SHOULD I TAKE MULTI-VITS,DOC?

As a medical practitioner dealing with cardiac diseases, I am often asked by my patients if they should indulge in multi-vitamin tablets as recommended by their friends, relatives, or other agents selling them. My answer has always been that you can take it. It causes no harm, I think. I am also quite sure that it does do not much good. Taking a balanced diet is just as good, if not better.

The recent publication by a group of researchers from Copenhagen, lends me some support. They studied some 233,000 subjects, some with disease conditions and most who are healthy. It was a meta-analysis (we all know that meta-analysis cannot be conclusive) of 67 studies (having screen through 870 studies) and concluded that those who were taking multi-vits (including vitamin A,C,E and selenium supplements) were not helped, and may be harmed by the seemingly innocent multi-vits. I am sure that this meta-analysis will not put an end to the billion dollar health food industry, but it at least gives me a basis to say that there is no conclusive evidence that health supplements help.

I do not see anyone doing a conclusive RCT on food supplements, so perhaps, I will never know the answer. I used to be a firm believer of the late Prof. Linus Pauling (I respect that man) who wrote that high doses of Vitamin C is good for the body, and may have an anti-oxidant effect, and can prevent cancers and heart disease. Well, I must say that as more evidence evolve, my faith in that theory is growing weaker. Perhaps the subject of oxidative stress and anti-oxidants, is just too complex for a simple one line answer. As for now, I would like to suggest that all of us should take a healthy diet, plant base primarily and with adequate consumption of vitamins and low fat animal proteins. Oh yes, minus the salt please.

HOW TO MANAGE T2DM? DIABETOLOGIST, CARDIOLOGIST, UKPDS, ACCORD, ADVANCE. OH WHAT A MESS.

In diabetes, there is reduce insulin activity either from insulin deficiency or insulin resistance (example, in metabolic syndrome). This results in too much sugar in the blood stream, but no sugar in the cells that so desperately need the sugar to function, almost reminding us of the poet who said "water water everywhere, but not a drop to drink". Naturally, this understanding gave rise to the notion, that controlling blood sugar saves lives. That is by and large true, in some ways thanks to the seminal work done by Dr Best when he discovered insulin. While insulin injections are life-saving for patients with insulin deficiency they are not so good for patients with insulin resistance.

As diabetes treatment developed further, we soon began to understand that it was a very complicated disease requiring a multi-disciplinary approach. Diabetologist (specialist in diabetes treatment) evolved as a specialty. They soon began to realise that patient with diabetes usually die from cardiovascular complications. Yes, those with hyper or hypo-glemia, can die from a direct sugar problem, but not usually, especially after insulin became available and after Prof Alberti taught us how to manage diabetic coma. I dare say nowadays, diabetic coma is a rarity.

Diabetologist soon began to attend cardiology meetings as it became more and more obvious that diabetes may in fact be a cardiovascular disease, and a CAD equivalent. When we began to hold joint meetings, it became rather obvious that we were speaking slightly different languages. In Sept 1998, diabetologist in UK carried out a very important and very large landmark diabetes study called the UKPDS. At that time, it cost them 2 million pounds. It showed that when blood sugars were controlled, cardiac complications and cardiac death, reduced. This was indeed very important fact to know. Sadly, however, all later diabetic studies rely on blood sugar levels and HbA1c level as their primary endpoint. Cardiologist, on the other hand find this very inadequate, as blood sugar and blood HbA1c level is at best a surrogate endpoint. Blood sugars may be well controlled by the drugs that they study, but what is important for us is, did the better sugar level control resulted in reduction in MACCE? When we ask that, they always reply that that was shown in UKPDS. It is very strange that this very cardinal point of diabetes management rely almost entire in one large clinical study. For example, to establish the important position of "statins " cardiologist undertook no less than 6 large clinical trials, across all three large continents, before we are prepared to accept it as infallible truth.

