so I edited out the other information which you can find in DBC's website.
I have linked DBC in the Private centres links of the MMR. As it is not a doctor's clinic or hospital, I have created a separate subsection called Others.

Tuesday, January 18, 2005

Feedback: Signboards

Lester writes:

I saw a sign board in front of Dr.X's clinic in Kuching which says "Treat all kind of
illness". Can a private medical practitioner do that??

Well do you mean if he is allowed to put up that information in the signboard or his capabilities to treat "all kinds of illnesses"?
Well, I can say that I am not aware of any single individual doctor who is competent enough to treat every illness on earth! The only ones who claim to do so are inevitably your herbalist, sinseh, bomoh, alternative praticitioner or road side medicine man.
As for what a doctor can or cannot put up in the signboard in his clinic, there are strict guidelines which the MMA has laid out as Ethical Guidelines (PDF format)

Testing for Colorectal Cancer

Currently the American Cancer Society recommends the following for screening and early detection of colorectal cancer (note that "blood tests" for cancer markers are NOT recommended):

Colon and Rectal Cancer

Beginning at age 50, both men and women at average risk for developing colorectal cancer should follow one of these five testing schedules:

* yearly fecal occult blood test (FOBT)* or fecal immunochemical test (FIT)
* flexible sigmoidoscopy every 5 years
* yearly FOBT* or FIT plus flexible sigmoidoscopy every 5 years**
* double-contrast barium enema every 5 years
* colonoscopy every 10 years

The Star/Ap reports that a recent study reported in the Annals of Internal Mediine shows that FOBT as is used fails to detect colon cancer quite often and that repeated home-tests give better yields.

A common screening test failed to detect potentially cancerous colon growths 95 percent of the time, falsely reassuring patients and doctors, according to a new study.
Researchers found that the digital, in-office test on stool samples was not as reliable as a six-sample test given to patients to do on their own at home - although even that test detected potentially cancerous growths less than 24 percent of the time.
"What we found is that it was pretty worthless,'' Dr. David Lieberman, one of the study's authors, said of the in-office test.
"It's a wake-up call that we shouldn't be relying on this test.''
The study, published Tuesday in the Annals of Internal Medicine, was conducted at 13 Veterans Affairs medical centers and involved 2,665 patients - most of them men - who were given the at-home test and the in-office test followed by a colonoscopy.
The digital fecal occult blood test was positive in only 5 percent of patients with tumors or large, precancerous growths called polyps; the take-home test found 24 percent.
The reliability of the at-home test, however, improves if patients use it every year, said Lieberman, gastroenterogy chief at Portland VA Medical Center in Oregon.
Because polyps and tumors often bleed intermittently, the chances of detecting them increase as more samples are taken over periods of days and years, he said.
Early testing can find growths before they turn cancerous, a process that can take five to seven years, Lieberman said.
The take-home test was positive for 43 percent of patients who actually had cancer, the study said.
An accompanying survey of physicians also published in the Annals of Internal Medicine found that about a third used only the office test, a fourth used only the home test, and about 40 percent used both.

What about in Malaysia? The National Cancer Society of Malaysia's websites does not yet have published guidelines for screening as the screening section is "still under development. However I still find patients going to private labs which are still doing the worthless "cancer marker" blood tests. I think we should be advocating FOBT home test kits with follow up by sigmoidoscopy/colonoscopy as indicated

ACS Links:

Colon Cancer Screening
Can Colorectal Polyps and Cancer be Found Early?

Sunday, January 16, 2005

Plague and Pestilence

When He opened the fourth seal, I heard the voice of the fourth living creature saying, ‘Come and see.' So I looked, and behold, a pale horse. And the name of him who sat on it was Death, and Hades followed with him. And power was given to them over a fourth of the earth to kill with sword, with hunger, with death and by the beasts of the earth
Revelation 6:7-8

The Bubonic Plague of the 14th century killed some 20 million people. We in Asia especially in recent times seem to be "plagued" with a multitude of lethal infectious diseases, including new disease entities.
- Nipah Virus (wrongly called "JE" by a misinformed Health Minister; a new virus probably originating from fruit bats, spread on to animals like horses and pigs and transmissible to humans by close contact with infected animals)
- SARS (a new mutated coronavirus; highly infectious; high fatality rate from pneumonia and respiratory failure)
- Avian Flu (While Malaysia proudly declares itself free of bird flu, Vietnam recently reports 5 new deaths. I wouldn't be so confident in pronouncing ourselves safe from bird flu as birds can fly across borders and don't go thru immigration check points; and chickens who can't fly get smuggled across the border anyway)

As if our lives aren't made more miserable enough by the Tsunami disaster, we are now in the throes of a major Dengue outbreak in Selangor and a new HFM outbreak (hopefully not the more severe EV71 type) in Penang.

