Mma September 09(l)

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Contents 4

SEPTEMBER 2009 www.mma.org.my

President’s Page The First 100 days…

8

Secretary's Page From the Desk of the Secretary

10

Message from the

PPS Column Quality in General Practice

12

EDITOR

From the Desk of: Tan Sri Dato’ Seri Dr Mohd Ismail Merican Better Prospects for Doctors Working in the Ministry of Health

14

SCHOMOS SCHOMOS Meets Director-General of Health

16

Insurance Update on Hospitalisation Plans for MMA Members

17

Press Statement Australian Park Named After Malaysian Doctor

18

Book Review Clinical Atlas of Nasal Endoscopy

19

Letter to Editor 1st MMA/MAAH Urban Outreach - Programme at SMK Sri Sentosa KL

20

Mark Your Diary

21

Classified Advertisements

24

Report Introductory Plantation Health Seminar

26

CME Update

28

-

30

Branch News

32 33

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34

SP’s Korner

Limbal Stem Cell as Potential Therapy to Blinding Corneal Conditions Colour Blindness

MMA Wilayah Activities Briefing to the Private Sector on Influenza A (H1N1) in Penang MMA Perlis Pain Workshop MMA Perlis Dinner 2009

MMA EXECUTIVE COMMITTEE MEMBERS: 2009-2010

Medical Tourism: Are we ready for it? Medical tourism is described as a practice of traveling across international borders to obtain healthcare. This happens when citizens of other countries find quality healthcare cheaper in another country. Singapore and Thailand have been in this business for a few years and Malaysia seems to be slowly catching up on its own bit in promoting medical tourism. We are more conducive to attract a bigger medical tourist crowd but are we doing enough and do we have the correct focus? One of the main concern is the brain drain from public hospitals to private hospitals. Doctors are fully aware that medical tourism flourishes well in private hospitals especially when payment is in cash without any hassle from the local MCOs. Limited private practice in government hospitals, which was initially aimed for foreign patients, seems to have failed miserably. Medical tourism promotes foreign exchange income and elevates our standards, as we have to compete to be the best. One of the serious constrain is lack of medical manpower particularly doctors and nurses. Though we may have the highest number of medical schools per capita in the world [23 medical faculties for a population of 27 million], we are still running low in numbers of doctors in public hospitals. We also know that the bubble will soon burst as the medical graduates are soon going to graduate and will fill up all the empty post right up to the interiors of East Malaysia. Maybe then we can promote medical tourism with enough doctors for our rakyat and medical tourists. Our worries will not end with increase foreign patients [medical tourists] in the next few years as we also may face challenges from foreign doctors having their practices in Malaysia after the AFTA comes into effect. It will be rough turf for local doctors to keep up with this competition. Malaysian doctors will be allowed to work within our region but how many of us will do so? I foresee tougher times in the future for doctors and maybe the medical profession will not be a favorite choice anymore within the next decade. Some serious proactive steps should be initiated now.

DR DAVID K. L. QUEK

DR KULJIT SINGH

Regulatory Requirements

President 2009-2011

Honorary Deputy Secretary

DATO’ DR KHOO KAH LIN

DATO’ DR SARJEET SINGH SIDHU

Immediate Past-President

Honorary Deputy Secretary

DR MARY SUMA CARDOSA

DATO’ DR MOHAN SINGH PANNU

President-Elect

Member

DATO’ DR N.K.S. THARMASEELAN

DR HARVINDER SINGH

Honorary General Secretary

Member

Do we need more agencies, societies or associations to regulate doctors and their practices? Are we not frustrated enough with By-laws and Acts? We do not need any more governing instruments on our practices in the name of quality. It is often ridiculous to register in so many different registers, government agencies and societies, which portray quality control. The medical practice itself has its difficulty in managing MCOs, insurances and ‘consulting’ pharmacies. It is not at all acceptable for doctors to face additional burden of complying with quality control societies. We should stand strong to reject any more regulating instruments into our practice. Doctors are noble enough to self-regulate and practice within the domain of medical ethics and best patient care.

DR HOOI LAI NGOH Honorary General Treasurer

EDITORIAL BOARD Editor: Dr Kuljit Singh E x - O ff i c i o : Dato’ Dr N.K.S. Tharmaseelan A d m i n i s t r a t i v e O ff i c e r (Publications): Matilda Cruz

E d i t o r i a l B o a rd M e m b e r s : Datuk Dr N. Arumugam Dr Mary Suma Cardosa Dr Chen Wei Seng Dr Saraswathi Bina Rai Dr Andrew, Tan Khian Khoon Dr Harvinder Singh Dr Krishna Kumar

My best wishes to all like always, and let us work out a better future for doctors.  Dr Kuljit Singh Editor

DISCLAIMER: The views, opinions and commentaries expressed in the BERITA MMA (MMA News) do not necessarily reflect those of the Editorial Board, MMA Council or MMA President, unless expressly stated.

Published by:

Printed by:

Malaysian Medical Association 4th Floor, MMA House, 124 Jalan Pahang 53000 Kuala Lumpur. Tel: 03–4042 0617, 4041 8972/1375 Fax: 03–4041 8187, 4041 9929 Email: [email protected] / [email protected]

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4

President’s Page

The First

100 days…

1. How has it been, the first 100 days in office? As I have commented earlier some 2 months ago, the office of President of the MMA has been quite demanding and taxing, yet it is a very challenging learning process. Clearly, not many doctors understand the burdens of office and the mandated responsibilities of the President of the MMA. I certainly did not expect such an onerous if ponderous task. One could of course, just take this in one’s stride, and carry on as per usual, accepting the position as President of the MMA as just another feather in one’s cap of personal achievement or ambition. But this, I believe would seriously undermine the status and understated strength of purpose of the MMA. Anyone who aspires to be an MMA leader must be aware of the responsibilities and tasks ahead. He or she must necessarily wish to do more, to represent the profession more robustly and with fullest attention to details of the multifarious issues, which pertain to the medical profession and healthcare scenario in the country and beyond. Not surprisingly, much is expected of the President as the presumed spokesperson and the recognised opinion leader of what must be the most respected association in our society, especially when the MMA is seen to represent the interests of the largest number of our doctors. I think many among the public are aware that we still represent the rational voice on healthcare issues in the country, and would like very much to listen to our viewpoints, although increasingly with more and more skepticism and mounting mistrust. Certainly many officials in the MOH and the Health Minister himself regards us highly as an important sounding board on all aspects of health, which impinge on our Malaysian healthcare scene. I was pleasantly surprised that a recent Malaysian public survey found that doctors are widely regarded as having the second most stressed profession! A few years back, some 72% of the public polled also found us to be the most trusted among all other professions! This gives us hope that we can still offer meaningful and beneficial services to our rakyat, despite mounting grumblings of physician carelessness and callousness. Journalists, news editors and health officials expect the MMA to have an opinion on myriad issues no matter how esoteric or fatuous they might be (e.g. what do I think of so-and-so’s inane comment that “masturbation may predispose to the H1N1 flu”?!!). Curiously they all appear to believe that the President should readily have all these information, ideas and opinions at his or her fingertips! The President must be able to respond nearly immediately and clearly— often with an impossibly unrealistic black-and-white certainty. He must also be the know-all with regards any health issue, no matter how remotely connected! Perhaps this underscores the respect and the expectation that the MMA is the de facto body where our opinions matter and ought to be sought… We are flattered, but at the same time bemused at the hysterical approaches of some of these media people, anything to stoke the interests of the readers! It is with this in mind that I have felt compelled to try and actively engage with as many organisations and authorities as possible, i.e. any influential body that requires our input and ideas. How much we have managed to impart in terms of influence or suggestions, remain to be seen. But it is clear that if we had not been there, then our doctors’ interests might not have been represented at all.