Now comes the problem. Over the Chinese New Year period, the researchers of the ACCORD study, terminated their study prematurely because their Drug Safety and Data Monitoring Committee reported that their intensive treatment arm, had more cardiac events when compared to the standard treatment arm. The ACCORD study, was undertaken to see if intensive sugar lowering was better than standard levels of control. In technical terms, is lowering HbA1c to less than 6.5% better than lowering HbA1c to 7%. Well, the ACCORD investigators stopped the study early because they noticed that the intensive sugar lowering arm, had more cardiac problems. That was bad news and as clinicians, we became very concern, maybe partly due to the fact that one of the drug used in the study was rosiglitazone. And we all know the controversy with rosiglitazone. Well of course, the problem did not end there.

There is currently an ongoing trial called ADVANCE, undertaken in Australia, looking at the same issue, is intensive lowering of blood sugar better than standard treatment? This study was not due to end, but because of the results from ACCORD, the Drug safety and data monitoring committee decide to take a look at their data, without unblinding, and found that there was no difference in cardiac events, despite almost the same level of blood sugar and HbA1c control. Now, we are really confused. Is it the treatment regimes, the drugs and their doses, the population under study, the level of BP control or is it just chance or bad luck? I really do not know. We await the studies to be completed and the data unblinded, or perhaps other data from other studies. How I wish that someone out there will repeat a UKPDS look alike study (if possible not to use rosiglitazone), to help us be sure that lowering blood sugar does reduce cardiac events. Now we are confused, uncertain of our bearings and our yardstick.

International day for evaluation of Obesity

I do not know when the International Day for the Evaluation of Obesity is, but the effort to spot likely obesity is timely. Cardiologists want the world to know that we are all getting too fat too fast. The data for this evaluation apparently is published the latest Circulation. The doctors did get to evaluate about 168,000 people from across the world. They used the BMI and waist circumference. We could always argue about their criteria. But I believe that it is true. The world is getting too fat.

I was surprise to note that there was not as much obesity in South and East Asia. I thought that we were equally bad. Apparently not. I suppose traditionally, we will blame the western diet of fast food and the lack of exercise for the high rate of obesity in Canada and South Africa. Please note that this one day study did not include the USA, which I believe will mirror Canada.

I must add my little voice to this worldwide effort to warn us all to eat more veges and fruits, less salt, more white meat and avoid carbonated drink at all cost. It helps to exercise daily or at least three days a week. Brisk walking will be great. Jogging is fine. About 15 kilometers a week in divided portions. To my simple, senior Chinese patients who do not quite know what 15 kilometers is, I just ask them to walk for about half hour or 45 mins, enough to work out a sweat. The consequences of obesity is all to familiar, diabetes, hypertension, CAD, strokes, DVT, increase risk with all surgical procedures, sleep apnea, etc., Basically, to be fat is not glorious. It is asking for trouble. Do I need to go on? And no, whatever the good genetic professors say, eating too much or eating wrongly is not 100% genetically determined. There is a large self indulging element to this. Let us not blame the genes for our eating too much and of the wrong food stuff too.

Healthcare insurers to register but no action yet against pirates

This appeared in the Star yesterday. Of course, we are coming up to an election and no one knows what the situation will be on March 31 next year. I'm quite sure this will happen if elections are not held yet by March 31, otherwise, it's anyone's guess.

We've spoken about limiting healthcare and medical ethics on this blog before, note that although insurers are being asked to register, no action is yet being taken to discourage future attempts to tie the hands of honest doctors or to remedy the damage already done by pirate firms profiteering off the lifeblood of their subscribers.

Healthcare insurers must register

All insurance companies providing healthcare facilities must register with the Health Ministry by March 31 next year.

Minister Datuk Seri Dr Chua Soi Lek said the companies should not think that they were not regulated by anyone except Bank Negara.

“Bank Negara deals with the financial regulations."

“But all health and health related matters come under the Health Ministry, including insurance companies which provide healthcare facilities,” he told the press after launching Vamed's 20th anniversary celebrations here last night.

