By Datuk Dr LEE YAN SAN
Changing trends of medical practice in Malaysia.
AFTER graduating in medicine from Australia, I started medical practice at the beginning of 1969. I have witnessed vast changes in medical practice. I came home to Malaysia at the end of 1971 before completing my postgraduate training in teaching hospitals in Sydney when my father took ill.
Back home, I joined the government service in Taiping Hospital and then University Hospital in KL for nearly five years. Then I went for post-graduate studies in Edinburgh before returning to Malaysia to start my own private practice.
I have therefore been through and seen the changes of medical practice in Malaysia for over 40 years. Recently, there have been many changes affecting medical practice and therefore I feel this will be an interesting topic, which I am qualified to write on, especially being a past president of the Malaysian Medical Association (MMA) and a council member of the Malaysian medical Council (MMC).
Clinical practice to investigative practice
Doctors are now depending more on machines and are no longer are as good in diagnosing using clinical acumen, with the help of basic clinical examination tools.
I predict that in the not too distant future, stethoscopes may even become obsolete!
Clinical practice to investigative practice must be the most obvious change in medical practice. The actual practice of medicine has changed tremendously, and doctors are now depending more and more on gadgets and procedures rather than their clinical acumen.
In the past, without the easy access to such modern diagnostic tools, doctors had to be trained to rely mainly on their clinical skills to diagnose diseases. Experience and knowledge are important.
Unfortunately, these days, doctors no longer bother to go through basic examinations to come up with a diagnosis, as it takes more time and effort. All they need to do is to order a non-invasive brain CT or MRI scan to make the diagnosis. Some young doctors, through force of habit, do not even bother to listen to the lungs of patients complaining of chest symptoms, but just send them for a chest x-ray.
In the past, doctors were also trained to accurately diagnose heart defects purely by listening for typical heart murmurs, but now, with new gadgets such as the echo-cardiogram, this is no longer routinely practised.
But is it all good? Depending on gadgets may not create any problem if you are practising in places with such equipment available to you, but certainly, the doctor will be at a great disadvantage if such equipment are not available. This also increases cost, which may not be necessary.
Changes in medical training
Medical teaching and clinical training have changed greatly due to the vast increase of medical schools, with insufficient number of teaching hospitals and qualified teachers, which are of real concern.
Nowadays, due to the large number of medical schools, both locally and overseas, there are too many medical graduates produced annually, leading to insufficient facilities and patients to train them adequately. Some housemen do not even have the opportunity to learn to deal with emergencies.
The housemen will therefore not get sufficient experience and training as the hospitals and consultants are not able to cope with such large numbers.
The Government must seriously look into the declining standards in the training of housemen as the quality of medical care in the future depends on them. Internship is crucial to allow graduates to put medical training into practice under the supervision of senior doctors.
There is concern that many graduates from medical schools with inadequate teaching facilities will not have adequate core knowledge to treat patients.
New laws governing doctors
Malaysia used to have only the Medical Act 1971 to govern the medical profession. There are now new laws governing medical practice in place.
The scenario in private practice has changed drastically. Until recently, to start a private clinic, a doctor did not need to have a business license as medical practice was not considered a business and doctors were trusted to do the right thing, and that was looking after the health of the community. To start a clinic, a doctor only needed to register with the MMC to make certain they are qualified to practise as a doctor. They did not even need an annual practising certificate.
The main routine work was to keep decent medical records, a precise record of drugs stocked, and maintain an accurate financial account for the Inland Revenue Board.
Today, it is not easy to set up a private practice, especially a general practice. In the past, the doctor could just concentrate on his role as a healer. A doctor now has got to be a good administrator as well. Doctors now have to handle various issues such as rental, building requirements, and so on. The doctor has to answer to various government agencies that include the local council, the labour department, the statistic department, the fire and building departments, the pharmaceutical department, and if you happen to own an x-ray machine, the physics department as well, just to name a few.
More recently, the Private Health Care & Facilities Act was enacted. The Act dictates in great detail what doctors must do and should have in their clinics, many of which are unrealistic, and quite unnecessary.
Doctors in this country are practically accused of being greedy, immature, unscrupulous, and unethical, with the threat of heavy fines and jail terms if they don’t toe the line.
I hope to see the Government giving private doctors some breathing room. Some “black sheep” in the profession have caused mistrust, and this has led the Health Ministry to think that the private sector needs to be supervised in a stricter way. Doctors are all against those unscrupulous doctors who tarnish the reputation of their profession. Those doctors have no regards for ethics or law, but the rest of the medical practitioners should not be made to suffer because of them.
Surely it is more economical, more efficient, and fairer for the authorities to try and weed out the black sheep and deal drastically with them.
The Medical Act is already there and sufficient to control the doctors and to punish any in a fair way. If not, new amendments to the Medical Act can see to that.
Already, many general practitioners in solo practice are not doing well, so much so that doctors nowadays prefer to specialise, which is another new trend. This is an unhealthy trend as family (general) practice still plays a very big role in the healthcare of our country, and the authorities should do all they can to encourage it and not cause it to be less attractive by imposing too many rules.
Increase in the number of specialists
Forty years or more ago, there were hardly any specialists in private practice. The family doctor had to refer his patients to government hospitals if they needed specialist care. Now, one big change is the vast increase in the number of specialists in private practice.
Nowadays, specialists tend to specialise only in a particular and limited field. In the past, we had only general physicians and general surgeons. Medical knowledge and treatment procedures have advanced so much that it takes many years of training just to become such a specialist.
For example, for Internal Medicine alone, there are no longer general physicians who are trained to handle a wide variety of diseases. Instead, there are now physicians specialising only on certain parts of the human anatomy, such as cardiologists, gastroenterologists, renal physicians, dermatologists, neurologists, and endocrinologists, just to name a few. Surgery also follows this trend.