There are still quite a lot of misgivings and negative impressions about doctors in private practice, the healthcare system and the MMA in general— that we are too concerned with our own parochial interests, some of which I have tried hard to dispel by responding more with the authorities that be. But all this requires greater interaction and positive dialogue on a personal level with more consistent engagement and commitment.

Dr David K.L. Quek President 2009 - 2011

2. What are your issues/plans for the MMA in the near and longer term? Many of the issues that have arisen during the first 100 days of my presidency are not all new. However, these have been raised and are now under discussion, with the view to some degree of resolution or action. Among the most pressing issues include the following: a) R e v a m p a n d r e j u v e n a t e o u r M M A S e c r e t a r i a t and motivating our staff to be more productive and professional; b) E n c o u r a g e o u r m e m b e r s t o r e c o g n i s e t h e i r o w n i m p o r t a n t i n d i v i d u a l r o l e as well as collectively, and instill increased participation in the affairs of the medical profession, to remind physicians about their calling, their vocation, their kindlier more caring nature, as well as to remember to be our patients’ greatest advocate; c) E n c o u r a g e o u r M M A l e a d e r s h i p ( E x c o a n d C o u n c i l m e m b e r s ) t o t a k e u p m o r e r e s p o n s i b i l i t i e s, more in-depth interests, develop and acquire training and leadership skills, so that together we can better plan for more concerted policies and a more meaningful, more participatory and influential role for our august association, vis-à-vis healthcare and professional issues in our country; d) E n g a g e w i t h t h e M a l a y s i a n P h a r m a c e u t i c a l S o c i e t y , pharmacists in general and their leadership to move towards greater professionalism, cooperation and collaboration; e) W o r k w i t h o t h e r p h y s i c i a n g r o u p s towards greater unity of purpose and direction, e.g. FPMPAM, Academy of Family Physicians of Malaysia (AFPM), Academy of Medicine, MOH; f) R e v i s i t t h e d i r e c t i o n a n d p o l i c i e s o f t h e M M A ’ s n a t i o n a l h e a l t h p o l i c y c o m m i t t e e, including re-establishing an updated blueprint for ‘Health for All’ Malaysians, including equity and access issues; g) R e - e n g a g e a n d c r i t i c a l l y r e v i e w t h e i s s u e o f s i n g l e - p a y e r N a t i o n a l H e a l t h I n s u r a n c e S c h e m e for our Malaysian healthcare system revamp, the continuing role of our private sector, its possible integration or greater assimilation with the public sector, reconsider other financing options, e.g. DRGs/case-mix, catastrophic coverage/safety net, etc.; h) L e a d d i s c u s s i o n s o n t h e i n a p p r o p r i a t e n e s s o f u n p o p u l a r a n d u n n e c e s s a r y r e g u l a t i o n s on the private medical practitioner, especially with regards the possible extension of M S Q H a c c r e d i t a t i o n of private clinics, repeal of agreed-to unpopular arbitrary regulations of the Private Healthcare Facilities and Services Act 2006, working with the AFPM to further strengthen primary care services and standards; i) R e c o g n i s e t h e i m m i n e n c e o f n e w A F T A a n d M R A p o l i c i e s when they come into play in 2010, and how they impact upon our profession and our members, engage with the authorities (MITI, MARTRADE, BIM, EPU) to mitigate the possible professional implications on some sectors of our healthcare providers; cont’d...pg 5

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

President’s Page (cont’d) cont’d...from pg 4

j) A d d r e s s l o c a l c o n d i t i o n s o f h e a l t h c a r e, particularly the concern of too m a n y m e d i c a l g r a d u a t e s in the immediate future where training, supervision and experience may be compromised. More than 2,000 new doctors now enter the job market annually, and with the new scheme of 2-years of housemanship, followed by another 2 years of compulsory service (recently just revised downwards by the MMC and MOH), these may be shortchanging our future doctors and their professional skills and competency. There have been concerns that our training positions may be inadequate for this larger influx of recent years. k) P u b l i c s e c t o r p r o f e s s i o n a l i s s u e s t o b e s t r e n g t h e n e d. At the same time SCHOMOS will continue to fight for better and better working conditions, fair and appropriate remuneration and career prospects for our doctors in public service. l) Too many Medical Schools. In the light of the above scenario, MMA joins other bodies concerned as to the possible glut and redundancy of future medical graduates. Too many are now being produced or are returning. Medical schools and colleges locally should be scrutinized so that the ‘mass production’ of more graduates does not undermine the standards and the needs of the country. MMA subscribes to the view that there should be a moratorium on new medical schools and that existing medical schools should not be allowed to exceed their capacity to churn out more graduates than have been agreed upon, without adequate minimum standards of necessary skilled teacher-student ratio, the availability of medical student clinical clerkship opportunities in our overcrowded training hospitals, and the ‘needs’ basis for the country. m) M e d i c o - l e g a l c h a l l e n g e s. This will continue to escalate as more and more of our patients are increasingly empowered, become more knowledge-savvy, as well as expect a lot more. Medical errors and mishaps are now tolerated poorly and then often are met with more medico-legal challenges and complaints. With the rising costs in medical care, there is also a tendency to expect greater clinical results, failing which disputes on charges are rising, with mounting threats of litigation and threats of professional complaints to MMC and the mass media. n) E n g a g i n g w i t h o t h e r h e a l t h a n d m e d i c a l p r o f e s s i o n a l b o d i e s o n t h e i n t e r n a t i o n a l l e v e l (WMA, CMAAO, MASEAN, IPPNW) to spearhead consistent policies of common concerns, e.g. global warming-climate change initiatives, human rights in conflict or state-controlled nations, custodial torture and deaths, nuclear disarmament, ‘orphan’ communicable diseases control, global poverty eradication (Millennium Development Goals), healthcare equity and access for all, etc. 3. What is MMA's role in outbreaks like the A/H1N1 influenza pandemic? The MMA has under my lead chosen a cooperative and engaged approach with regards this recent outbreak. We have taken the lead to disseminate patient education and defuse public panic as well as to support the MOH’s directives and plans to cope with this novel pandemic. We have also voiced our concerns as to the limited and frustrating role of private sector doctors during the earlier phase of this pandemic, the lack of consistent downstream transmission of timely information, inadequacy of algorithms of clinical approaches and therapies, confusing access to referral, medicines and appropriate testing, etc. Happily, most of these have now been ironed out and are much better understood and practiced. We have also managed to successfully convene an urgent Pandemic Flu Conference with the full cooperation from the MOH, which was well received and actively attended by over 700 participants. We will continue to help voice our input and suggestions to further improve the approach towards this still unraveling pandemic, so that our public can be best served, and our doctors better protected and empowered.

