The recent introduction of the 1Malaysia clinics has more political connotations than a genuine attempt at providing quality healthcare to the poor. Clinics run by medical assistants with the minimal of equipment is to me a waste of public funds. As a person who has worked for many years with medical assistants, I can attest to the fact that the government is toying with the health of the public in order to earn some political points.

The quality of medical assistants is suspect, from the selection of candidates to their training methods. Many of these medical assistants lack basic aptitude to practice medicine. Some are even poorly qualified. Training of medical assistants are different and hardly involves the rigours of medical schools. Their diagnostic ability is questionable. Their role in the rural community is understandable but to allow this responsibility of managing clinics in the urban areas where doctors suffice, is tantamount to dereliction of duty by the policy makers.

Would any of our VIPs visit a medical assistant for even a simple ailment? Many would flock to ‘specialists’ for the best available care. Why then are we toying with the health of the general public?

The reason of providing accessible healthcare to the urban poor is a misdirection. There are many clinics in the urban area, way too many actually. It might have been more prudent to implement schemes for the poor where their visits to the general practitioner is subsidised. There are actually existing programmes in place via the Welfare Department to cater to these group of individuals where their healthcare is fully borne by the government. So what is the role of 1Malaysia clinics?

The name speaks for itself. Promoting a political agenda using tax payers money with total neglect of their wellbeing.

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Africanisation of Malaysian healthcare- Malaysiakini

HbA1c May Be Useful for Diabetes Screening, Diagnosis in Routine Clinical Practice

January 22, 2010 — Hemoglobin A1c (HbA1c) may be useful for diabetes screening and diagnosis in routine clinical practice, according to the results of a study reported online in the January 12 issue of Diabetes Care.

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The use of HbA1c for diagnosis was once deemed wrong. However, it is now suggested that HbA1c is gaining credence as a diagnostic and screening tool, apart from its usual purpose of monitoring control of diabetes.

If widely accepted, it is set to replace the cumbersome oral glucose tolerance test which is certainly more labour intensive and uncomfortable for the patient. Will the OGTT test remain relevant in the years to come? Perhaps its relevance will remain in patients with gestational diabetes where the OGTT is logically more sensitive than the HbA1c which will take time to rise.

As mentioned, the pitfalls of HbA1c are in those patients with hemoglobinopaties and anaemia, where HbA1C will be inaccurate, in addition to the higher cost of this test.

The jury is out there.

It was recently reported that the MOH is planning to reduce the number of years of compulsory service to 2.  This authoritarian rule has the noble intention of forcing doctors to serve in busy government hospitals and clinics upon graduation. Mind you, during this period the working conditions are appalling and the pay is a mere pittance.  Things have improved somewhat over the last decade with the number of doctors increasing and the pay scale much more appealing than it was years ago. It was forecasted that by 2020, there may be even more doctors than there are available positions.

Soon there will be jostling for positions even in rural Government clinics as the positions become saturated and increasingly competitive in an open market. There will no longer be any need for compulsory service as any available positions will be a blessing in itself.  As the cost of medical care increases, more patients will flock to public hospitals hoping to pay only a fraction of the amount. As healthcare expenditure rises, the Government can no longer maintain the current subsidisation strategy, and privatisation becomes inevitable. Retrenchments will then become a surreal reality for doctors as many will have to look elsewhere to ply their trade.

Doctors in Malaysia have never had to worry about jobs as the demand for doctors currently still outstrips its supply.  However, the number of doctors under the purview of MOH is increasing exponentially as evident from the number of housemen flooding in from the 28 local medical schools and those from foreign universities. With a declining birth rate, we will soon race past the 1:600 doctor to patient ratio.

So why do you think the MOH is keen to shorten the duration of compulsory service? Their reason of appreciating those that have long been in service appear distant and unrelated. Surely the expense needed to maintain a bulkier service is not ideal for a country with a shrinking budget. They are well aware of the fact that many choose to leave upon completion of their Government service. So what is the motive for the reduction in the years for compulsory service?  You make the deductions.