Changing scene in private hospitals
As mentioned earlier, the private healthcare scene has changed greatly. Because of this, cost of treatment has also escalated steeply.
In the past, doctors were in control in most of what they did when practising in private hospitals, but now, due to the commercialisation of private hospitals, which started about 20 years ago, doctors are no longer in control and have little say in the daily running of the hospital.
In the past, it was the medical superintendent, a doctor, who saw to the whole running of the hospital. Now, hospitals are run like a business concern, often by a group of businessmen who are not doctors. The administrators make the final decision. Doctors are just employees to make money for the hospitals, unlike in the past.
Private hospital practice is now getting more and more commercialised and less personal in many ways, including the doctor-patient relationship. This is due to the involvement of Managed Care Organisations (MCO). Cost of private healthcare has increased tremendously, partly due to this trend. It is really sad to see such penetration of commerce into the province of medical practice. In 1999, the Government was even considering privatising public hospitals. The plan was fortunately put on hold after the MMA protested. Privatisation will be disastrous for the poor, especially if the country does not have a suitable national health insurance scheme in place.
Managed care was first introduced in the US to cope with increasing healthcare costs more than 40 years ago. Now it no longer serves such a purpose, and has in fact become a big source of commercialisation of medical care, causing marked increase in healthcare costs.
Increasing drug prices
The tremendous rise in drug cost has affected medical practice to a great extent. In the past, medicines were very cheap, costing less than 10 sen per tablet, and many doctors practising in private clinics were able to even absorb the cost of medicine in their fees.
Now the price of medicine has escalated by leaps and bounds. In fact, some regularly used routine medicines such as those for diabetes, high blood pressure, or lowering cholesterol drugs, which you need to take regularly, cost up to RM5 to RM7 a tablet, which is a 50-fold increase! The cost of medicine now forms the main proportion of the total cost in a doctor’s bill.
Private doctor income
The changing trend of medical practice in Malaysia has affected the doctor’s income in private practice. Group practice is now more popular than solo practice. The general practitioner’s ability to earn a decent living is very much affected. This is due to the vast increase in overhead expenses, yet their charges have not significantly increased over the years.
Inflation has seen rising costs of materials, rental, electricity, and drugs, and this has affected the general medical practice.
Salaries for clinic assistants and nurses have also risen. Expenses now also include contribution to SOCSO and EPF, which have also risen. Rental and other bills such as water, electricity, and repairs have also increased.
In spite of all these, a doctor’s consultation fee has hardly increased. Consultations charged by doctors are now much lower than any other profession, including taking your pets to a vet surgeon, or your electrical appliances for repair!
Other professions, except doctors in general practice, have increased their income substantially. Even TV and car repair men are charging more than 10 times the previous rates. Food price certainly has increased tremendously. For example, a plate of char koay teow, which used to cost 30 sen, is now over RM5; thus an increase of nearly 20 times.
The great increase in the number of general practitioners has also affected their income. Even the increase in the number of specialists in private practice have also contributed to this due to patients going directly to see a specialist instead of their general practitioner first.
The Government’s effort to increase the doctor-population ratio unfortunately did not take into consideration the distribution of doctors, which tend to be concentrated in urban areas. There are already too many doctors in the urban area, and the Government’s effort to attain so many doctors in so short a time is affecting the quality of medical practice in urban areas.
The Government must be realistic in its target so as not to compromise quality.
Defensive medical practice
The practice of medicine is also heading towards defensive medicine due to more lawsuits and complaints. This has caused a marked increase in premium for medical insurance due to increasing claims and liabilities.
It can also make even the best doctors become too careful for fear of making mistakes. This will eventually also lead to increased investigations, referrals, etc, to avoid taking any risk, and thus will affect the quality of patient care. Because of this, medical insurance premiums will continue to rise steeply due to increased claims and liabilities.
Unfortunately, even the most careful doctor can make mistakes. There is too much expectation of doctors in general. Patients and even doctors themselves have created an impossible expectation of perfection, which makes it impossible and difficult for doctors to admit to mistakes and thus learn from them.
Society demands a perfect outcome from doctors. Even an isolated case of a mistake by a doctor will be sensationalised by the press. Other professionals do not face such expectations from the public.
Everyone is always so quick to blame doctors whenever there is a mistake. This is even so when the error was not directly due to doctors but their auxiliary staff.
In the US, nothing less than a perfect outcome is acceptable to consumers. It was reported that in 1993, an estimated 84% of US physicians practise defensive medicine to protect themselves from potential lawsuits. This also accounts for more problems arising from unnecessary tests, x-rays, and procedures, which in the long run will be even more harmful. For example, normal vaginal delivery has been replaced with caesarean sections at the slightest indication of difficulties.
Every procedure or treatment carries a certain amount of acceptable risk. Doctors should take every care to do his best in the performance of his duties to avoid being accused of negligence. It is important for doctors to have good communication with his patients.
Looking towards the future
The practice of medicine has certainly changed substantially. However, doctors should not abandon the old ways of spending more time with their patients; take more time to examine their patients, and take good history. Although the use of the latest equipment may be necessary, doctors should avoid being too dependent on them.
Doctors should make every effort to find ways to resist commercialisation of medical practice.
Before implementing any new rules affecting doctors, the authorities should seek the opinion of doctors who are well informed and knowledgeable of their own profession for discussions. This is in the best interest of the public as well as the medical profession.
There has been increasing pressure for doctors to adopt business strategies, which is in direct conflict with our professional ideals. Doctors must be trained and persuaded to resist such trends. Medical ethics must never be compromised and is a priority for doctors.
Hopefully in more years to come, we can still be respected as compassionate healers and not businessmen. Only those who have the passion to heal should become doctors.
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