The MMR wishes all readers a Happy Merdeka!
I’d like to point out this great post by Dr. Alex Tang on Andrew’s Letter to his Son about Merdeka

As I watched you and your classmates today, and the kids from all the other kindergartens walk up on stage to receive their certificates, I was reminded that this country of ours, Malaysia, is as much yours as it is mine. God has allowed me and all the other adults in this country a time to take care of it for you. But the day will come when we will have to turn it over to you and your friends.
I hope we won’t have messed up. I pray that we will have the strength and the courage to do the right things, so that we will be able to pass on to you, son, and those of your generation, a country that is successful. Not just rich in the things that we have — the tall buildings, the big houses, the fancy shops. But rich also in our hearts. To share love with one and all, to be kind and decent to others, to be fair and just to everyone, to let anyone who wants to come and live here and do an honest day’s work the right to call this country home.

We share Andrew’s prayer. God bless Malaysia.

The MMA made the call a few years back and then the DG was quoted to say:

…the policy of requiring doctors to wear their white coats, shirts and neckties would not change unless there was a “body of evidence” which proved that neckties caused infections to spread.
“It is a long established policy that we have had since Merdeka. Doctors must maintain their dignity and dress properly,” he said.

A study by Jimbo et al shows that there is indeed a High prevalence of methicillin-resistant Staphylococcus aureus (MRSA) on Malaysian doctors’ neckties

We discovered that more than half (52%) of neckties worn by doctors were contaminated with Staphylococcus and out of these, 62% of them were identified as MRSA. In contrast, none of the student’s ties were contaminated with MRSA. Due to the high prevalence of staphylococcus detected on doctors’ neckties, we recommend that health care workers do not wear neckties.

So DG and MOH – perhaps the “dress code” for doctors should change now that there is local evidence?

Related MMR posts:
Scotland bans doctors white coats, and it’s high time we should do the same
No neckties for docs
New Dress Code for UK doctors

Dr. David Quek sends this in:

This year a group of MMA members are seeking to amend the constitution to have all elections for President, PE, HGS, HGT conducted at the AGM only, doing away with postal balloting which has been with the MMA for decades.

This is purportedly to empower those who do turn up for the AGM with greater rights and responsibilities, with an even weaker argument that this will encourage those interested to turn up for the AGM (which is seeing a decline in attendance over the years).

Some of us and esp. senior members are extremely uneasy about this. We feel this will in effect disenfranchise even more members although they may not wish to turn up for the AGM. As many as 2000 to 3000 members regularly vote via postal ballot every year and I feel that this is infinitely better than having just over a hundred delegtes deciding on the fate of the leadership in the MMA.

Unfortunately, these hundred or so AGM attendees have been vociferously making many interpretations and changes via resolutions and now also Constitutional amendments. We must defeat this once and for all to enshrine this right of members to help protect the sanctity of the Association. Allowing just AGM delegates to vote could lead to vote buying and other irregularities, e.g. just sending in a few busloads could clinch a presidency etc.

So please highlight this dilemma, and urge MMA members to turn up in full force for this AGM–the meeting will take place Friday through Saturday.

This is also the reason why more doctors must play a larger role and take ownership, otherwise, vested interest groups can usurp the power and possibly weaken the MMA, which is still the largest organization representing doctors in the country, although with declining representative percentage due to our huge increase in medical graduates. Even this we are fighting a losing battle, but we are alerting the authorities about the impending glut. The bigger the numbers we have, the stronger will be our voice. Please help by becoming involved!

Sincerely
David

FYI all MMA Members.

Kendall Lee, M.D., describes deep brain stimulation surgery, and how it is is typically done with patients who remain awake, so neurological functions can be measured and maintained.

(via Unbounded medicine)

We also mentioned Awake Brain surgery back in December 2009 and coincidentally around that time, one of our neurosurgeons gave a lecture and presented a video of such surgery taking place in a local hospital on a young man, in order to preserve his speech function.