He said all healthcare providers were regulated under the Private Healthcare Facilities and Services Act 1998 and doctors by the Medical Act 1971.

“This is a warning. If they do not comply, they can be fined up to RM500,000."

“Hospitals that provide healthcare to patients through such insurance schemes must also register with us, or they can be fined up to RM300,000,” he said.

He added that he was “not happy” with recent cases of insurance companies that “arm- twisted doctors to not only cap their fee but reduce their charges.”

It was recently reported that an insurance company had proposed a new Healthcare Service Provider Agreement, which doctors had claimed was unethical and would limit patients' access to healthcare.

The new terms included doctors not being properly reimbursed for emergency and critical care outside of office hours and a limit to the number of chargeable visits allowed for specialists in certain disciplines.

“When people are sick and go to a doctor, and they (insurance companies) put all sorts of caps on the charges ... that is not fair,” he said.

The Onion Conumdrum

Used to be that onions were tempting treats that used to serve as an interesting form of prophylactic birth control. After a few onions, end of social life, no need to worry about pregnancy.

However, over the weekend, I read an interesting report by the Institute for Food Research in the UK. Some food scientists were looking into the lesser known nutritional aspects of food. The Atherosclerosis Study reported that onions seemed to have anti-inflammatory properties. Onions, like grapes (wine) and some other fruits and green veges, contain the all important flavonoids, which seem to reduce the inflammation that LDL-cholesterol induces on the arterial wall. In that sense, it acts a little like a statin.

From my reading, they tested the effects of the metabolites of quercetin (the flavonoids in onions) on the arterial wall. No details were given. I suppose, if the researchers were cardiologist, they would have measured the serum hs-CRP, but they did not. They measured the cellular response to atherosclerosis.

For effectiveness, you may wish to know that you need to consume almost 100-200 gms of onions a day, for the reported effect. That's about half a large yellow onion (5 of these in my kitchen weighs 2 KG). For those of us who want to find a partner, get married and then reproduce, it may still be easier to eat about 4-5 servings of veges a day for the same effect.

Anyway, it looks like onions have now achieved the new status of "nutriceutical". So mummy was right all along. Eat more veges, boy, it is good for you.

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.

What of the PHFCS

The PHCFS Act 1998 and Regulations 2005 was launched by YB MOH with pomp and ceremony on 24th April 2005. That sent many GPs into a frenzy, as the Act had stringent (read as un-Malaysian) requirements. The "feng shui requirements" in particular, including the size of doors and whether the toilet doors should swing out or in, meant the need for renovations in many existing clinics in order to comply.

Along with the act came a big stick. The penalty for failure to register was RM 300,000 fine or six months in jail or both. If you register and do not comply, the penalties are also very punitive. In addition to the big stick, they shrink your carrot to be a doctor. The Act spells out a fees schedule for doctors' fees, ostensibly so that there is no "overcharging". Nothing is mentioned about inflation and how doctors will get to sick people when the price of petrol hits 5 ringgit a litre.

Back in those days in 2005, we travelled across the country trying to gather feedback and also pacify the many fears that GPs had. I remember that some of the meeting across the country were very heated and some doctors even advocated industrial action, including downing tools (which I thought was quite funny. Can you see our kiasi GPs downing tools?). We were then so fearful, that the ACT and Regulations will give overzealous "little Napoleons" great opportunity for "side income".

With a touch of good luck, we established a channel of communication with MOH (remembering YB MOH is from MCA), and we were able to negotiate some toning down of the Regulations. We were advised that the Act 1998 was not negotiable, but the Regulations (and enforcement), we could amend.

It is now 15 months after the Act came into force and we just had a meeting (23rd August 2007) with MOH to "finalise" the amendments to the regulations. So far it has taken 15 months to have 3 rounds of negotiations.Do not be surprised that nothing in the amendments had been decided (after 15 months). MOH is very pleased (also the Cabinet, as we are told), that 90 over percent of GPs have registered (in other words the act is a success).