5

4. Do you think that MMA should be THE provider for CME / CPD, or like the specialist register this should be given to the Academy of Medicine or MMC? There is no doubt that the MMA remains the best organisation to administer and coordinate the CPD mechanism for doctors in the country. Our approach has been simple and well documented, and has served to ensure that doctors can keep track of their continuing professional development efforts, when they register for such activities. Of course we can further strengthen this mechanism to include web-based learning and documentation and therefore more accurate logging in of CPD points. At this juncture, the MMA believes that the Academy and/or the MMC do not have the logistical, secretarial or manpower support to administer this duty. However, the MMA also hopes that we can be offered greater incentive to continue this function, which we are now performing without any due recognition or financial support. While the specialist register is now within the purview of the Academy of Medicine, its implementation is now incomplete and delayed because of its requirement for registration fees, which we understand is time limited. If the administration of CPD function is to move anywhere, it should not further burden the practicing physician. The fact that GPs and family physicians are making efforts for continuing education and professional development should be sufficient to ensure that the MMA continue to support their endeavours, ultimately for our patients’ benefits. 5. Should it be compulsory for all doctors to have a certain number of CPD/CME points over a certain period to continue obtaining their APC? With the implementation of the revised Medical Act some time in 2010 (?), we expect that the practicing license will be linked to proof of CPD for physicians, the final quantum has yet to be finalised, but is in the order of some 50 to 60 CPD/CME points over 2 years. This will mandate that doctors take greater responsibility to update themselves on a regular basis. It is estimated that thus far only some 10 to 20% of our doctors attend any sort of CPD programmes, and then only sporadically at that! This expected rise in registration and collection for CPD programmes/points will stretch our administrative function and capacity, and thus we hope to be able to perform this with adequate and fair support from the MOH or the MMC. Otherwise this exercise may hit stumbling blocks of gridlock and missed opportunities. Ensuring that more than 25,000 doctors get their CPD registered points will be a definite challenge, but I believe we are up to it. We are in the midst of streamlining registration techniques such as the use of ID card readers and automatic data capture/entry, but cost constraints are real issues. 6. When or should Malaysian doctors give up their role in dispensing medications? The short answer to this, is ‘NO’, not yet anyway. In my view, I think we are still far from yielding our rights to dispensing medicines and therefore separate prescription from dispensing. I urge the Minister of Health to seriously avoid making any arbitrary and hurried action with regards this contentious issue. This viewpoint persists despite our continuing dialogue with the MPS and their continuing lobbying for such a move. Perhaps the most important reason against such a move is the fact that our citizens have yet to learn the difference between what it means to be a doctor and what the pharmacist’s role is. For too long, our rakyat have come to assume that consulting with a doctor for a health ailment meant being accompanied by some given medicines for the healing process—no medicines, no charge, many still feel and expect. That the patient-doctor consultation process is a professional exercise is rarely accepted as a means of fair remuneration for the doctor, although increasingly more and more are accepting specialist visits as such. Thus, the recognition of appropriate fees cont’d...pg 6 • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

6

President’s Page (cont’d)

cont’d...from pg 5

for professional consultation must be made aware of and inculcated into the public mindset. Furthermore, pharmacists too are professionals, and are not merely dispensers of drugs and medicines, nor convenient suppliers of health and beauty products! They too have professional duties, which command more than the simplistic view that their tasks are simply to dish out cheaper discountable medicines and free drug advice! We need to continue to educate our patients and our rakyat that both doctors and pharmacists are professionals who are expensively and extensively trained for specific tasks at helping patients obtain the best healthcare advice and experience. Until such time, patients and our rakyat cannot abdicate their personal duty and opt for the simplest way out. Purchasing medicines without prescription or reviews at doctor visits, is dangerous and self-defeating in the long term, and may even be catastrophic. The public must recognised that most scheduled medications should be used correctly and must be supervised and monitored by their doctors; this step cannot be dispensed with, just for saving a few dollars! Our continuing professionalism demands that we expose such wrongful illegitimate activities, so that together both doctors and pharmacists can further enhance their roles up a few notches. We need to re-educate our rakyat that doctors and pharmacists are not just medication dispensers! Cost and convenience considerations while important should be better managed and understood by all. 7. What is the MMA’s stand on private hospitals, insurance companies and MCOs taking a percentage of professional fees for administration? Isn’t this a form of kick back or fee splitting? What about specifying and volume contracting for lower fees as well? We are in principle opposed to any form of discounted business arrangements, which encourage promises of greater volume of patient referral to certain medical establishments. This inducement can be construed as fee splitting and may constrain patient choice unfairly based on pure economic incentives rather than professional reasons. We recognise that some private hospitals are very aggressively marketing their services with such incentives in mind but which only undermines the professionalism and morale of their doctors. The MMC has already responded to queries by the MOH Amalan Division, by stating categorically that volume discounts and bulk purchasing of professional services (doctors fees) is tantamount to kickback and fee splitting, and thus, should not be allowed and may breach professional conduct. However, other nonprofessional services such as laboratory tests, room charges and pharmaceutical charges may be subject to market forces. 8. What are some other obstacles you face or anticipate encountering? Having not having enough time, personal resources and energy to tackle all these issues. I worry about continuity of purpose and involvement from our future leaders and membership. Too many doctors are simply not interested enough, and expect a few dedicated volunteers to take up the cudgels of responsibility and action to get involved. This is not to imply that as leaders (for a relatively short span of time, 1 to 2 years), we can all make earth-shaking impacts which last—but we have certainly to try leave some imprints which define our better nature and perhaps would have left some legacy of trickle-down, step-by-step advances in our lives and that of our healthcare system and our profession. Events may actually overtake us if we do not represent ourselves more vigorously and with full support from our doctors—we need greater participation and more support both ideologically and • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

physically. We need to increase our membership numbers to swell our ranks of meaningful representation—30% is simply too small a number as of now! We need our doctors to speak up and come forward on issues that affect our professionalism and our livelihood, or that may adversely affect our patients. Reaching out to members is proving to be quite difficult and perhaps not timely or quickly enough. The monthly Berita MMA appears wanting in its reach. Dissemination of information and news does not appear to be fast enough for our members. So much so that some members have voiced frustrations and strong views that the MMA leadership has not been seen to have done or acted promptly enough concerning some urgent professional or practice issues. Doctors must learn to use the Internet more proactively and access information and MMA’s standpoints on various issues, more quickly. We continue to experience some hiccups with our MMA website. We are trying to improve and upgrade this so that this http://mma.org.my will be a much better, more speedy and contemporary site for our official news and views. In the interim, I have offered my personal health blog (http://myhealth-matters.blogspot.com/) as a more constantly updated news and views website, which focuses on mainly professional and practice issues. I am also available for email ([email protected], or [email protected]) inquiries, contacts and commentaries, which may help reach out to more of our concerned members out there. Finally, members must understand that the mainstream media (MSM) do not and have not always responded to all our press releases. The MSM very rarely feel the need to publish any of our many communications, and only those, which they feel are newsworthy for the day or week. This means that most of our press releases go unpublished despite our best efforts—most of the publishing remains the prerogative of the editors and the reporters, as frustrating as this may be to us, when we seem not to get our message across to the public and the doctors at large. However, there is a silver lining: most of the alternative internet media such as Malaysiakini, Malaysian Insider, Malaysian Mirror, Malaysian Medical Resources, Nutgraph have been receptive to our press releases although some editing takes place. So please learn to access these alternative media streams for more timely updates and opinions from our MMA, and myself as the president. 9. Are there any controversies that are unpleasant to discuss in the open, but which should be shared with all members? Issues of involvement/engagement with the MOH: the MOH’s general and still persistent view and perception that private sector doctors and institutions are only interested in making money, are too uncaring, too blasé as to public health issues such as communicable diseases, e.g. dengue fever and the recent A(H1N1) flu, and that our standards of care are below their expectations! The MMA must lead in dispelling such misperceptions, and work towards greater cooperation and commonality of purpose. National issues which impact on health and human rights must be addressed and be openly brought out into national consciousness: national health financing issues, integration of public-private sector plans, pharmacist-doctor separation of duties, planned Quality assurance programs such as MSQH for all private clinics, AFTA/MRA trade opening of the healthcare sector issues; inadequate debate on the required number of medical schools, doctors for our healthcare system and its potential glut and potential declining standards, etc. We must take the lead to expose injustices, perceived wrongdoings and social inequities so that we can enhance civil society as a whole, as part of a more enlightened professional movement. There is much to do, but these are challenges, which I am convinced that the MMA can make important contributions, and perhaps leave a little impact of good and social justice in our wake. 

