Tuesday, August 14, 2007

YB MOH on specialist medical care

A national daily carried a report, quoting YB MOH, saying that there were specialist who were taking care of patients outside their areas of specialization. It would appear that the YB was ill-informed about what a medical specialist is and how health care should be delivered.

Doctors commonly acknowledge that there are three areas of medical specialization after a doctor has obtain his MBBS. Should he wish to specialize, he would decide on whether he wishes to specialize in a medical discipline like internal medicine, or paediatrics. These are the two broad medical disciplines and the doctors then sit for the MRCP, Master of Medicine, or some such equivalent. He or she is eligible to sit for this exam usually 18 months after graduation. Should he pass, then he is allowed to go into that area of specialist training. Having undergone a broad based training in internal medicine or paediatrics, usually a year or two, he can sub-specialize into the various sub-specialty like cardiology, neurology, nephrology, endocrinology, gasteroenterology, dermatology, etc.

Similarly in the surgical disciplines. They initially sit for the FRCP, Master of Medicine (surgery), or their equivalent. Upon he or she passing the exams, they then undergo specialist training, in the broad field, before specializing in their sub-specialty, like neurosurgery, urology, hepato-biliary surgery, cardiac surgery, etc. So also for orthopedic surgery specialty, or obstetrics and gynecology disciplines.

In short, all specialist have a broad base specialist degree like the MRCP and FRCS, and so can handle common medical or surgical diseases at a specialist level. Of course, if he finds that the disease is more complicated than initially realised, it is incumbent upon him to consult with his colleagues who may be better trained in that sub-specialty, ie a complicated cardiac problem needs a cardiologist, and a complicated neuro problem needs a neurologist.

In the MOH hospitals, common medical problems like dengue fever and renal failure are handled by a medical officer first, who may then refer the patient to an internal medicine specialist, who, if he or she cannot cope may refer to sub-specialty like cardiologist, neurologist nephrologist, etc. These are all established protocols of medical practice.

The three examples given further illustrates the point. Dengue fever, in the common form, comes under the care of the medical officer, and internal medicine specialist (even in the MOH hospitals). When the patient does not respond to the treatment regime, the specialist may refer the patient to a sub-specialist. This is often done. Sometimes the disease progresses so rapidly, that there is hardly enough time to assess the patient adequately and refer. So the details of the case becomes important to establish mismanagement.

It is useful to note that auto-immune diseases commonly present themselves as renal disease as auto-immune disorders often affect the kidneys. Therefore to say that nephrologist cannot handle autoimmune problems is to show ignorance. As for the third case mentioned, it is well established that one of the medicine used for stroke prevention by neurologist is aspirin, which can cause gastric upsets. Therefore, sometimes neurologist too have to manage patients with gastric upset because of the aspirin used.

Dr Chua Soi Lek, is a qualified MBBS. I am sure that he knows that. But this issue of General Internal Medicine specialist looking after common medical problems and when to refer, is an ongoing debate. It is not as straight forward as the YB MOH make it out to be. Surely, to advise patients to sue the specialist is just irresponsible. He should advise the patients to file a complaint to the hospitals concerned so that the cases can be thoroughly investigated, and if there is wrong doing, appropriate actions should be taken. The rising cost of healthcare in developed nations is largely due to excessive litigation against medical practitioners. Doctors then have to pay more for medical indemnity and "lawyer up" unnecessarily. Guess who has to pay for all this.

Can the YB MOH imagine a situation where a specialist sees a common every day "dengue fever" problem and refer the patient to the infectious disease specialist (viral infection), the blood disease specialist (low platelet count) and the cardiac specialist (fast heart beat with the fever), the bone specialist (aches and pains), so that the specialist can be absolutely protected. Is that what YB MOH wants for healthcare in Malaysia?

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