Indeed the clock has already started ticking. Soon fresh graduates will be clamoring for that one position in rural Sabah.

Links

Proposal to reduce compulsory service for doctors

The recent massive earthquake in Padang has left a trail of destruction and destroyed the lives of many Indonesians in Padang. The devastation has resulted in almost instantaneous offer of help internationally mainly in search and rescue efforts. However, Malaysia has taken no chances and decided to evacuate all citizens. Notably present in this group are medical students from Andalas University.

Despite a relative calm and a call by the university to return, these medical students have refused that offer and instead insisted on a transfer to local medical institutions. As the university itself is pleading for volunteers, these to-be doctors have shyed away from what many thought would be naturally brave and selfless characters. The visions of doctors in volunteer groups like Mercy Malaysia and Doctors without Borders, contrasts starkly to these cowards.

I strongly urge local medical schools to not accept these medical students. Making cheap advantages in another’s misfortune is hardly qualities worth considering. The least these students can do is to remain loyal to their chosen alma mater.

Update: The students have finally decided to return to Indonesia to complete their medical studies. We wish them well.

Source : The Star:Docs violating patient confidentiality, says NUBE

“Employees seeking medical treatment were issued with guarantee letters which required them to sign consent authorising the doctor to reveal the workers’ ailment including present and past medical history with copies to the bank,” he told Bernama.

Failure of the doctor to comply with the ‘directive’ of the company will surely jeopardise the position of his/her clinic within the list of panel clinics. Losing ‘clients’ in this way is surely not good business sense.

Unfortunately, neither is it a good business sense for the company to allow its employees to abuse medical leaves. Medical leave is certainly a perk rather than a right. I know of individuals who will ‘utilise’ the allocated medical leaves, in addition to the quota for annual paid leave. So companies are trying hard to curb this ‘fraud’.

This takes me back to the doctors who issue these medical certificates. Certainly there are some ailments that can be fabricated. A patient that comes complaining of menstrual pain would certainly get a medical certificate and the doctor can hardly know if she may or may not be malingering. Recognising abusers of the system may be more than an art than science.

Certainly there are two sides to the coin here. On one hand, there are employees abusing the system daily, and on the other, companies disrespecting the privacies of these individuals on their payroll. Both parties should stop such hostilities.

Although the ‘Docs’ get the headlines this time, I feel this is an issue between employer and employee.

Over the years, the role of subspecialties in internal medicine has expanded. Many procedures, which were previously under the purview of other specialties, have since been mandatory skills to be obtained during subspecialty training. In rheumatology, ultrasound is gaining acceptance as a vital tool in aiding diagnosis and monitoring of therapeutic responses to assisting invasive procedures, for example, intraarticular joint injections.

Ultrasound is an imaging modality that is very operator dependant. The skill of the ultrasonographer can determine the quality of images obtained as well as the interpretation of those grainy images. Even existing grading systems are subjective and reproducibility is suspect. Time constraints during patient consultations can also be a deterrent for busy rheumatologists in performing ultrasounds in clinics.

However, if performed well, it could be a potentially important diagnostic tool. In rheumatoid arthritis for example, early damages to the cartilage can be detected even before any changes in Xrays is evident. Even the microarchitecture of tendons and its surrounding structures can be scrutinised for damages.

Ultrasounds can also be used to aid invasive procedures like intraarticular joint injections. Even a fluid collection of 1mm2 can be aspirated under ultrasound guidance. It can also aid in more accurate delivery of drugs to intended targets, like steroid injections which were previously done blindly.

Would musculoskeletal radiologist be pleased? I think that it will be an opportunity for a greater collaboration between specialties.

Guidelines for musculoskeletal ultrasound in rheumatology

MSK ultrasound in rheumatology

With the hype over this global pandemic intensifying, there appears to be an argument as to what this illness should be called. As the world waits intently for a vaccine to be developed, the only method of containment is isolation. With expected rise in the number of cases, it will surely become more costly and labour intensive to maintain a reasonable tab on the cases and their respective contacts. What then can we expect in the coming months?