8

Secretary's Page

From the Desk of

the Secretary.... Fig. 1: Number of Meetings Per Ye a r

Dato’ Dr N.K.S. Tharmaseelan Honorary General Secretary

he MMA is an organisation involved with the mammoth task of looking after the welfare of doctors. In doing so we need to look after several aspects related to the medical profession. It would be virtually impossible for the office –bearers themselves to look after the affairs of the MMA. MMA has thus, formed several Committees – 3 main and 28 other Committees with 34 other representatives to several NGOs and MOH Committees. To function effectively, the Committees within MMA meet about 100 times a year. The total number of meetings with MOH itself amounts to almost 200 with a similar number of meetings with NGOs.

T

N o t e : T h e re m a y a l s o b e a d d i t i o n a l e m e r g e n c y m e e t i n g s

Total Number of MOH Meetings Number of NGOs/Other Meetings MMA Exco Meetings MMA Council Meetings HGS-Staff Meetings Managers/HGS Meetings

167 210 6 6 6 52

Fig. 2: MMA Membership Statistics F rom 1 Jan - 31 July 2009

MMA calls for volunteers annually to serve in these Committees. They are usually limited to a five year term provided they attend meetings regularly. This would give a larger number of members a chance to serve the MMA. Normally before the AGMs a circular is sent out to this effect, seeking members to volunteer to serve in these Committees. The PPSMMA and SCHOMOS Committees are elected at the AGM. Members must appreciate the immense work done by MMA to promote the welfare and look after the rights and concerns of doctors (even non-members). Doctors are urged to become members of the MMA and be more involved in the affairs of the MMA, after all it is the only national association for doctors.  Main Committees Other Committees Total Number of Committees

3 28 31

Number of Meetings per year Representatives to MOH Representatives to NGOs

78 9 25

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

Life Members Ordinary Members Renewals Lapsed & Rejoined Students

No 26 225 2454 201 250

P e rc e n t a g e 1 7 78 6 8

Fig. 3: To t a l N u m b e r o f M M A M e m b e r s

Total number of members (excluding students) Total number of student members

8046 2633

10

PPS Column

QUALITY IN GENERAL PRACTICE by Dato’ Dr Mohan Singh PPS Chairman

Definition of Quality The Institute of Medicine defines quality as:

“…….the degree to which health services for individuals and the population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Donabedian argues that ‘every healthcare practitioners and every healthcare institution has two major objectives: (1) to provide care of the highest possible quality, and (2) to provide care at the lowest possible cost. He identifies three components: • S t r u c t u res: material resources, facilities, equipment and the range of services at the practice level. • P ro c e s s e s : what is done in giving and receiving care. • Outcomes: the effects of care on the health status of the patient and the community. The ‘Health For All’ policy outlined a quality framework for advancement of health promotion internationally. Colloquially known as the Ottawa Charter, the framework identifies a series of principles and strategies. The principles are: • The prerequisites for health such as peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. • Advocacy within political, economic, social, cultural, environmental, behavioural and biological systems. • Enable equity in health care for all; and • Coordinated action by all concerned to promote health. The strategies are: • Building healthy public policy; • Creating supportive environments; • Strengthening community action; • Developing personal skills; and • Reorienting health services. The six dimensions of quality: 1. Safe – avoiding injuries to patients from the care that is intended to help them. 2. Effective – providing services based on scientific knowledge to all who could benefit and retaining from providing services to those not likely to benefit (avoiding under use and overuse, respectively). 3. Patient-centred – providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions. 4. Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care. 5. Efficient – avoiding waste, including waste of equipment, supplies, ideas and energy. 6. Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socioeconomic status. (Source: A Quality Framework for Australian General Practice, Background Paper July 2005, The Royal Australian College of General Practitioners)

Donebedian, an American writer on medical quality talks about quality in healthcare as examinable using the concepts of structure, process and outcome. Structure This refers to the systems you have in place to deal with aspects of running the practice. If you bulk bill all your patients or are a cash only practice, you can get by very easily with a manual accounting system. If you have multiple surgeries, issue accounts to all your patients and have several categories of fee level, your accounting needs may be better handled by a computerized accounting system. The structure of your practice will determine how you may best deal with patient accounts. Process Process refers to how the structures you have in place function. Let us assume you are bulk billing all your patient contacts. Process issues would include items such as: • Do you get vouchers signed for all your patients? • Are the vouchers correctly filled in? Outcome Outcome refers to what happens after an event occurs. In financial terms this is the amount of money you take home from the practice. In other areas of practice performance, outcomes may be more difficult to measure readily. (Source : www.racgp.org.au/runningapractice/evaluation)

Seven Steps to Patient Safety in General Practice S t e p 1 : B u i l d a S a f e t y C u l t u re • Carry out an audit to assess your team’s safety culture. • Highlight successes and achievements in improving safety, and be open and honest when things go wrong. • Apply the same level of rigour to all aspects of safety, including incident reporting and investigation, complaints, health and safety, staff protection and clinical quality assurance. • A strong safety culture requires – leadership, teamwork, accountability, understanding, communication, awareness of workload pressures and safety systems. Step 2 : Lead and Support your Practice Te a m • Talk about the importance of patient safety and demonstrate you are trying to improve it by including an annual patient safety summary in your practice report or your Practice Quality Report. • Include patient safety in in-house staff training, including the use of improvement methods, and ask for it to be part of continuing education outside of the practice. • Promote safety in team meetings by discussing safety issues and making it a standing agenda item. Step 3 : Integrate your Risk Management Activity • Regularly review patient records (e.g. using case note review tools) so that areas of common harm such as delayed or missed diagnoses/treatment can be identified. cont’d...pg 11

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

PPS Column (cont’d) cont’d...from pg 10

• Involve wider primary healthcare team members in improving patient safety and use information from as many sources as possible to measure and understand safety issues in the practice. • Risk management is built into many aspects of a practice’s work: complaints handling, infection control, monitoring environmental risks, protecting vulnerable children, protecting staff, insurance and reviewing repeat prescriptions before they are signed. • A key element of risk management is prevention. A safer practice: o Includes patient safety considerations in every decision the practice makes; o Has complete and accurate medical records; o Uses computerized decision support and responds appropriately to computer warnings, but does not let the computer stop them being alert; o Uses regular systematic case note review to identify and measure adverse events; o Does regular audits looking for avoidable acute admissions (many of which in the elderly are due to medication), interactions and patients lost to follow up (on anticoagulation for example); o Tries to anticipate risks (e.g. double-checking drugs before injection). Step 4 : Pro m o t e R e p o r t i n g • Record events, risks and changes, and include them in your annual practice report. • Cascade safety incidents and lessons learned to all your staff and other practices through your primary care organization. Step 5 : Involve and Communicate with Patients and the Public • Seek patients’ views, especially on what can be done to improve patient safety, and use complaints as a vital part of a modern, responsive practice. • Encourage feedback using patient surveys and websites. • Involve your practice population via patient groups, open meetings or by inviting patient representatives to patient safety meetings. S t e p 6 : L e a r n a n d S h a re S a f e t y L e s s o n s • Make the discussion of significant events and the national analyses of patterns of risk everybody’s business, including the wider primary healthcare team as appropriate, and act on your findings. • Share experiences with other practices by making your patient safety lessons widely available. S t e p 7 : I m p l e m e n t S o l u t i o n s t o P re v e n t H a r m • Ensure that agreed actions to improve safety are documented, action taken and reviewed, and agree who should take responsibility for this. • Use technology, where appropriate, to reduce risk to patients. • Involve both patients and staff as they can be key to ensuring proposed changes is the right ones. • All actions, where possible, need to be simple, appropriate, easy to achieve, measurable, sustainable and effective. Set a timescale and agree who will be responsible for carrying it out. Agreed actions should be reviewed to be sure that they are being implemented. The key steps are : o Raise awareness of the risk or issue. o Measure the size of the problem where possible. o Increase understanding of the problem and the potential solution. o Identify the best solution to the problem.