The enforcement arm had made 20 raids to nab those in breach of the Act. As Dato Khairi of MOH Jabatan Amalan, puts it, "we will continue to act on our intelligence, and go after the bad guys. You good guys have nothing to fear ". So far, we have not heard of any instances of the "little Napoleons" who may come by, with overzealous enforcement. To cut a long story short (we spent 2+ hours in MOH), we realise that the MOH officials were severely overworked, and it is very likely that we will not see any of our agreed amendments in print anytime soon. My personal hope is to see it in my lifetime. We were reminded that they are still trying to process the 6,000 over registrations (they have now process 4,000+), and with the recent passing of the Pathology Bill 2007, the same people in MOH are also doing the enforcement, so "they do not know when the PHCFS Regulations 2005 amendments will be done". In the meantime, "you good guys don't have to worry. we will go after the bad guys ".
So what of the "feng shui requirements"? We are told that the toilet doors must swing out. Looks like the AG chambers feel that this is very important for a medical facility. The emergency medicine clause is still undecided. We continue to press for basic life support as the basis, with no need to keep IV drugs, ECG and defibrillators. They even said that the doctors fees schedule could be negotiated (No word yet on whether we have to wait for petrol to hit 5 Ringgit before this happens).

I thought that that was one of the main reasons for the Act. Doctors were "over-charging". What surprised me at the whole afternoon, is the MCOs (Manage Care Organisations). Although their role in private healthcare is stated in the Act, there is no regulations for them, and they cannot be held accountable. We all can tell all kinds of horror stories about the MCOs, but there are laws to control them. We were told that they may need to have a "MCO Act". Please see MCOs as very rich and powerful people who are very influential, and out to make a quick buck. So I really doubt that I will see a "MCO Act " anytime soon. Anyway, we have done our part in trying to get a fairer deal for our private practitioners. Let us see what will come about, in print, I hope, for posterity.

Too Many Medical Graduates From Too Many Medical Schools

I wrote earlier about the present scene of too many medical schools, many with poor teaching staff producing questionable medical graduates. What are the implications of medical schools when some of them are degree mills which would be better off producing sausages rather than bad doctors?

It is obvious that the politicians see flooding the market with too many MBBS' as one way of controlling doctor's fees. A deluge of medical graduates also mean that there will be enough doctors to go around. How else can they hope to man all stations at public hospitals?

YB MOH has been quoted as saying that, "you doctors are so choosy as to where you wish to be posted. Very soon, you will be begging to work in any public hospitals". Alas, with so many medical schools, bringing out so many medical graduates, that statement may actually become true. What kind of doctors will these be? Are they safe? As a physician, we should first do no harm, even if we cannot do any good. Will these graduates from some of these "suspect" medical schools, do any harm? Will the VVIPs be happy to be treated by these medical graduates, or is there going to be one kind of doctors for the elites, and another kind for the common man-in-the-street?

Yes, having many GPs in any one location will bring down the fees charged and we call that "market forces", but do not forget that the same market forces, can also force the same GPs to "cheat" in order to survive. For example, in order to make ends meet, they may be forced to sell MCs, make false claims against insurance companies, sell psychotropics, maybe even peddle drugs, or sell nutritional products (ala direct sales pyramid schemes), just to survive. Note that I am not making excuses for the "badhats". However, the plain truth is churning out
large numbers of doctors of questionable quality exacerbates the problem and invariably will lead to an increase in badhats. This in turn will lead to legislation to counter badhats which will make it harder for the rest of us to practice good medicine.

Worse yet, if you couple the oversupply of medical doctors, of various quality, with an oversupply of lawyers in the country, then you can only have an oversupply of medical law suits. For those who don't know, law suits cost money even for good doctors when we have to pay to insure. Insurance shifts liability from the badhat to the masses. We suddenly see a most interesting thing called the "law of unintended consequences". Churning out doctors whatever the quality, to lower medical costs based on the law of supply and demand actually leads to higher costs. Suddenly YB MOH's plan to bring costs down has actually driven costs up.

