Tuesday, January 13, 2015


Sometime in Nov 2014, I met up with YB Tony Pua. In the midst of discussion on other matters, he discussed their Impian Sarawak program. My patient form Sarawak has also given me a feedback that this Impian Sarawak program by DAP has caught the eyes of the Sarawak state government. YB Tony suggested if we doctors would be interested in running a healthcamp in the interior of Sarawak. The answer is of course a big YES. We have always felt that without the support of the people of Sarawak, it would be almost impossible to change the tenant at Putrajaya. It is in this light that I began working on this project. The understanding was that DAP will be our logistics partner as they have a set-up in Sarawak that can help facilitate the organisation of the Camp.
         Following the meeting with YB Tony, I met up with Dr Steven Chow ( President FPMPAM ) and he also was in support of the idea. He agreed that we could use the FPMPAM-CARE banner. I began recruiting doctors and raising funds. God was kind. I managed to recruit 10 doctors of various specialties, including 2 GPs. There were also 7 nurses and 1 administrator. One of the doctor will double up as our official photographer. We intend to capture this event, both for our sponsors sake and also for FPMPAM branding sake.

 It was heartening to see support coming in from many well wishers. Some doctors donated drugs. Someone donated 1,000 tooth brushes for the residents. I had to buy about RM 12K of drugs ( we will have a rather large pharmacy ). The DAP have managed to organise for us to work in the Bawang Assan, Sungai Aup and Bintangor area. It is YB's impression that we will be seeing 300-400 patients a day. The camp dates are 19-21st January 2015.
          Coming along with us, is a senior dermatologist, a dental surgeon armed with a portable dental chair, adequate to perform dental extractions if necessary. The ophthalmologist is equipped with a slit lamp and tonometer to do full eye examination and screening. There is a senior OG with an abdominal ultrasound scan. We also intend to offer breast examination screening for breast cancer. Sounds exciting.

       Wish us well please. It is my first time in rural Sarawak. I have always been to Kuching and surrounding.
       Organising this project has kept me busy over the last 1 month.
       If what YB Tong and YB Oscar estimate is correct, I may also take this opportunity to do a rural health survey of the rural Sibu area.

Well, lets see how it goes.

                                                     MY APOLOGIES.
                                                       MY APOLOGIES.

Friday, January 02, 2015


In my reading, in between all the other "rubbish" that I am doing, I came across this very interesting article about Medicine in the future. Of course, this thought provoking article is by non other than Dr Eric Topol. In his younger days, he was a learned Cardiologist ( often, a rather controversial one ). But in his senior years, he has taken on a role of senior physician mentor, and where medicine is going as we head deeper into the 21st Century. I must say that I agree with many of his thoughts and in particular, this article on " Doctor let go!" No he is not writing about terminating care in a critically ill patient or "NFR ( Not for Resus.) situation.
Doctor let go, challenges us doctors to let go of some of the sacrosanct areas of medicine, that we all hold so dear to, from our undergraduate days. There are 3 important areas to let go. Even if you do not want to let go, the patient will make you let go.

1. That doctors know best about my health. Doctors use to think that when patients visit them, the doctor does all the examinations ( tests ) and tell the patient the data. In this day and age, that is not necessary any more. There is a growing trend of " Patient Generated Data ( PGD ). Good examples are home BP monitoring, glucometer readings, exercise monitoring, weight monitoring, etc etc. Patients have learned to handle these facts, and also learn to understand them.  If you care to teach them, fine, if not, they will just "google" and search the "net". Doctors no longer have the monopoly of patient data and information. Doctors must learn to empower patients, share management strategies with patients, thereby getting better cooperations, complaince and better outcomes. Keeping patients in the dark is no longer an option. Doctors "must let go" of the monopoly to their knowledge about a patient. He must be prepared to discuss using PGD.

2. This is the I want what I want when I want in century, or "IWWIWWIW" century. This is the age of instant culture. I want an opinion now. I want to see you now. I want it at my convenience, not at yoyr ( doctor's ) convenience. This will be further enhance by telemedicine, so that patients can do a virtual consultation, without a physical consultation. Even in my small practice, I see more and more of these. Patients have my email, and they will email me complaints and lab  reports and ECGs. So doctors, you "must let go" of your convenience.

3. The third is most clear cut. Doctors "must let go" of the privacy of the patients case notes. The case notes is about the patient, is paid for by the patient, so it belongs to the patient. Sure, doctors can keep a copy, but when requested, doctors must allow patient to have a copy. Either you do it willingly and nicely, or you allow the patient to insist, with all the other consequences to you. Hospitals can have their recods, you can have yours, but when requested, patients also have a right to their revords. So becareful what you write there.