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o Try to find solutions which design out the problem so that it is difficult to get it wrong. o Introduce the solution that fits and explain to everyone why. o Test it using small scale change methods and keep checking until you feel it is fully implemented. o Review the actions after a period of time to see if they have worked. o Keep finding new solutions until the data shows acceptable improvements. (Source: Seven Steps to Patient Safety in General Practice, National Patient Safety Agency, National Reporting and Learning Service)

Evaluating Physician Competence There are two categories of methods for the formal assessment of physician activities – the assessment of performance in test situations, and the assessment of performance in actual practice. Testing for competence is a broad and complex subject. It seems, however, that testing for knowledge alone is insufficient. The test situation should be so constructed as to elicit clinical judgment and problem solving skills. Ability to elicit and interpret sensory data (for example, in auscultation) should also be included. It is likely that even the availability of multimedia productions the assessment of actual patient care will remain the ultimate test. Actual practice may be assessed by observation, either directly or through videotape; by records of care kept by the physician, other professionals and, even, the patient; by interviews with the physicians, or questionnaires; and by formal ways of obtaining the opinions of other knowledgeable persons in the informal network to which we have already referred. Each of these methods has uses and limitations. There is now no one best method for assessing physician competence. We must rely on a system of assessment that includes attributes, activities and achievements. Our quality assurance system must also include attention to all three components. In particular, health care programmes must not be restricted by structural and process standards, and we must be unalterably opposed to such suggestions so that these programmes can experiment in new and more efficient ways of achieving comparable outcomes. The search for more efficient ways of achieving given outcomes is a major research undertaking which must be conducted with rigorous controls by fully qualified and unbiased investigators. More important than the technical refinement of the system of quality assurance that is adopted is the commitment to quality which makes the system work. Physicians must insist that any system for quality assessment be congruent with a realistic view of what constitutes good care, their obligations to safeguard the interests of their patients, and the means at their disposal. (Source: Evaluating Physician Competence, Avedis Donabedian, Bulletin of the World Health Organization, 2000, 78 (6))

H e a l t h P re v e n t i o n a n d P ro m o t i o n i n G e n e r a l P r a c t i c e More than any other area of medicine, general practice is the specialty where GPs can help patients work toward being the healthiest they can be. It is personalized case based on an ongoing relationship with patients in the context of their family, friends and community. Preventive case is based on a partnership between a GP and a patient, designed to help each patient reach his/her goals of maintaining or improving health. cont’d...pg 13 • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

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From the Desk of

Tan Sri Dato’ Seri Dr Mohd Ismail Merican Director-General of Health, Malaysia

Better Prospects for Doctors Working in the Ministry of Health

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h e re h a v e b e e n m a n y l e t t e r s a n d c o m m e n t s m a d e a b o u t t h e ro l e o f t h e M i n i s t r y o f H e a l t h ( M O H ) i n i m p ro v i n g t h e l o t o f d o c t o r s w o r k i n g i n t h e p u b l i c s e c t o r. It is obvious that many do not know how the gover nment machinery works. While the MOH can come out with brilliant ideas and innovative strategies, these may not mean much if the central a g e n c i e s a re n o t s y m p a t h e t i c o r u n w i l l i n g t o d i g e s t t h e a r g u m e n t s w e p u t f o r w a rd. You may sense that I sound disappointed or frustrated but that is the re a l i t y. Granted, the central agencies have done a lot under t h e p re s e n t C h i e f S e c re t a r y, Ta n Sr i Mohd Si de k Hassan and the Dire c t o r-General of Public Services D e p a r t m e n t , Tan Sri Ismail Adam. Indeed, you cannot get better supporters than these two fine gentlemen. O u r S e c re t a r y - G e n e r a l o f H e a l t h , D a t o ’ S r i M o h d N a s i r Mohd Ashraf, is also very supportive but what I find disconcerting sometimes is the lack of urgency of the i m p l e m e n t a t i o n o f i n s t r u c t i o n s f ro m t h e t o p . S o m e o f o u r t h e m i d d l e m a n a g e r s e i t h e r re s p o n d s l o w l y t o i n s t r u c t i o n s f ro m t h e t o p o r p u t i n c o n d i t i o n s u n k n o w n t o t h e i r b o s s e s t o e n s u re t h a t a l l d e c i s i o n s m a d e a re ‘ c o r re c t ’ a n d ‘ f o l l o w p ro c e d u re s ” . T h e re i n l i e s t h e b u re a u c r a t i c t r a p . P e r h a p s t h e y m e a n w e l l b u t t h e y s e e m c o m f o r t a b l e b e i n g e n s l a v e d b y t h i s b u re a u c r a c y and because of this and the fact that they thrive on orthodox practices, decisions made collectively at the t o p m a y s o m e t i m e s b e i m p l e m e n t e d m o n t h s l a t e r, that t o o a f t e r s e v e r a l re m i n d e r s . The Ministry of Health (MOH), as the primary government agency responsible for providing healthcare to the public, is committed to providing equitable, accessible and affordable healthcare services to all Malaysians. The role is all the more daunting, taking into consideration the mounting challenges in the planning of optimum and acceptable services including changing disease patterns, a well informed and demanding public, rising costs of healthcare, new medical technologies and globalisation and liberalisation. One of the most important components in improving the effectiveness of the healthcare delivery system is an efficient and competent medical workforce. As such, the MOH is working tirelessly to address the shortage of skilled medical and health personnel, especially doctors. For this purpose, 24,135 posts of doctors have been created. However, as of December 2008, only 57% (or 13,762 posts) have been filled. Only 2,545 of the posts filled are specialists from various disciplines and grades (UD 41 and above). Even though the current number of healthcare workers is far from satisfactory, the Ministry of Health is commited to providing the

best healthcare to the public. In 2008, government doctors provided services to 2 million in-patients and 62 million outpatients in 2008. This year the number of patients seen has escalated significantly following the current economic downturn and the Influenza A (H1N1) pandemic. To complicate matters, in 2008, only 60% of doctors are in the public sector although they are responsible for serving 77.4% of the total hospital beds in Malaysia. The remaining 40% of doctors are in the private sector and are responsible for the remaining 22.6% of hospital beds. Our doctors and other allied health professionals have been working very hard to provide the best of care for our patients despite the many constraints, challenges and risks they face everyday. The Ministry of Health has been working very hard to improve the terms and conditions of service, remuneration and working conditions of the doctors. Various measures have been taken and will be further implemented to ensure doctors continue to serve in the MOH. These include the creation of new allowances, improving current allowances such as the critical and on-call allowances, providing incentives for those working extended hours (RM80.00/hr) and those operating on Saturdays (RM200/hr), allowing locum in private healthcare settings and servicing private patients after office hours or during weekends (full paying patients) and many more. In addition, the MOH has created more opportunities for doctors to get promoted to higher grades to retain them in the public health system even though the monetary gain is relatively lower than in the private sector. Efforts have also been made to improve the working environment by providing conducive examination rooms for doctors especially those in new hospitals with IT facilities. Those working in older hospitals, sadly, are sharing rooms, making it difficult for them to protect the privacy of their patients. The MOH has already made an urgent appeal to the government to provide more resources to upgrade these older hospitals in terms of renovations and refurbishments, providing more ICU beds and examinations rooms, modern equipments and others. The Government is sympathetic and we hope to get clearance soon to be able to do this in many of our older hospitals, some of which are more than 20 years old. We do appreciate the sacrifices of our house officers and doctors. We are doing everything in its power to fight for better remuneration, allowances and better promotional prospects. We have also made a proposal to set up the Medical Services Commission. Many of our recommendations need the support of central agencies in the government. We are also mindful of the sacrifices of parents in funding medical education for their children and has recommended to the Malaysian Medical Council (MMC) to reduce the compulsory service from the present 3 years to 2 years. cont’d...pg 13