The origins of this strain of influenza A (H1N1) is still relatively unknown although it closely resembles those found among pigs. It is clearly a mutated strain. Fortunately, the virulence of this virus is low as compared to their cousins, the bird flu or the SARS virus. Most confirmed cases are usually well and might have recovered even without the aid of Tamiflu. Why then are we concentrating our healthcare resources on a ‘mild’ virus?

My belief is that previous deadly encounters with firstly the SARS virus and then the bird flu, has made Asian countries extremely sensitive to such viral outbreaks. The consequences of inaction is no longer acceptable to the general public. Therefore, Governments have taken a cautious approach lest they be accused of being lackadaisical. I prefer to belief that this ‘real life drill’ could be paramount in our future responses to more deadly air borne viruses.

The virus is bound to spread further and the numbers of confirmed cases is expected to rise. Our actions of containment appears only to delay the inevitable. It is hoped that with increasing infections, the global community will develop a herd immunity towards this virus. Until and unless, a vaccine becomes readily available, our strategies only appear to be surmountable barriers for the virus.

Our only prayer is that this virus will not mutate into a more deadly virulent strain that could then inflict high number of casualties.

A H1N1 variant of the influenza virus which started from Mexico, and now suspected of spreading to the United States, has potential for human to human transmission. Although the mortality is reportedly only 1-3%, dozens have died in Mexico.

Our Health Minster has directed screenings and checks at our entry points especially those from Mexico. How or whether it has truly been enforced is left to be confirmed. Mock preparations by hospitals from previous H5N1 scare might come in useful. Hospitals must strengthen their protocols and all doctors, nurses and paramedics must be well versed in wearing the Personal Protective Equipment.

Useful resource
CDC
WHO

Recent problems with IV access in patients with dengue shock syndrome has brought to light interosseous(IO) access, even in adults. Unfortunately, unlike in pediatrics, the expertise of inserting IO lines among adult medical staff is lacking.

IO access was first researched among military personnel especially during combat situations, where IV access may be difficult. It has also been advocated during pre-hospital emergency care when iv access is difficult.

How much fluids can we run into the marrow cavity in adults? What are the complications of such a procedure? Are there better alternatives?

IO lines are not advocated more than 24 hours, during which time an IV access is preferable or a new site of IO is made. The risk of infection in prolonged IO access is a concern. Getting the needle into the marrow proper in adults can be difficult as the marrow has contracted in most long bones. Improperly placed IO lines can pose more problems. Insertion of IO lines can be very painful and sedation will be necessary. In the context of shock, sedation may not be ideal. On most occasions, the patients would have to be artificially ventilated first. Moreover, IO sets are reportedly expensive.

Alternatives are centrally placed lines or a venous cut-down. Unfortunately, these procedures require time to be inserted, a luxury not available in must resuscitations.

So should IO lines is advocated in our patients especially those with dengue when an IV access is not available?

A decent into a calamitous ward, which was thought extinct after years of progress. Beds stacked beside each other like sardines in a can, where the stench of sweat from one patient could make the other puke. A place where nurses and medical officers scramble to ensure a decent level of service in a land that prides itself with its majestic twin towers. A hospital which is supposedly one that will treat its royals.

But surely the royals will never ever see the dehumanising condition that its subjects are dealing with. No, there is a plush haven for them, tucked into a quiet corner, where even the decor has been meticulously chosen. Its residents are always afforded personal attention by the higher echelon, ensuring a quick delivery of service.

Sadly, those not lucky enough to be born with a silver spoon, will have to make do with decrepit conditions prevailing in normal class wards. A daily statistic that clearly proves that they are functioning over its maximal capacity. Compounded by shrinking budgets, the direction of progress is sadly in the reverse. Administrators appear contented and solutions are extinct.