Interesting ideas. I believe that these issues will get more prominence as we move further into this decade.
                               HAPPY NEW YEAR 2015
                               to you and all your love ones too.

Tuesday, December 30, 2014


It is important that specialist, whether cardiac or no cardiac, attend medical conferences to update themselves. This is a continuous process that occurs every year, or else, as medical science advances, these specialists will be left behind, out dated. Yet, these specialists or super specialists have patients who may need their help. What happens to these patients should they fall ill when their specialists are away on conference?
Interesting question.
There is a paper out in the Dec 22nd issue of JAMA Int Medicine to address this question. Dr Anupam Jena and coleagues from Mass General, Boston, working in conjunction with RAND corporation, California, looked into this issue. Their paper is entitled, " Mortality and treatment patterns among patients hospitalised with acute cardiovascular conditions during dates of National Cardiology meetings". This is a retrospective analysis of Medicare database.The two cardiac meeting chosen were the American Heart Association Annual Scientific meeting ( year end ),  and the American College of Cardiology, Annual Scientific Meeting ( year beginning ). They study patients records on admission ad discharge and 30 days mortality, for 3 periods, period 1, the 3 weeks before the Meeting, 2. The period of the meeting, and 3 for 3 weeks after the meeting. They screened all admissions for AMI, Heart Failure and Cardiac Arrest, and their 30 days mortality and also their revascularisation rates in the case of AMI.They further divided the data sets into high risk and low risk admissions, and also examined the data from teaching hospitals and non-teaching hospitals separately. Quite comprehensive, I must say. However, this is still a retrospective study.

The results show that for Heart Failure and Cardiac arrest, the overall 30 days mortality was better in the meeting days ( when specialists are away ) than on non-meeting days, especially in the high risk group. There was no difference in the low risk group. As for AMI, they found that there was no difference in mortality between meeting days and non-meeting days, but there was a higher rate of PCI during non-meeting days, meaning that the specialist did more procedures when they were around and yet showed no difference in outcome. As for the low risk group, there were essentially no difference between meeting and non-meeting days, and also teaching and non teaching hospitals.

Interesting. How do we explain this? Does it mean that it was safer with no specialists around? Were they doing more PCIs than the needed to, with no difference in 30 days mortality. Was it that when specialists are away, the staff left behind were more hardworking and conscientious? Or that doing more procedures in AMI did not improve outcome and all the other AMI studies need to be relooked?

There is probably some truth in all the above arguments. I suppose, one thing that we can all agree on is that this is a retrospective study, that there are deficiencies with retrospective studies. However, it does make us ponder. Perhaps this question of "too much specialised cardiac care" may not be doing more good that good average standard care. Or are we doing more and getting less outcomes? Is industry making us do more, just for business?

Interesting thought.

                     HAPPY NEW YEAR 2015
                     to you and all your love ones too.

Monday, December 15, 2014


I spend my weekend in Ipoh to conduct the ICF 2014, at the Kinta Riverfront Hotel.
The meeting went very well. It is now essentially an ASEAN Interventional Forum ( just that we did not seek to glorify it that way, although we were suggested to. Besides the 50 Malaysian Interventionist who were there, we had 11 Thais, 4 Indonesians, and 2 Singaporeans with one Indian ( Dr Kirti, who is our Faculty member ). The faculty had 1 Indon, 1 Indian, 1 Thai and 2 Singaporeans. So we had an attendance of about 70 doctors and about 15 sponsors ( a total of about 85 people ). Over the one and half days, we reviewed about 40 cine angiograms and PCI, show casing cases from India, Singapore, Thailand, Indonesia and Malaysia. It was a truly wonderful small meeting of minds and sharing of ideas.
Undoubtedly, the scientific program went well, and many are asking about the next one. It was heartening to note, over the last 9 years ( this is our 9th meeting ) that the standard of angioplasty has improved in Malaysia. There are now more instruments and devices being used to treat our patients, and outcomes are getting better. Looks like the Malaysian operators are also getting more skilful. The other obvious fact is that the presenters of the cases have improved. The cases all went smoothly with minimal time wasting, and the presentations were well done. In fact, in closing, I encourage them to take their cases to the next level so that their good work can be appreciated. It is true that we are still a minor step behind the Thais and a step behind the Singaporeans, but we are getting there.
The problem that I face was the meeting venue. Ipoh is a very nice town with good food, that is still cheap. But there is a lack of good hotels. I choose Kinta Riverfront out of no choice, as I needed a hotel that will cater for 100 people and also a conference room that can hold 100. There are non. Kinta Riverfront was the closes fit. But although Kinta Riverfront is but a few years old, the service is terrible. The staff was reluctantly cooperative. My room had a door lock that was not functioning well, and a bathroom facility that was broken. How can for a 5-star hotel. One the last day, I was looked out of my room. The food is so so. The buffet spread for breakfast and dinner was basic.
No lah. Not Kinta Riverfront again. I hope that the hoteliers will out up better Hotels in Ipoh, when Ipoh bloom and get richer.
Anyway, as the intellectual discourse was good and gratifying, I will not allow Kinta Riverfront Hotel to get me down.
I was most happy, to see the young ones come up and they are getting better. I shall rest easier. Our job is half done.