What does this all tell us? We need to pay more attention to basic public health - proper housing, proper water supply and waste dispoal, sanitation, overcrowding, pollution, rape of the environment (destruction of forests and jungles, water catchment areas, mangrove swamps) , over-development etc. We need to respect Nature and Mother Earth. If not we are going to pay dearly.

This has been your MMR's friendly end-times warning....

Thursday, January 13, 2005

DBC Physiotherapy

Yeo Kay Bin writes in:

I am a patient at this place called DBC Spine & Rehabilitation Centre. My orthopaedic referred me there. The treatment programme really help.
Just to let you know that there is such centre dedicated to spine rehab. ING paid for my treatment.
Recently I heard that SOCSO has recognised their centres.
You can find out more from www.dbcsam.com

Thanks for informing us Yeo. Glad to hear of your positive experience but nevertheless this is an anectdotal account which has little weight in saying a particular treatment really works or does not.
The title of their website is "Evidence based physiotherapy". I like that because in this day and age any treatment we advocate must be backed up by clinical evidence/trials/studies and not personal/individual experiences. I haven't read the PDFs available from their websites yet though.

Another scam

Spotted in dobbs:

I have a patient bringing me a brochure distributed door to door, promoting Kumpulan Perubatan Eletronik. The claimed that they are "The leader in Electronic Medication", with " The latest technology in medicine which combine modern physic and nature healing". They can treat everything from stroke, leukemia, diabetes, high blood pressure, and stated that EVERY DISEASE CURABLE".
There were a few personnel with their photographs printed in the brochure, including a few doctors with MD (UKM).
They are having a lot of setup from KL, Johor to kedah, and claimed that " akan segera dibuka cawangan Kedah, Pahang, Sarawak dan 200 lagi di seluruh negara!!"

People. Don't fall for this sort of scam.
The hallmark of medical fraud is any treatment which claims to "cure" all or a multitude of diseases. There is not a single clinical trial to back any of these audacious claims.
They will often like to use words like "holistic", "natural" and nowadays you also see pseudo-scientific jargon as well (I suppose in order to impress)
I don't know whether it is true doctors with MD (UKM) are involved but this is serious enough to warrant reporting to the MMC as doctors are ethically bound not to be involved in scams like this.

Wednesday, January 12, 2005

PBLs

OK. An anonymous person sent in feedback about a PBL s*cked Blog and Chatterbox which is allegedly setup by a PBL facilitator and purpots to:
- Collect student's perceptions on how PBL
- collect sugggestions on how things could be done better
The person asked us "pass it along to the IMU blog world."

Who needs PBLs? Really artifical form of learning I say.
During my time (and I am old enough to say this :P ) the best form of learning - the kind which sticks in your brain - is the spend as much time in the wards and clinics. You learn alot more clerking as many patients as possible, hanging out late nights at the A&E and seeing real medicine in action. We were hungry for practical knowledge. How to stitch. How to remove fishhooks stuck in a finger (I learnt this one from a HA in Penang GH). How to remove foreskins stuck in zippers etc.
You think you'll learn all this from PBLs? :P

3 in 1 Fund

Apparently now, it'll be the Three Gov't Medical Funds To Merge Into One

The Health Ministry plans to set up a Medical Assistance Fund (MAF) under which the National Health Welfare Fund, Special Chronic Diseases Fund and Special Fund for Handicapped People with Chronic Disease will be merged.
Minister Datuk Dr Chua Soi Lek Tuesday said the ministry would soon table the proposal in the Cabinet for approval.
"This follows the Cabinet decision last year that the health fund be merged with the fund for chronic diseases to facilitate better channelling and management," he told reporters

Well I am all for making things easier and less bureaucratic. The previous Health Minister was under attack in the press for allegedly tardy disbursement of financial aid from the National Health Welfare Fund.
Till this day, I am not aware of the mechanism of how to apply for aid for patients under this National Health Welfare Fund. I hope the mechanism will be more transparent under the new system and will not be simply the old system under the guise of a new name and still choked by bureaucracy. Wishful thinking?