Alas, a new leader but an old face. A machinery that looks weary after decades of underperformance. An energetic display that is likely to fizzle out as we battle the economic storm.

The reality remains as I step into a ‘battlezone’ where lives are saved and lost, where the camaraderie of patients are respected, and young comrades are thrust into a surreal reality of our medical wards.

God help us all.

From Star Tech,

The medical advisor on your wrist

SERI KEMBANGAN: Applied research organisation Mimos Bhd is working on commercialising a medical semantics application on a wrist-watch-sized computer which was developed at its labs over the last six months. continuing story..

Call me a sceptic, but I fear that this device will only be a failure and did not even deserve a mention in the first place. The article claims that, as medical interns, or commonly known here as housemans do not have enough guidance, this wrist device is to act as a substitute for professional medical advice. Punching in data about the patient will churn out a diagnosis in a flash. Wow, any doctor’s dream machine? And so it appears.

Why would anyone even bother to create a device that obviously will remain flawed to its very core? Unless they could replicate mechanical human-like processes, making an automated diagnosis will forever be viewed with suspicion by both doctor and patient. At best, the computers can assist in making a list of possible diagnoses especially when there is a diagnostic dilemma involving rare disorders.

To suggest that a junior doctor rely on such a tool is not only dangerous but negligent. Harnessing one’s acumen in making a correct diagnosis is an art that cannot be replaced by digital technology. It can be a tool in assisting doctors but any suggestion for replacing a human touch is downright irresponsible.

Would anyone put their lives in the hands of a medical device worn by an incompetent doctor? This innovative technology can be put to a better use.

Housewife sues hospital, govt for RM5mil
By EMBUN MAJID

ALOR STAR: A housewife is suing the Government and the Sultan Abdul Halim Hospital for more than RM5mil in damages for alleged negligence that resulted in her suffering chronic kidney failure.
K. Hemalatha, 31, from Taman Sutera, Sungai Petani filed a suit at the Alor Star High Court Registrar Office on Monday.
In the suit, Hemalatha has named the Sultan Abdul Halim Hospital director and the Malaysian Government as the first and second defendants respectively.
She is seeking RM55,557.30 in special compensation, RM5mil in general damages and exemplary compensations, and other relief and cost deemed fit by the court.
In the suit, Hemalatha claimed that she suffered from chronic kidney failure due to the negligence committed by doctors who attended to her when she delivered her fourth child via the Caesarean section on July 11, 2007.
She claimed that the doctors had failed to conduct the necessary tests and diagnose her condition before the surgery.
She also claimed that the doctors had failed to make abdominal and renal evaluation to identify the correct stage of her renal failure before the surgery was performed.
Hemalatha further claimed that her stomach became bloated and she had difficulty in breathing the following day (July 12) after the Caesarean section was done.
She was told by a doctor who examined her that she had internal bleeding.
Hemalatha claimed that she was operated on for the second time on the same day and an ultrasound performed on her later showed that both her kidneys had shrunk.
She claimed that she then underwent an ultrasound at a hospital in Penang on Aug 28, 2007 and was told that both her kidneys have failed to function and she has to undergo dialysis treatment for the rest of her life. She is now under medication.

Much information has been left out in this article and it would be unwise to comment on the rationale for this suit.

However, I find that the press should not highlight litigations when it has yet to be brought forward to the courts. This move deflates confidence in the healthcare system and does little justice to those who have been working hard to maintain a good quality of healthcare. It passes unfair judgements to those involved.

My recommendation to the press is that they should thoroughly research the facts before putting it on paper.  Many litigations are done without proper grounds. Highlighting each and every one of them will certainly tarnish the image of healthcare in Malaysia. They should have an independent panel of doctors to decide the factual basis of such allegations. Criteria for publication should not be the inflated sums of money to be contested.

As of now, the only reason for such a press report is to sensationalise a topic that often times tickles the sensitivities of many, making them a good read.