This apart, we are presently also seeing the beginnings of medical graduates taking up non-medical duties, like becoming medical advisers to pharmaceuticals, and insurance companies. Soon, not too long from now, we may see doctors becoming physiotherapists, nurses, drug sales representatives, laboratory technologist, and other allied medical disciplines, so that as the standard of medical care falls, the standard of paramedical care will rise. If this trend continues, then there will eventually be less enrollees at medical schools. Then there will be some shortage of doctors for awhile, and the cycle continues.

In the end there doesn't a method to this madness we are undertaking. Of course, by that time I would have retired and so would YB MOH. The long term plan here seems to be to retire ahead of the game while the rakyat continues to suffer.

Producing Competent Doctors in Malaysia

Sometimes it is very difficult to understand politics, and in particular, our politicians. Everytime an election come by, universities are promised to states where votes are needed. Sometimes, as part of those promises, a medical schools is thrown in, just to win more votes. I'm sure the politicians will claim that this is all part of a grand plan. If so, none of us are aware of it except them.

It is true that having a university and medical school, brings with it developmental funds and also some commerce. It develops the state. I was told that Kampar was a sleepy town until MCA brought TAR university there. It is now buzzing. Students, after all, have to rent homes in which to sleep and go to eating establishments to fill their bellies while the universities attempt (successfully or not) to fill their minds.

Commerce aside, surely along the way, some thought must be given to two important issues. Especially where medical schools are concern. Firstly, are there too many? Secondly, how do we maintain standards?

Are there too many medical schools in Malaysia? At the last count, there are 19 medical school in Malaysia, a land of 27 million people. If each medical school spits out 100 doctors per year, there will be 1,900 doctors entering service yearly from local universities. Add to that about 500-1,000 doctors returning home from abroad, then you have about 2,500-3,000 doctors, entering service yearly. This is a big number. Not so many old doctors leave service yearly. There will be a net gain in number of doctors entering service. Of course politicians always say that there is a shortage of doctors. They all justify flooding the market with doctors as a means of controlling doctors professional fees, which they argue is the reason for rising medical cost. Alas, a quick look at the medical bill of patients discharged from hospitals and medical centers will easily show that a large part of the bill is made up of hospital charges, something which the politicians make no attempt to control.

As I understand it, there is no shortage of doctors in Malaysia, just a severe mal-distribution. Most doctors leaving public hospitals start their practice in the main towns like KL, Penang, Johore Bahru, Malacca, Ipoh, and the like. There is a shortage of doctors in the interior of Pahang, Kelantan, Sabah, and Sarawak. The last two is also partly government sponsored shortage, because there is a law forbiding West Malaysian doctors from working in East Malaysia, without special permission.

With so many medical schools, how do we maintain standards. It is very frightening to note that some public medical schools are initiated with just one or two lecturers per department, or in some medical schools, one or two lecturers per medical school. Maybe only the opposition wants to talk about this problem. The few lecturers are recruited often from foreign countries, whose medical degrees may not be recognized in Malaysia. Often times they are recruited in a "just in time" manner probably arriving on the same flights bringing the students in.

Just to fulfill promises made during the election campaign, medical schools are started without adequate planning and staffing. Medical lecturers are then recruited from all over, of various sorts, some not even speaking English (the lingua franca of the medical fraternity), and whose degrees are doubtful. How then can we have good doctors for our rakyat, when the teachers of doctors are doubtful? When the teacher is a monkey, is it surprising that the student suddenly gains a liking for bananas.

It is often said that when the VVIPs are sick, they have their own personal doctors, of the highest quality in the land, or some VVIPs even go overseas for minor suegery (like not so long ago, a VVIP went to Australia for a simple nose operation). The ordinary rakyat have to face the "half past six doctors". I was told that some of our KL public hospitals emergency rooms look like emergency rooms in some south Asian or middle eastern hospitals.