Friday, November 28, 2014



Healthcare should be GST-exempt as promised in 2013
Kuala Lumpur, 27 November 2014 In response to the statement from the Minister of Health, Datuk Seri Dr. S. Subramaniam, that not all drugs will be zero rate, the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) calls for the Government to assess the GST implications for healthcare and fullfill its pledge made in October 2013 on the Budget 2014 that both public and private healthcare services will be GST exempt.

On October 10, 2014, at his Budget 2015 speech, our PM further added that medicines on the National Essential Drug List (NEDL) would be zero-rated thus giving the impression that the sick who are already burdened will need not be further burdened by additional tax for what is needed to treat their illness.

However, the guidelines and many briefings by the Jabatan Kastam DiRaja’s GST team now tell a different and rather complicated story.
1.        Not all medicines (including many essential ones) will be GST-exempt.
Patients and the public may not be aware that the NEDL is not the complete pharmacopeia or Wish List for treatment of all the important diseases and all its complications.
Of the so-called 2900 items on the NEDL, there are actually only 208 different medications. Many of the 2900 items includes repetitions of various preparations (different brands) of the same medications.[1]
Imposing GST on the many essential medications that are not on the NEDL will increase the cost of treatment and will be a burden to the sick. Prior to GST all duly registered medications were exempt from sales and service tax, in other words, zero percent. With the impending GST the cost of all these medications have already shot up. It will go up further when the cost of administrating the GST is passed down the line. Even patients from the government sector who require these medications will end up paying more.
Treatment using the restrictive NEDL will be cause a fall in productivity, with increased sick-leave due to dissatisfaction, morbidity and mortality arising from use of, and change to different medications, or patients' choice to forego medicines due to increased costs.
The Federation urges the Government classify “Zero-rated” on all duly registered medications (Schedule Poisons Group B & C) including clinical disposables and essential treatment items like stents, prostheses and to immediately form a broad-based panel to review the deficiencies and inadequacies of the NEDL.
2.             Healthcare services including surgery and procedure fees provided by doctors in        private hospitals will incur GST [Ref: Royal Malaysian Custom GST Guidelines on      Healthcare Item (12)]
For healthcare provision in private hospitals, it is clearly stated in the above that GST exemption is only for services provided by doctors employed by private hospitals/private healthcare facilities.
This is a major mistake.  The majority of the doctors especially the specialists in private hospitals are not employed but work as “independent contractors”. The situation is made even more complex with the many different individual versions to this legal concept of “independent contractors”  in different private hospitals and the existence of multiple layers of middle-men agencies like MCOs, TPAs, and insurers etc. collecting and processing fees before payment is finally paid to the hospital and only subsequently to the doctor. Each transaction at each level is fraught with GST implications and complex computations.
With this complicated scenario, imposing GST on private doctors’ consultation, treatment procedures, surgical and other essential treatment fees will not only be administratively costly and complicated but will also escalate the cost of providing private healthcare generally.
Patients will end up paying significantly much more next year for the same treatment. The multiplier effect will have a major adverse impact on the national expenditure on healthcare.
3.         Other Ancillary items for operating a clinic are also not exempted.
The other ancillary items in the running of a private clinic like medical indemnity insurance, utilities, rental of clinic space, servicing, leasing and rental of medical equipment  including other non-medical professional fees will also incur GST. Accountants have already informed doctors that if GST is imposed on medications their accountant’s professional fees is expected to increase 50% to 60% due to the increased work because of its complex structure.
4.         Healthcare needs more help, not more taxes
As a non-subsidized, self-paying provider, the private sector is already taking a major load off the public healthcare system. Even at this time, the public healthcare system is already not able to cope with the present demand for medical care despite the fact that a substantial load of out-patient primary care is being provided by the private sector.
It is not true that patients opt for private care because they can afford it and hence should pay GST. The fact of the matter is that the long queues and waiting time in public facilities is a major reason why many choose to opt for private care. They need to get well fast so that they can go back to their jobs and be productive.
The private doctors are already severely burdened by the administrative provisions of the PHFS Act 1998/Regulations 2006. GST imposition is a further burden and a distraction from the basic objective of providing affordable, accessible and quality care.
GST for healthcare in its present form is an administrative nightmare and financial burden to the provider as well as the recipient. Healthcare is a basic right of every rakyat. No Rakyat chooses to be sick and if they do become sick, taxation should not be imposed on an involuntary condition.
We hope the Government will abide by the PM’s pledge and implement GST exempt across the board for healthcare services as promised in October 2013. The Trust of the Rakyat must not be breached.