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

From the Desk of (cont’d) cont’d...from pg 12

We appreciate the long hours houseman and junior doctors have put in. Housemanship training is a period of apprenticeship after graduation from medical school before new graduates are given full registration to practice independently as doctors. The 2-year housemanship training is necessary to further improve the capacity and capability of our trainee doctors. Upon completion of the housemanship training, they will be confirmed in service and be promoted to UD-44, a big jump considering that there are doctors serving more than 4 years who are still on U-41. To rectify this, the latter group will be automatically promoted to U44 by the end of this year. There are still some problems with this exercise. Apparently many of our young medical officers have not obtained their full registration from the Malaysian Medical Council (MMC). It is obvious that the reason for the delay is because our housemen have not applied for full registration even after successful completion of their housemanship. Attempts to get the various sections signed by the relevant specialists may prove difficult as some of the specialists may no longer be there. So I urge SCHOMOS to inform all house officers to make sure they fill up the forms for full registration well before they complete their housemanship to avoid unnecessary delay in their promotion. Housemanship training program, to me, is the most important part of a doctor’s career. It moulds the housemen to become good and safe doctors. It is also the first big step for them in the long journey of the medical profession. But for training to be effective there has to be mutual respect between our younger colleagues and the more senior ones. The senior doctors must fulfill their responsibilities as service providers, teachers, trainers

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and mentors and set a good example for our younger colleagues. The junior doctors must have the perseverance, resilience and patience to go through the training expeditiously and obediently. If they feel they are being shortchanged or treated unfairly, I will be happy to see them. As for medical officers who do not have specialisation, we are working on a timed-based and flexible promotion for them. It saddens me to learn that some of our medical officers (without specialization) have retired on low grades even after putting in long years of valuable and loyal service. With this proposal, they will get promoted when due even if they stay on as ordinary medical officers. Those who obtain their postgraduate qualifications will of course be promoted earlier. With this new initiative, the days of medical officers, some of whom are gurkhas in the department, being neglected or overlooked for promotion, will be history. Please be patient while we work on this. To address the shortage in the short term while waiting for our long term measures to bear fruit, the MOH has invited those working abroad and those in the private sector to work with us. We have already placed advertisements and hope they will respond favourably and rise to the challenge of providing good quality healthcare to all who seek treatment in this country. The MOH, despite the many constraints, challenges and limited resources, will strive to deliver the best medical and healthcare to the public. We have a great team that is overworked and stressed. We hope the central agencies will respond favourably to all our many requests to improve the working conditions, remunerations and career propects of our healthcare personnel. They certainly deserve better. 

cont’d...from pg 11

Prevention is often defined as having three levels: o Primary – the promotion of health and the prevention of illness, e.g. immunization and making physical environments safe. o Secondary – the early detection and prompt intervention to correct departures from good health or to treat the early signs of disease, e.g. cervical screening, mammography, blood pressure monitoring and blood cholesterol checking.

o Tertiary – reducing impairments and disabilities, minimizing suffering caused by existing departures from good health or illness, and promoting patients’ adjustment to chronic or irremediable conditions, e.g. prevention of complications by self monitoring of defined parameters supported by their GP. GPs provide comprehensive, holistic health care to patients, including preventive, curative and rehabilitative care on a continuous and long term basis to all member of a community. A key role of general practice is to prevent disease. 

Prevention Services Level

General Practice Example

Health enhancement/promotion Risk avoidance/remaining healthy

Health lifestyle counseling including nutrition and physical activity advice. Ensuring that those at low risk of disease remain at low risk through immunization, encouragement of breastfeeding and physical activity. Targeting individual patients or groups with a moderate or high risk of disease or injury. Includes advising on smoking, alcohol, unsafe sexual practices, mammography and screening and treating patients for risk factors such as high blood pressure and raised serum cholesterol levels, opportunistic screening for depression. Screening those detected with diseases at an asymptomatic stage when treatment can improve the outcome. Risk is assessed through consideration of the evidence applied to particular patients or groups. Includes recommending mammography screening, pap tests, faecal occult blood test for colon cancer. Prescribing treatments for those with an illness to prevent further complications, including influenza immunization for those with a chronic disease, pneumococcal vaccination for smokers, use of warfarin in the presence of atrial fibrillation to reduce the incidence of stroke, lipid lowering agents to reduce the incidence of subsequent coronary events, best practice management of chronic disease, e.g. tight control in diabetes, hypertension.

Risk reduction

Early detection

Complication reduction

(Source: The Role of General Practice in Prevention and Health Promotion, Policy endorsed by the 48th RACGP Council, 18 May 2006) ( N e x t i s s u e O c t – Q u a l i t y a n d S a f e t y i n H e a l t h c a re ) • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

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SCHOMOS

SCHOMOS Meets

Director-General of Health

by Dr Harvinder Singh National SCHOMOS Chairman Front row L – R : Dato’ Dr N.K.S. Tharmaseelan, Dr Harvinder Singh, Tan Sri Dato’ Seri Dr Hj. Mohd Ismail Merican, Dr Mary Suma Cardosa, Dr Hooi Lai Ngoh and Dato’ Dr Khoo Kah Lin Back row L – R : Dato’ Dr Mohan Singh, Dr S. Thevendran, Dato’ Dr Maria Ithaya Rasan, Dr S. Elangovan and Dr Kuljit Singh

CHOMOS with MMA Exco were fortunate to have met up with Tan Sri Dato’ Sri Dr Ismail Merican, Director-General of Health, Malaysia recently on 1 September at Sheraton Imperial, Kuala Lumpur. This yearly informal meeting was held in conjunction with the Ramadan Buka Puasa. Dr Mary Suma Cardosa, President-Elect, represented Dr David Quek, the President of MMA.

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Many issues were brought up during this informal meeting and DG was kind enough to listen to SCHOMOS and update us on many important issues. Below is a summary of the issues discussed. 1) M e d i c a l S e r v i c e C o m m i s s i o n – DG had already prepared and presented a comprehensive proposal to JPA and Ministry of Finance. This is awaiting approval before this matter can be brought up to Cabinet. 2) UD 44 Pro m o t i o n s – Currently on-going with many teething problems, but is optimistic that this exercise can and must be completed by October 2009. DG gave his personal assurance that he will personally look into this matter with great importance. 3) E l a u n B a l i k K a m p u n g – Circular is on JPA website dated 1 January 2009. 4) H a rd s h i p A l l o w a n c e – SCHOMOS brought this issue to DG’s attention because the circular is not yet available although the approval was announced by the Health Minister recently. 5) Public Health Pro m o t i o n a n d A l l o w a n c e I s s u e – DG commented that this issue had been solved at MOH level and awaiting JPA approval. 6) H o u s e - Officers’ Grouses i) Shift Duty – DG clearly stated that this practice is a “no-no” and is shocked that certain departments in certain hospitals are still practicing this policy and vowed to investigate the matter with SCHOMOS help. ii) H o u s e m a s h i p e x t e n s i o n - House officers’ grouses regarding extension of housemanship due to failure of completion of log book as a result of OT closure in Hospital Taiping was also brought to DG’s attention. He sympatised with the house officers and promised to look into this matter. 7) M e m b e r s h i p D r i v e d u r i n g I n d u c t i o n o f n e w d o c t o r s – DG agreed to help SCHOMOS on this matter whereby a slot will be alotted to SCHOMOS during the induction period for membership drive. SCHOMOS will also be organising a second seminar on “Rights and Responsibilities of Government Doctors” on 5 December, 2009 in Penang. The first such seminar was held last year in Kuala Lumpur with overwhelming response. DG has consented to deliver the keynote address at this seminar. It is hoped that many government doctors will take this opportunity to attend this one day seminar. 