It is not entirely true that Malaysians are not willing to help teach in local medical schools. You must see the amount of redtape that one have to go to, to be employed. Frankly speaking, the working conditions in local medical schools is really something else, and I am not talking about difficult students. Even my old boss, the late Tan Sri Prof TJ Danaraj, had his fair share of problems with the University of Malaya and the Government of Malaysia, about passing and failing students, in the good old days.

We tried to broach the subjects of some of us, "senior specialist" helping to teach and see patients in the public universities. Alas no, we are told. Thank you, but no thanks. If we do that, they are very afraid that we will steal their patients. Yet they will allow their teaching staff to hold "private practice" clinics, and steal the publics time to collect private practice money. A coronary angiogram by the lecturer on university time will have to wait 1 month, but on his private practice time, can be done tomorrow.

I only wish that the politicians who decide public policies take cognizance that poorly trained doctors are a greater danger to our society then the bus driver who killed 20 passengers recently. How I wish that when our VVIPs are sick, they have to go for treatment, unannounced, at our local public hospital emergency department and line up like the rakyat. Perhaps then they will see what harm, their medical education policy can do? But alas, that is not going to happen.

The next time a VVIPs motorcade zooms past you during rush hour remember that you just waste a few minutes. The same thing is happening in our emergency rooms are lives are just simple being wasted because we got the government we voted for.

Update: Thanks to MMR for featuring this post.

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?

Part Privatisation (Piratisation) of Government Hospitals

Malaysia at the moment has one of the best healthcare system in the world. As we have posted earlier, we spend only about 3.6% of our GDP on healthcare and yet achieve standards better then many of our ASEAN neighbours. Yes, there are deficiencies in services rendered, but nothing that cannot be remedied with some relatively cheap revamp. Alas, the politicians are very keen on a total change to the system. They have already employed eight healthcare consultants to advise them on how to, but the last one (final report handed to the cabinet in April 2007) has failed to impress the politicians or fulfilled their (the politicians) objective.

Yesterday, in one of the dailies, we read of the hon. minister of Health, announcing a minor privatisation of the government hospitals. The newspaper tells us that w.e.f. from 1st August, patients seeking treatment at the Putrajaya Hospital or the Selayang Hospital, will be allowed to choose whether they wish to be treated by their own specialist. Of course they will be admitted to the first class ward, and they will pay "private" rates. Supposedly, the specialist will get to keep all or part of the professional fees, thus boosting their income. All this sounds great, right?

This dream sounds so great until you wake up and the truth gets in the way. It has already been proven terribly wrong for the other patients. We need look no further then our own University of Malaysia Medical Center and the University Kebangsaan Medical Center where patients can chose to be treated in the public wing, or the private wing. This started probably some five years ago. It has not stopped specialist leaving to private practice, at best one could argue that it slowed it down. The only problem is that these "advances" came at the expense of patient care and it was a terrible price to pay.

If you need some elective surgery at UMMC, and you see the specialist, he will tell you that if you choose the public wing, the surgery will be scheduled 3-4 months later (we have one report of an elective gastroscopy scheduled for 7 months later). If you choose the same specialist and the private wing, it could be done this evening, or tomorrow. How can they not learn? This can only worsen the government hospitals, or is the Hon MOH wanting to worsen the government hospital so badly that he can quickly approve a whole privatisation (read piratisation) process? Or is he secretly working to promote patient movement to private hospitals? Worse of all, it's an election year where politicians need to be seen to be doing something even if the patient has to pay for a bad choice. Can you imagine what the patients at Selayang Hospital will face come 1st August. All those opting for "private" care, will be seen and taken care of by the specialist and all the rest of the public patients will be seen and under the care of the junior doctors. Is that better for healthcare? Only the Hon. MOH seems to know.