Sunday, January 09, 2005

More on Road Safety

When I read reports like Family drive ends in death of toddler where children get thrown out of vehicles in accidents, I wonder how many little lives could have been saved if the parents had used car seats or booster seats with seat belts for their kids. I see too many kids on the laps of mothers in the front of cars, some even bouncing up and down. The kids do not know any better but the parents should.
I think it is high time for legislation to protect the children since many adults are otherwise indifferent.

To dispense or not to dispense?

...that is the question..
This has been a bone of contention between the medical and pharmaceutical profession for a long time now. Pharmacists don't want doctors to do the dispensing and want doctors only to write prescriptions. Doctors say it's inconvenient for patients to have to trudge to a pharmacy after seeing the doctor and besides, while there are 24 hour clinics, there are few 24 hour dispensaries. They also claim there are pharmacists playing doctor by making diagnoses, taking blood pressure, prescribing treatment etc. There is also a fear there will be poor enforcement as far as prescription items go and the overall cost of treatment may go up.
So basically pharmacists accuse doctors of doing their jobs. Doctors accuse pharmacists of playing doctor and so on.....

Recently the controversy has been going on in Singapore too. In Docs not swallowing the bitter pill, the Straits Times reports that "a move to separate consultation from the sale of medicine among doctors is causing a hue and cry in the profession". This is quite a balanced article and examines in depth the pros and cons of such a move from all perspectives.

General practitioners (GPs) in particular depend significantly on the sale of medicine to augment their income. They will argue that without this source, they will need to raise consultation fees.
Since their money comes from patients, it's inevitable that they will find another way to get it. And who can fault them? No one is out there doing a job for altruistic reasons.
Patients may also end up paying more as both the clinic and the pharmacy need to make a profit. So separating the prescription from the sale could add another layer of cost.
A GP who said the market is highly competitive, with patients voting with their feet, is not exaggerating. Some GPs have shaved so much from their consultation that they have become essentially medicine sellers with a licence to prescribe.
[snip]
But separating consultation from the sale of medicine may not do much to curtail rising health-care costs unless the ministry inserts a system of checks to ensure that pharmacies do not take over where doctors leave off; that is, sell more expensive alternatives, or branded rather than generic medicine to patients for larger profit.
One suggestion by WHO is for pharmacies to charge a flat dispensing fee, regardless of the price of the medicine which is sold at cost. While this may raise the cost of cheap medicine, it will reduce significantly the cost of pricey ones.
In some places, pharmacists have to offer patients cheaper alternatives if they exist.
The Government may also need to set up its own pharmacies to offer cheap medicine, or as is done in Australia, control the prices of essential medicine at commercial pharmacies.
The ministry must also ensure that pharmacies do not offer kick-backs to doctors who prescribe more expensive medication.
This won't stop pharmaceutical companies from influencing doctors to prescribe their brand of medicine, but it is not a new situation.
So, by confining the change to specialists only, Prof Satku would stand a better chance of pushing it through, for the benefit of patients in the long run.

So what do you think? I thought it would be timely for another MMR Voting booth!

Thursday, January 06, 2005

The Classic Case of a Cheat

Following up on the legitimacy of Chinese physicians, it is intriguing indeed that despite increasing cases of litigations against medical doctors, many still subject themselves to clearly unproven medicine by so called traditional practitioners. The emergence of these "pseudodoctors" and their grandious proclamation of miraculous cures have deprived many patients of good and responsible medical care.

The practice of traditional practitioners are currently unregulated. Their claims of successes are on most occasions dubious and controversial. Their treatments are shrouded in secrecy and backed by little scientific data. Perhaps I should isolate one that was particularly brave in "exposing" themselves in the web.

Let me introduce you to Master Leong Hong Tole. He is the founder of Tole Instutite and Herbal Medicine. His Institute was given the recognition by our former Health Minister YB Dato' Lee Kim Sai. No surprises here as our Health Ministers were previously medically naive.