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

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Insurance

Update on Hospitalisation Plans for MMA Members by Dr Hooi Lai Ngoh Honorary General Treasurer & Chairman MMA Insurance Committee

I am writing to provide an update and review of hospitalisation medical plans available in collaboration with AON Insurance Brokers (M.) Sdn. Bhd. for the benefit of members of the Malaysian Medical Association. 1. Pacific Insurance Berhad 1982 – 2004 T h i s G ro u p M e d i c a l I n s u r a n c e S c h e m e i n c l u d e d t h e f o l l o w i n g f e a t u re s : (a) Daily room and board benefit ranging from RM100 to RM150. (b) Reimbursement for hospital services and supplies, intensive care unit and theatre benefits on an “as charged” basis. (c) Cover for daily hospital income was incorporated. (d) There was an overall annual limit. There were no complaints from members about this scheme which was in force for a good 22 years. However, Pacific Insurance Berhad gave notice of withdrawal effective from 1st September 2004 since the amount of premium generated was not substantial and the company suffered losses each year from this scheme. 2. P a c i f i c I n s u r a n c e M e d i - C a re Insurance Scheme 2004 2009 This catered for the renewal policies of members insured under the Group Medical Insurance Scheme which was terminated in 2004. The features included: (a) Daily room and board benefit ranging from RM80 to RM400. (b) There were sub limits for hospital services and supplies, intensive care unit, surgical fees and other benefits. (c) There was an overall annual limit. There has been two complaints from members in recent months particularly relating to inadequate coverage for Hospital services and supplies (sub limit RM2,000 to RM6,000 depending on the plan selected). This was related to escalating medical charges for Hospital services and supplies in recent years. Pacific Insurance Berhad has informed members insured under this scheme that it will not be inviting renewal of policies that fall due from 1 January 2010. 3. J e r neh Insurance Berhad Hospitalisation Plan 2001 - 2008 The scheme was launched in 2001 and had the following f e a t u re s : (a) Daily room and board benefit ranging from RM150 to RM300. (b) Reimbursement of major benefits including hospital miscellaneous services, surgical fees and anaesthetist fees on an “as charged” basis. (c) Maximum benefit under any one disability ranging from RM40,000 to RM75,000. There was only one complaint from a member who wanted three related medical conditions to be considered as separate disabilities, and an amicable additional settlement was made to conclude the case. Jerneh Insurance Berhad had to underwrite losses every year from this scheme; in view of the unfavourable claims statistics the company gave notice of withdrawal from the scheme effective from 1 September 2008. • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

4. M e d i c a l P l a n s f ro m A l l i a n z L i f e I n s u r a n c e M a l a y s i a B h d and Prudential Assurance Malaysia Bhd. These two plans were short-listed in 2008 after an analysis of existing hospitalisation plans available to the general public. In view of the unfavourable claims experience of previous Group Medical Insurance schemes for MMA members mentioned above it was not possible to persuade any insurance company to underwrite a special hospitalisation scheme for doctors. The Allianz plan allows entry up to 60 years of age whereas the entry age for the Prudential plan is up to 70 years. Both plans ensure guaranteed renewal up to 80 years of age. T h e A l l i a n z p l a n p ro v i d e s t h e f o l l o w i n g : (a) Daily room and board benefit ranging from RM80 to RM300. (b) Reimbursement for major benefits including hospital services and supplies, surgical and anaesthetist/operation theatre fees on an “as charged” basis. (c) There is an overall annual limit ranging from RM25,000 to RM150,000 and an overall lifetime limit ranging from RM250,000 to RM1.5 million. (d) Some outpatient services such as those for renal dialysis, stroke and cancer treatment are covered with annual limits ranging from RM5,000 to RM20,000 depending on the plan selected. (e) The amount deductible from the policy (zero, RM2,000, RM5,000, RM10,000 or RM15,000) can be selected by the insured member and the premium will be lower if the amount deductible is increased. (f) Premiums increase each time the member falls into a higher age band. T h e P r u d e n t i a l p l a n h a s t h e f o l l o w i n g f e a t u re s : (a) Daily room and board benefit of RM200. (b) Reimbursement for major benefits including hospital services and supplies, surgical and anaesthetist/operation theatre fees on an “as charged” basis subject to co-insurance at 10% or a minimum of RM3,000 - RM6,000 as selected. (c) There is a lifetime limit of RM225,000. (d) Cover for outpatient renal dialysis and cancer treatment on an “as charged” basis subject to 10% co-insurance amount. (e) Premium will be charges based on entry age (next birthday) and will remain unchanged at each renewal. The details of these two hospitalisation schemes can be accessed from the MMA’s website at http://www.mma.org.my/MemberServices/Insurance/tabid/73/D efault.aspx otherwise please contact: A O N I n s u r a n c e B ro k e r s ( M . ) S d n . B h d . 7th Floor, Bangunan Malaysian Re No. 17, Lorong Dungun Damansara Heights 50490 Kuala Lumpur Tel: 03-2095 6628 Fax: 03-2095 6618 Contact Persons: Mr. Sarjit Singh (Mobile: 016-2012413) Email: [email protected] Encik Zaidon Mohd (Mobile: 016-3756884) Email: [email protected]

Press Statement

Australian Park Named After Malaysian Doctor M E L B O U R N E : The city of Ipswich, about 40km from Brisbane, has dedicated a new 18ha park in Redbank Plains to a muchloved Malaysian doctor who has served the local community for nearly 30 years. Mayor of Ipswich Paul Pisasale said the park was named after Dr Kamalakaran ‘Harry’ Ratnam “to celebrate his professionalism, dedication, loyalty and compassion to the Ipswich community.” “Dr Ratnam, who arrived in Australia, and in Ipswich in 1981 with his wife Raji after an invitation from the Agent General of Queensland in England, has served the community ever since, and I believe it is fitting for this magnificent park to be named after him,” he said. In 2007, Dr Ratnam, who is the younger brother of former judge R.K. Nathan and a first cousin of billionaire Tan Sri T. Ananda Krishnan, was awarded the prestigious

Order of Australia Medal on the Queen’s birthday honours list for service to medicine in Ipswich. “I never dreamed in my life that I would get an Order of Australia and then a park named after me,” he said. “I never expected to be rewarded in this way.” Dr Ratnam, who had his early education at St John’s Institution, Bukit Nanas, Kuala Lumpur completed his schooling in Dublin, Ireland. He then entered the Royal College of Surgeons and Physicians in Dublin, graduating in 1977. Since coming to Ipswich, Dr Ratnam has served on many health and welfare committees, especially with the elderly.