[1] We must note that the World Health Organisation has two EDL one for adults and one specifically for children. After combining both lists and eliminating replications, there are 359 medications (by generic names) in the WHO EDL compared to our Malaysian NEDL which has only 208 items. Our NEDL has 151 medications less than the combined WHO EDL notwithstanding the fact that the WHO list has only 6 medications which is specifically for diseases (African trypanosomiasis & American trypanosomiasis), which is not common in Malaysia. Thus there are major deficiencies in the Malaysian NEDL.
If one looks closer our NEDL is clearly not designed to cater for all the important diseases and complications of the various disciplines of primary and specialist care. Specific treatment for many common diseases are not in this NEDL.

Tuesday, November 25, 2014


We use to advocate that the ER ( Emergency Room ) or pre-hospital phase on management of Acute Myocardial Infarction should begin with MONA, an acronym which allows junior doctors to quickly remember what should be done. MONA stands for Morphine, Oxygen, Nitrates and aspirin. Well over the course of the last 10 years, we have seen the use of "nitrates" being challenged. Some say that nitrates may help, white others say that nitrates may harm, because nitrates may divert much needed blood from the vital infarcted segments to the more normal segments because of its unequal dilating properties for normal vessels and atherosclerotic vessels.
Well the "O" in MONA is also under attack now. A paper presented by Dr Dion Stub, formally of Monash Australia, presently of the St. Paul's Hospital ( Vancouver ), at the just concluded American Heart Association Annual Scientific Meeting, Chicago, seemed to show that giving O2 to people with normal O2 saturation post chest pains, may do more harm then good.
Dr Stephen Bernard ( lead investigator ) and group ( 9 hospitals in the Melbourne area ), studied 441 patients with STEMI. He divided these patients into the O2 group and the no O2 group. All of them ( inclusion criteria ), had suspected STEMI with chest pains of not more than 12 hours duration, and relevant ECG and enzyme changes. They all had O2 saturation ( by pulse oximeter ) of >94%. This was deemed as the normal. 218 of these patients received O2 at 8 L/min and the other group of 223 patients received room air ( avoid O2 ). This study was called AVOID ( Air Vs Oxygen in STEMI ). The primary end point was infarct size as measured by cardiac enzyme, and secondary endpoint was infarct size estimation by cardiac MRI. All of them upon admission received primary angiopasty.
At the end of hospital stay, those receiving room air ( avoid oxygen group ) has lesser CPK enzyme rise when compared with those receiving O2. There was no difference in mortality and morbidity endpoints, as the study was under powered for that. The 6 months cardiac MRI also showed that those receiving O2 had larger infarct size when compared to those who received room air.
What could be a possible explanation?
The theory is that after 15 mins of O2 at 8L/Min, the blood becomes hyperoxic. These will cause changes in the coronary microvasculature which may become vasoconstricted because of the instant hyperoxia.  This will increase free radicals in the infarcted zone, and the bottomline is that infarct size may increase.
Caution is required here as this study is small and there are studies showing that administering O2 cause no difference.
For the moment, the jury is still out on routine oxygen therapy post STEMI. Most of us will reflexly give it. Those who forgot to, now have some evidence to back them.
As for MONA, well we may end up with MOA or even MA.

Monday, November 24, 2014


I was at the Mkini Open House on 22nd Nov 2014, amidst a pouring rain. It was a small struggle getting there because of the rain and I also had some difficulty finding the place as Jln Tandung was not my usual haunt. Anyway find it I did after a couple of U turns. Arrived there at about 5 pm.

