Monday, August 27, 2007

To write or not to write

I read an article in the Star titled "Patients need right docs" which quotes YB MOH. At that time there was an urge to fire off a letter to the editor. If anything one thinks I should still send it off, please leave your comments.

The issues discussed in the article was whether there is such a thing as a right doctor or a wrong doctor and whether the patient is better of seeing the wrong specialist as opposed to a generalist.

The debate is very relevant to modern day medical practice. What is a generalist, a specialist, and a super-specialist. Equally relevant, at which point of a country's development journey is this discussion taking place. I agree whole heartedly that specialist should not manage patients out of their specialty, BUT there must be a caveat, when there are specialist in that specialty around. YB MOH may do well to remember that there are many medical specialties (and medical specialties are growing by six monthly to a year) in Malaysia, where there are literally a handful of specialist around. Before I go on to the controversial Nephrologist-Dengue Fever problem, let me also say that in patient management, especially MRCP neurologist, managing a complex neurology problem, there must be some flexibility for him. After all, we cannot insist that all strokes must be seen by a neurologist?

Many MRCP specialist in General Hospital take care of the "bread and butter" strokes. If all strokes were to be referred to the Neurology center in KL then, firstly, the Neuro center cannot take care of more urgent neuro problems that require their neuro expertise. There must also be some flexibility for a MRCP specialist to manage a case. He must be allowed to exercise some discretion, as to when to refer, and we must trust that he will (in good faith).

Now to the Nephro-Dengue issue. Let me begin by saying that we are all very sad that a patient died. As doctors, we are always sadden when our patients die, for whatever reasons. The YB MOH probably has investigated the problem, as he has some details of the case. I can agree with him that keeping a dengue case under your care for 2 weeks is a little unusual.

A dengue fever case can be managed by a MRCP nephrologist. A dengue fever case managed at the Nephrologist level, should get well enough for home in 5 days to a week (straight forward case), or even sooner sometimes. Otherwise, the nephrologist should begin to realize that things are not going right and that a second opinion from an Infectious Disease specialist (if one is available) should be solicited. That judgment call (when to refer) is really up to the Nephrologist. Just as YB MOH is keen to know why he did not, so are we, in the medical community.

I feel that we should not apportion blame, but investigate as allowed under the new PHCFS Act, into the facts of the case, and also allow the Nephrologist to defend his actions. This airing our opinions over the press is not good. While the YB MOH is right in the initial comments, he seemed to have forgotten that there are but a handful of infectious disease specialist in Malaysia, and certainly many, many handfuls of private hospitals. Not all private hospitals have infectious disease specialist. It is very likely that that private hospital may not have an infectious disease specialist. To refer the dengue patient, who is so sick, across to another hospital, also has its problems.

Does YB MOH wants to set a rule that all dengues must be attended by an infectious disease specialist? Let him first consult his DG and see if it is feasible. He will quickly find that his General Hospitals will be so full that they cannot take care of other patients. We are a developing country trying to train more specialist. In our context, he must understand the Nephrologist's dilemma.

Also, perhaps YB MOH was misquoted when it was reported that he asked the patient to sue. That must have been an oversight. Suing doctors will only increase health care cost. Not necessarily help the patient's family. In the interest of time, I will not go into that now. Maybe he meant that he will look into the matter and ask the hospital involve to undertake a thorough investigation and report to him within two weeks as allowed for by the PHCFS Act. He has the power to take the appropriate action. Study the matter first, consult with his advisers and then take action. Certainly fighting with the Medical community through the press, is so un-polish. No class. Perhaps, it was all just political rhetoric after all.

1 comment:

Hua Jern said...

Most govt hospitals do not have ID specialists. MOs are treating DF (often competently I might add), and MRCP specialists in the larger district and state hospitals. Often, there isnt a single ID specialist in the whole state.
Lets not get into the other disciplines.