Reading through the main index would reveal their obvious poor grasp of English. But the fault certainly does not lie here. It however will reveal as, I will demonstrate, a case of "cut & paste" in their efforts to impress readers with their "knowledge" in human anatomy and physiology. This page will reveal a long list of medical conditions that they claim to have successfully treated. Let me draw your attention to their description of breast cancer.

You will notice that the initial few paragraphs were written in flawless English that you see in standard textbooks or medical websites. Sure many would be impressed at this stage with their "medical knowledge". Take a look at the following paragraph.

CURE and Treatment
Most of the stages of Breast cancer could be SAVE WITHOUT Operation by THE TOLE'S WAY OF MEDICATION. It normally takes between 4 weeks to 4 months depends on their conditions and the patients age. The earlier you starts the treatment the better the change of full recovery. Some may be too late, so please act now and e-mail to us first then we can work with you mostly by sending you some herbal medicine.You have to let us have all your medical history and conditions now and when did it start. Other complications as well.
Some patients likes to use our herbal medicine and acupuncture treatment with Chemotherapy together. It has also shown good result too.
Herbal Treatment
For those who cannot come to our centre then you can e-mail to us your conditions and we can send you the tailore made herbal medicine for your recovery.
Then we will guide you from here with e-mail, and we will let you know what to do and what not to do, and your dieting conditions.

You have to let us know your full medical history and scan reports and biopsy reports.
Herbal Medicine to prevent cancer
Many can be prevented, we have the special herbal formular that can help to prevent you from getting cancer. Mostly are the relative of cancer patients that needs to take this herbs to prevent them from getting the cancer. Prevention is always better then cure.

You will notice that the English has dramatically deteriorated and worse still the accuracy of medical information has dropped in tandem. You will notice that first, they claim to be able to save patients at most stages of breast cancer without operation. We know that this is not true. Next, their "special" herbal concoction can help prevent cancer. Any data to back that up? Probably not. On top of that, it appears that they can read CT scan reports and biopsy results. Even medical doctors with years of training have yet to grasp the skill of reading scans accurately what more a pathological specimen.

More madness,

Many a times that when the patients was suppose to go for cutting off their feet or legs , after our treatment they can keep their feets and legs (ganggrene), that is when the legs turn black and dry.

Preposterous! I would like to see that!

There are unfortunately many more of these "recognised" physicians which prey on the vulnerabilities of the sick for their personal financial gain. They often would gather a "cult-like" following for the purposes of recruiting potential customers. Should we then just sit and wait?

Wednesday, January 05, 2005

Feedback: Chinese Physicians

Janet Wong writes:

I am looking for contact of the Federation or Dr Chua of Ministry of health. I would like to know if a physician who said to be member of chinese physician are covered with an insurance to practise their medecine. Indeed my father was forced to take off his right leg caused by a mistake from a physician couple of weeks ago. We are desperated as the father has no medical insurance and we must pay the bill for a mistake done by unprofessional physician.

Thanks for writing in Janet. I gather you are referring to a practitioner of Chinese medicine and they fall under the Federation of Chinese Physicians and Medicine Dealers’ Association of Malaysia. Back in July, I blogged on Will the real TCM practitioner stand up? and mentioned that the Health Ministry has stopped recognising the five traditional medicine group including the Federation of Chinese Physicians and Medicine Dealers’ Association. These traditional medicine groups are poorly regulated and poorly supervised and I highly doubt that any of these traditional medicine practitioners have anything like malpractice insurance to back them up. The Health Ministry plans to set up a Traditional Complementary Medicine Council but this will not take effect until 2006 at least. You can direct complaints to the Ministry of Health (their contact is listed in their web page but good luck with Government bureaucracy!) or else seek legal advice from your lawyer.

Tuesday, January 04, 2005

The heart of the matter

There has been recently an exchange in the Letters section of Malaysiakini. In case you have not noticed, A Patient first wrote:

Something is not right at the Cardio Unit at the Hospital University Kebangsaan Malaysia in Cheras.
Professors and specialists who have left, as several did recently, are not replaced. The unit accepts no new referrals of cardiac cases. The thrice-weekly consultations is reduced to twice-weekly.
This places a higher workload on the unit. Cardiac patients who come for their regular and follow-up checks are either discharged or given a date a year ahead for their next visit. Or they are told to go to private hospitals or clinics.