We proposed, ages ago, that the Hon MOH should seriously consider charging all first class patients (presumably these patient have the means to pay the rates) the full private rates, and the second class patients, half subsidised rates and the third class patients fully subsidised rates. This will allow the MOH to improve their coffers. Specialist should get a pay rise across the board (and not on a per case basis so that they will continue to care for all patients), and encourage to go for courses, perhaps once a year, to improve themselves (some consultants are going on conference leave almost monthly). Putrajaya should reduce calling consultants for meetings all so often too. No going home, or playing golf at 3.30pm on Fridays, please.

The "Go Red" campaign

I read with interest the launch of the "GO-RED CAMPAIGN " by the wife of DPM yesterday. Many statistics were regugitated. It's accuracy is in great doubt. To the best of my knowledge, there was no community survey to gather data. It could be that they were basically admission data from the Ministry of Health hospitals, or from the Institute Jantung Negara.
If that be so, then the data will be very skewed and bias, reflecting those who had sought treatment. 45% of females above 50 yrs with heart disease would seemed to be very high.

I am not sure whether this data came from the CIA. In the NST article the following phrase is telling...

Yet, only two per cent of the United States National Institutes of Health budget is allocated to prevention.

It will be good to remember that last year, the American Heart Association and the American College of Cardiology, co-sponsored the American Go-Red campaign. Interesting, that we are following the Americans so well. We are surely good followers but without the facts and the infrastructure to see the campaign through.

Obviously, it is good to raise the level of awareness of heart disease. We are all for raising awareness, and that's why this blog exists. Scaring people is another thing altogether. I think it may not be a good long term strategy. The better way would have been to educate the public with well collected facts.

It is also interesting to note that the initiative for this campaign, a so called national campaign, was not publicised among GPs and cardiologist. My reading of the article did not pick up on the presence of either the President of the National Heart Foundation or the President of the National Heart Association of Malaysia (NHAM), although it appears the advisor of the campaign is a council member of the NHAM. Most notably absent was the Minister of Health and the DG of Health.

It would have made sense that for the campaign to reach down to the masses and doctors, getting the cardiologist involved. This would have seemed quite the natural approach. Is there some "kiasu" politics in this?

It is good to highlight the problem of heart disease among females, because females tend to have rather more severe disease when they present and are often missed and not given standard cardiac treatment at the opportune time. As I have posted earlier, I noted that females do live longer dispite their so called higher CVS disease incidence, and often present late, they still live longer.

Something is very amiss. I would like to wish IJN/DPM wife, a very successful "Go-Red Campaign", but I sincerely hope that they have female public and patient in mind, and not another private agenda. I also certainly hope that they are not made to be dupes by third parties.

Here's what really smells like yesterdays fish...

1) The author of the article in the NST is credited as follows

Rajen M. is a pharmacist with a doctorate in Holistic Medicine. He is a director of the Malaysian Herbal Corporation and a CEO of a group of companies in alternative healthcare.

He doesn't use the title "doctor" in the article by-line. There's certainly a Rajen M with a similiar profile here that's not so reluctant to use the term doctor.

2) A search on the go-red domain name owner (what a trail of bread crumbs) shows that the name is owned by someone with an email address in alterni.com. Alterni is the corner shop at the same row as New Paris SS 2. It also specialises in "holistic medicine"

3) What smells most like fish is that a visit to the site shows us ads for a product named "Pristin". If you use firefox like me then you will see what is known as a site icon. Notice how the icons for Pristin and Go-Red are identical.

4) A search into both go-red and pristin turns up that they both sit on the IP address 210.187.2.170. This means an apparent campaign by a bunch of people with seeming bona fide motives turns out to be sponsored by a corporate effort and sits on their server.

5) The two websites referenced at the base of the article www.womenheartfoundation.org and
www.hearthealtywomen.org were not found. Maybe we typed them wrongly into our browser. Can anyone try and let us know?

To sum up: No doctors of note or big guns from the ministry, a domain name owned by a pseudo-medical alternative medicine site, a domain hosted by a fish oil vendor and the article written by Rajen M who also wrote "Your Health/Alternative Medicine: Heart disease stalking the women" in the NST. While the original is gone you can look for the google cache version.

Someone please join the dots and tell us what is going on.