Nice place. Big multi storey building. I have never been to  a press center before, but they look fairly well equipped. Plenty of laptops al over the pace a some staff was working. Some visitors were going "on air" in one of the staged room. The crowd, well at 5pm was sparse, and the rain was a dampener. I am sure that it was larger once the dragon dance can and the entertainment began.

After finding my "brick" and those of a couple of my friends, and after a self tour of the whole building, I decided to leave. Took a drink and then left at about 6pm into a severe traffic jam along Fed Hwy. It took me a hour to get from the Jln Templer traffic light to Subang. When I reach the Subang entrance, I discovered that the whole Fed Hwy was closed at the Subang exit. Now I know, it was because of a new landmark in Subang, called " the leaning LRT beam of Subang". What kind of contractors do we have in Malaysia. After so many deaths and accidents, ( with instant promises of no repeats after each incident ), we now have the leaning LRT beam of Subang. When will we ever learn.

I could get home with the relatively minor detour, to USJ, but I pity the Klang folks who were not so conversant with the detour routes. The crude signage just say ( arrow pointed left ). So the Klang foks have to find their way to Klang either through Subang ( free tour of Subang ) or through the old airport road. There was no signage to help them.
This is Malaysia. Malaysia Boleh.

Thursday, November 20, 2014


This statement was send to Star yesterday, as letter to the editor. Let's see if they will print. I am very concerned that the Custom's Dept have no clue as to the workings of the private doctors. While public hospital supplies and services are all zero rated, 1-2% of private healthcare supplies and services are zero rated, and the bulk ( 98% approximately ) are standard rated. The PM's call for Healthcare to be exempted ( in a very broad term ) we know now to be a farce and simply untrue.

The YB MOH announced last week  that not all drugs will be zero rated. In fact, a quick calculation revealed that probably less than 10% of commonly used drugs will be zero rated. Following  the numerous briefings , seminars,  Q&As, notes, documents and meetings with Customs Department, a few things are very obvious in this GST for Healthcare due for implementation about 6 months for now. Firstly, that Customs Department did not realize how many types of disciplines and categories there are in Healthcare. They must have thought that there is a doctor who sees patients and  who charges patients. Little did they realize that there are GPs, family physicians, specialists in solo practice, specialists in private hospital practice, etc  etc  etc. Secondly, it is also fairly obvious   that Healthcare is GST exempt means that only the doctors consultation fees is GST exempt. Not his fees for surgery and procedures, not 90% of his medications, not his professional indemnity fees, not if hospital collects the fees for the consultant ( which is the majority of the private hospitals ). Since that is what the government wishes, and since doctors have family and responsibilities he will have to increase his fees to cover whatever GST will take away. I am sure that the private hospitals will do the same.
The sum total being, healthcare cost will surely rise. It is only the quantum of rise that is yet unknown.

In order to avoid this, we call upon the government of Malaysia, to make Healthcare GST zero rated all along the supply and service chain. If that is not possible, then be prepared to face a severe rise in Healthcare Cost for the patients come 1st April 2015. It may be best to shelve this GST all together, until proper studies are done and the customs understand the working of private healthcare system.

The public must wake up. and take the government to account.

Tuesday, November 18, 2014


Please come and attend this 1MDB public forum. See what Rafizi and Tony Pua have discovered.. I understand that Dr Mahathir is speaking too.
Tomorrow night at THE CLUB, Bandar Utama

Monday, November 10, 2014


The Election commission has announced that they intend to table in Parliament the new electoral boundaries for GE 14  However, they would not allow Tindak Malaysia or Bersih to have copies of the new electoral boundaries, even if they wish to pay for it. Just to make it difficult, these new maps will be presented to Parliament and placed in the various constituencies where they can be viewed. There is no soft copy.
So both Tindak Malaysia and Bersih have launch a campaign to look for volunteers to form groups of 3-4 people, to visit all the electoral constituencies and physically take pictures of all the new maps and bring them back to HQ, where they can be studied to see where the Gerry Meandering is so that we can go to court to dispute the new boundaries. All these work within 30 days.
This is all in line with the Federal Constitution.
We must uphold the Federal Constitution, especially 13th Schedule.
We need volunteers who can spare 3 days to help do this work. It helps if you have a driving licence and is good at photography.

If you are interested, please contact me at

Thank you. In any democracy, we must have clean, free and fair elections.