To which HUKM Dr replied:

In Hong Kong and Singapore, lecturers are paid separately by their health ministries for performing clinical duties. This is on top of their basic salaries (including clinical allowances) as a lecturer. Indeed, external examiners have often remarked how ‘unfair’ it is to be a lecturer at a Malaysian medical faculty.
The message is that medical lecturers elsewhere are always paid higher than their counterparts in the health ministry who opt not to teach at all.
The bottom line is that (good) people still leave the teaching universities because of the poor remuneration when compared to the private sector or other teaching institutions. How can we ‘replace’ the cardiologists if the bottom line remains the bottom line?

There are a few perks of working in Academia which HUKM Dr failed to mentioned. You get sabbatical leave - don't know what it is in HUKM but in PPUM, it is 5 months every 3 years or 9 months every 5 years. You also get research opportunities not readily available in the MOH. You also don't get transferred here and there unlike your counterparts in the MOH.
But I agree it is stressful not only trying to carry out heavy clinical duties, but also having to do research/pressure to publish, teach students (under and post-graduate) and the unending burden of having to organise examinations.
I agree with HUKM Dr that there should be greater incentives to attract quality academic staff in our medical schools. After all these are the people who are training our next generation of undergraduates and postgraduates. The remuneration has fallen far behind "marketvalue" and indeed a medical lecturer's salary is now roughly equal to the income of a pharmaceutical company's sales rep!
No surprises when the "brain drain" continues....

Addendum:
I wrote in to Malaysiakini and got published ;)

Site update: Padu

Dr Muhd Najib Mohd Alwi, PADU President writes in to inform that PADU, or the Persatuan Alumni Doktor USM's website has a new home : PADU
The MMR's webpage of links to Malaysian Medical Professional Societies and Associations has been updated accordingly.
Thanks for the feedback, Dr Muhd Najib.

Sunday, January 02, 2005

Radon in your home?

The effects of natural radon gas escaping the earth's surface into our homes is causing 9% of all deaths from lung cancer across Europe, and smokers are most at risk, according to a paper on BMJ.com (PDF) today (21 December 2004).

Radon has been known for quite sometime to be a cancer causing radioactive gas that arises from the natural breakdown of uranium in rocks and soil. I suspect that the majority of Malaysians are oblivous to this phenomenon and testing for Radon in our homes is something we hardly hear about. Yet when I see clusters of cancer in a household/family I really wonder....

Perhaps it is hightime that we pay more attention to this.
From the Home Buyer's and Seller's Guide to Radon, the US Environmental Protection Agency recommends:
# If you are planning on buying a home or selling your home, have it tested for radon.
# For new homes, ask if radon resistant construction features have been used.
# Fix the home if the radon level is 4 picocuries per liter (pCi/L) or higher.
# Radon levels less than 4 pCi/L still pose a risk, and in many cases may be reduced.
# Take steps to prevent device interference when conducting a radon test.

Other links:

Radon In The Home Responsible For 9% Of Lung Cancer Deaths Across Europe
How to reduce radon in your home

Does anyone know of any local companies which supply Radon detection kits?

Saturday, January 01, 2005

Decentralisation

The plan is for the Ministry To Decentralise Expertise At Overcrowded Hospitals

The government will decentralise medical expertise in major hospitals to smaller ones nearby in order to ease overcrowding.
Health Minister Datuk Dr Chua Soi Lek said the move would reduce the burden of major hospitals besides providing better comfort to the patients.
"We also plan to provide specialised services in hospitals near the major ones," he told reporters after visiting the district hospital here Friday.

I understand the MOH's plans but I am concerned about some aspects. If you move away specialised services, this may pose problems for the "specialised service". The issue is that "No Man Is an Island" really. I mean that quite often, specialists need to refer cases to other specialists. Patients too often have multiple problems. For example, the diabetic patient with end stage renal failure undergoing dialysis in the "specialist dialysis/renal service hospital" may have eye problems, cardiac problems and what-not. The "in-house" expertise may not be available and the patient will likely be shunted from hospital to hospital.
I wonder if the bulk of the load in a large hospital like Sultan Aminah comprises "General Outpatient Clinic" patients? This would mean it may be better to decentralise the outpatients - have more satellite outpatient clinics or even better with a National Health Funding system, refer these patients back to GPs.
What do you think?

Malaysian Medical Resources