Abdominal Aortic Aneurysm is probably under recognised in Malaysia and ultrasound screening for AAA in Malaysia I dare say is not commonly practiced as it is in the US for men age 65-75 years. Nevertheless we do encounter this from time to time, and one might be interested to know that recently in the NEJM the results of clinical studies on endovascular repair (as compared with conservative management or open surgical reoair) have been published. The results are not great and it seems endovascular repair does not improve long term survival.
Here’s an excerpt from the First Watch summary

In EVAR-1, nearly 1300 adults with large AAAs were randomized to undergo endovascular or open repair. While 30-day mortality was lower with the endovascular approach (2%, vs. 4% with open repair), after a median of 6 years, aneurysm-related mortality and total mortality did not differ between the groups. In addition, graft-related complications and reinterventions were more common with endovascular repair.
In EVAR-2, some 400 patients who weren’t eligible for open repair were assigned to endovascular repair or no intervention. During a median follow-up of 3 years, aneurysm-related mortality was lower with endovascular repair, but there was no difference in total mortality.

Our local cardiologist blogger has a more personal take on this. His description of the procedure is rather “interesting”:

One day I had the opportunity of observing one of the local, senior endovascualr interventionist doing a stent graft. His case was just before mine. I could see him struggling and trying to force a stent graft in position. The whole abdomen seemed to shake as he tugged and pulled to position the stent. I told myself that it was all so crude. Vascular interventions was not suppose to be like this. Soon after that, I was sitting as a moderator in another live demo course and the senior Japanese vascular surgeon was trying to insert two stent into the thoracic aorta. It was also so crudely done with pulling and tugging. One always wonder what happens to all the branches coming off the aorta, during all these forceful movements.

I didn’t realise it could be so “violent”? :p

A YouTube search shows quite a number of video clips on this procedure, so here’s one for your viewing pleasure:

The World Wide Web is indeed self-empowering. It enables patients to scour the Internet for information using their browser. Google is so powerful these days that searches are quite accurate, and indeed we mentioned that doctors could even use Google to help in diagnostic difficulties. There have been a few cases of patients or their relatives successfully using the Internet to make rare diagnoses as in the case of a mother of a girl with a mysterious illness who made the diagnosis with the help of the Internet.
It’s not as easy as it sounds, as symptoms are often common to many illnesses and symptoms by themselves are not the only clue to illnesses. There are also clues in other aspects of the history and not forgetting physical examination and physical signs which patients often do not appreciate on their own. It’s not uncommon these days to see patients “jumping to conclusions” after “researching” their symptoms on the Internet. Indeed not long ago in Bolehland, there was the case of the Retired teacher who used Google to make diagnosis and was unhappy with Govt. doctor. There are alot of pitfalls in this area and unfortunately the WWW is also full of misinformation as well. One needs to be quite discerning and critical.
My take is that patients can and should use the internet to search for information but you should be best guided by your doctor.

Why am I bringing this up? Well, I have been approached by a radio station to be interviewed on this subject. While preparing for this subject I would like feedback from readers (both patients and doctors) on your
- personal experience using the Internet to make diagnosis
- have you as a patient found it useful? Any specific examples?
- have you as a doctor found it useful in your practice?
- what experiences have you as a doctor found in your encounters with patients using the Internet to make their own diagnoses?
- what sites do you commonly use to search for information (Google, Pubmed, Medlineplus, Mayo clinic , Wikipedia etc.)?

Btw, if you are a tech-orientated doctor who would like to participate in the radio interview next week, please get in touch with me (palmdoc@gmail.com)

The MMR would like to wish all our blog readers a Happy, Healthy and Prosperous Chinese New Year!

We extend our condolences to the families of the three young doctors from QE Hospital Sabah who were killed in a car-bus accident.
The circumstances of this accident are not clear but we do implore young doctors to be extra careful if you are planning car trips after an exhausting call as we have heard of fatal accidents involving such tired doctors. Consider getting someone else to do the driving.

Fellow Malaysians, you can do your bit to help the unfortunate Haitians who have been struck by a devastating earthquake.
Donations can be made to:
Unicef Malaysia Haiti Appeal
and the
Malaysian Red Crescent

Even if the aftershocks have stopped, for the doctors in Haiti, the Worst is Yet to Come

Happy New Year to all! What will 2010 hold for us? As for the medical profession, I note that it starts with a bang with the MMA President making a New Year 2010 Call to Action. The reason for this is the controversial 1Malaysia Clinic plan the Government wants to implement. While the public may think this is a good idea David had already written that we should rethink this as the so-called 1Malaysia Clinics will be run by medical assistants and nurses rather than doctors.
It is ironically double standards being practised as clinics under the Private Healthcare Facilities and Services Act cannot by law hire Medical assistants. It seems to me, at least in this circumstance, 1Malaysia means 1 rule for the Government and another 1 rule for the private sector.
Please also read David’s post on MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.
Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or de-registered!
Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.
Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.
There should not be one law for some and another for others, even if approved by the government or the MOH.

We have our respects for our paramedical colleagues – the MAs and the nurses – who play a vital role in delivering healthcare in the nation. The concern here is that their role will be altered to one of a medical doctor in the primary care setting. For instance, will the MA or nurse be able to more reliably than a trained doctor determine if the so-called “minor illness” like “fever and cough” be an Upper respiratory tract infection or actually be a more serious pneumonia? This will put the MAs and nurses in a spot as they should realise that their roles and responsibilities in the 1Malaysia Clinics now take on an elevated position, one which they and the Government will ultimately be responsible for should there be mishaps and misdiagnoses in this setting.
The non-medically trained politicians must realise that patients when they seek care at clinics do so with problems and not with the diagnosis on the platter. It may be chest pain or a fever. It may be back ache, fatigue or weight loss. So you tell me if the MA or nurse is the one to distinguish IHD from anxiety neurosis? URTI from H1N1? Depression from Cancer? Dear Health Minister, calling it a “minor illness” is not as easy as you think.

Once again, read Dr. Quek’s Call To Action. David says the 1Malaysia Clinic plan will effectively “place our standards on the level of countries that have a scarcity of fully-registered physicians”. We already have a plethora of medical schools, with another one being planned in Perak and it seems that quality is not as important as quantity with the mushrooming of medical schools in this country.
Malaysia is NOT short of doctors. What is happening is that there is a mal-distribution of doctors, there being a rural-urban disparity. It only requires a better plan to get more doctors in the rural and under-served areas and that may be achieved to some extent with better private-public sector cooperation.

Teoh Beng Hock’s inquest will resume this month. A second post-mortem was conducted and one wonders the sparks which might fly if there is any truth to the allegation that TBH was murdered rather than it being “suicide”. There might be an interesting exchange between the reknown Thai pathologist Dr. Pornthip and the UK pathologist hired by the MACC if both are called to testify.
Already the Kugan case has cast a “black eye” on the medical profession, the pathologists in particular, since there are at very least implications on the impartiality of doctors if not the competence issue. As doctors, we have to assess and present the evidence as they stand. We cannot and should not provide evidence which only our political masters want us to produce. Doing so not only is a major failing to ourselves but a major failing on the trust patients and the public put on us.

I predict that in 2010 we shall see more instances of fake doctors and quack surgeries. We already highlighted this Miracle Surgery Scam to the MMA and the authorities (the MOH) but there has not been any feedback nor any apparent action taken. This disappoints us greatly. The original intent of the PHFSA was to safeguard the public against quacks and fraudulent medical practice. It is sad to see “doctors” like these practising with impunity, whereas genuine doctors are harassed by little Napoleons who are seemingly more concerned about clinic dimensions.
Please go after doctors promoting things like that Bleeding scam and fraudulent Ozone therapy. Surely that’s more important than a clinic’s ceiling height?

I predict too that in 2010, sales in supplements, herbs and traditional medicines will continue to skyrocket despite a lack of evidence any of these work. There will continue to be fraudulent practice where so called “natural” and “herbal” products are actually laced with poisons or potent substances notoriously in “Slimming products” and “aphrodisiacs”.
Never mind for instance if the evidence shows that Gingko is useless if you take it for the prevention of dementia or Alzheimer’s disease. People will continue to buy it and consume it, as they are influenced by unregulated commercials and mass marketing of these products which make unfounded claims on efficacy. I hold the powers-that-be in part to blame for their promotion of TCM in public hospitals despite such a paucity of evidence base in TCM practice.
We should not be proud of an “alternative medicine and supplements” industry which generates billions of ringgit, but should be ashamed that we can be proud of an industry which relies on gullible people being duped into parting with billions of ringgit for largely useless products.
The MMR will continue to keep track of news in our CAM Watch and Fraud Watch categories.

Have a good year!

The MMR would like to wish all our blog readers a Healthy and Happy New Year 2010!

Interesting video sent in by my sister which shows brain surgery being conducted on a patient who is awake – necessary if one wants to preserve certain functions e.g. speech.

FYI, this type of surgery is available in Malaysia as well.