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work done in this area by Dr Harry Ratnam.” Queensland multimillionaire Maha Sinnathamby, formerly of Rembau, Negri Sembilan said Dr Ratnam should be “very proud of his achievements.” “The whole community of Ipswich loves this man. He has done a lot for them,“ said Sinnathamby, who has a boulevard named after him. Most of the 200 people who attended the launch of the park at the weekend were Dr Ratnam’s patients. -- Bernama 

Published: The Star Online Tuesday August 18, 2009

It even prompted Jo-Ann Miller, Queensland State Parliamentary Secretary to the Minister of Health, to refer Dr Ratnam as “an absolute hero” in Queensland State Parliament in April 29, 2004. Ipswich city councillor Victor Attwood, who proposed the park be named after Dr Ratnam, said he did it “in celebration of the (Picture sourced from the Star Online)

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Book Review

Clinical Atlas of Nasal Endoscopy Author: Balwant Singh Gendeh

he technological advancements in the expanding field of rhinology has expedited the publication of this Malaysian contribution entitled “Clinical Atlas of Nasal Endoscopy”. In addition to his numerous academic clinical publications, Prof Dato’ Dr B.S. Gendeh has previously published two other books in his keen interest to keep Malaysians updated in his subspecialty of the nose. His two previous book publications were on “Sinus Surgery: State of the Art Technique” in 2004 and “Otorhinolaryngology” in 2006. Generally, books in selective specialized fields tend to be expansive, but his kind contribution towards rhinology may make this knowledge more easily available to the local medical and surgical fraternity. This vast collection of his own descriptive clinical photographs and facts viewed through the end of an endoscope, introduces the common man to the fascinating world of rhinology. Moreover, nasal endoscopy is a cousin to keyhole surgeries and similar to developments in gastrointestinal endoscopy in opening up new horizon in the state-of-the-art Minimally Invasive Surgery.

T

The book has six chapters. Chapter one briefly describes the development of nasal endoscopy. Chapter two emphasizes on how to perform outpatient endoscopy and the clear visualization of the normal or abnormal anatomy of the nose and paranasal sinuses. However, chapter three being the longest covers the pathophysiology of the disease and the common benign and malignant tumors of the nose and paranasal sinuses. Chapter four focuses on patient selection for surgery when optimum medical therapy fails and describes in fair details the surgical procedures that can be performed visualizing through the nasal endoscope. Furthermore, this chapter will interest the budding surgeons with special emphasis on endoscopic sinus surgery. Chapter five lists the instruments the trainee or the surgeon needs to know to be a good craftsman. Finally, the last chapter takes the discussion of the therapeutic procedures one step further, beyond the nasal cavity to the cranial base. As rhinologist has gained more experience in endoscopic sinus surgery, more areas in the skull base are accessible and surgery is safe. It discusses briefly the technological and surgical advancements in the expanded endonasal approach (EEA) to the ventral skull base. It conveys a message to the reader to “watch this area” with a potential in the near

Price: RM90

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

Website: http://www.ukm.my/penerbit

future. This collaborative effort has put the otolaryngologist and the neurosurgeon to work closely via the nose using the two holes and four hand technique performing the operation simultaneously which never happened before. Clinical Atlas of Nasal Endoscopy, as an introductory atlas contains over 170 illustrative coloured photographs with additional CT and MRI images by a single author. This book print obviously goes out to show about the author’s passion for his subspecialty interest in rhinology and anterior and ventral skull base surgery. I hope this book helps the author spread his passion for rhinology and help train more competent endoscopic sinus surgeons in Malaysia in the very near future. Department of Otorhinolaryngology, UKM Medical Centre, Jalan Yaacob Latif , Bandar Tun Razak, Cheras, 56000Kuala Lumpur. E-mail:[email protected]  Reviewed by: Dr Kuljit Singh

Letter to Editor

19

1st MMA/MAAH Urban Outreach Programme at SMK Sri Sentosa K L, 18 July 2000 Berita August 2009

In response to a complaint received from a concern doctor as to why General Practitioners located around Sri Sentosa were not invited to participate in the above programme, below was the REPLY received from Dr Nazeli Hamzah, Chairperson of the Adolescent Health SubCommittee. Sir, The target participants consisted of 100 `selected` students who went through a specific module to increase their resilience so they are more able to be in control of their actions and not be so easily influenced by negative elements. The facilitators were members of the Adolescent Health Committee of MMA and youth members of the Malaysian

Association for Adolescent Health (MAAH). All the facilitators had undergone training sessions to equip them with the necessary skills.

will be more than happy to involve you in our future activities.

Since studies have shown that adolescents communicate better with their own peers than with adults, we have always found that youths make great facilitators with supervision from adults. We are training a pool of youths to be drawn upon when we have similar projects.

Thank you. 

As this was our first project in an urban area we have not invited other doctors to be involved. We will be happy to invite you to join us for our subsequent programs. I take this opportunity to invite all doctors who have interest in Adolescent Health issues in their community to please contact the Adolescent Health Sub-Committee. We

Together we can make things happen.

Dr Nazeli Hamzah Chairperson Adolescent Health Sub-Committee Email: [email protected]

EDITORIAL NOTE: All ‘Letters to Editor’ must have full name of the authors and their membership number. The Editorial Board reserves the right to decline publishing any letters/articles without names of authors clearly spelt out.

ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA Akademi Kedoktoran Keluarga Malaysia Diploma in Family Medicine (DFM ) 2010/2011 The Academy of Family Physicians, Malaysia recognizes the need for training all General Practitioners to a level of competence in Good Medical Practice to meet the national healthcare delivery standards. AFPM has developed a two year (four semesters) Distance Learning Programme for Diploma in Family Medicine. The objective of this Online Learning Programme is to provide flexibility in learning for all General Practitioners who meet the entry requirement. The course delivers high level teaching materials covering all subject areas of interest to General Practitioners. With the Online tutorial support, Online assignment and MCQ test system, the students will be exposed to information technology and update their professional skills via the cyberspace community. The next academic year will start on January 2010 and it is open to all General Practitioners in Malaysia. The first semester will commence with a workshop to be held on the first week of the semester followed by the first four modules, which are to be completed each month over a period of six months. Upon completion of the DFM Programme, the candidate may continue studying by enrolling on the Advanced Vocational Training Program for two years to prepare for Membership Examination of the AFPM and the Fellowship Examination of The Royal Australian College of General Practitioners. (MAFP/ FRACGP) Application form can be downloaded from: http:// www.afpm.org.my/v2 / member.htm

The CLOSING DATE is 15th December 2009 Mr. Chin Yew Meng For further details, please contact AFPM office: DFM Programme Manager The Academy of Family Physicians of Malaysia Room 6, 5th Floor, MMA House, 124, Jalan Pahang, 53000 Kuala Lumpur, Malaysia Tel: +06-03-4041 7735 Fax: +06-03-4042 5206 Email: [email protected] Website: www.afpm.org.my

20

Mark Your Diary

OCTOBER 2009 AOEMM 11th Technical Update “Health Impact Assessment” Date : 10 October 2009 AOEMM 12th Technical Update “Work Related Occupational Musculoskeletal Disorders” Date : 11 October 2009 Venue : To be determined Tel/Fax : 03-4044 6030 Email : [email protected]/ [email protected] Website : www.aoemm.com 9th World Congress International Association for Adolescent Health (I.A.A.H) “Private Lives, Public Issues: Global Perspectives on Adolescent Sexual Health” Date : 28 - 30 October 2009 Venue : Shangri-la Hotel Kuala Lumpur Contact : Datin Saadiah Ahmad Tel : 03 - 2691 5379/ 03 - 2698 9966 Fax : 03 - 2691 3446 Emails : [email protected] or [email protected] Website : www.iaah2009.com Health Wellness Workshop Healthy Weight, Healthy Life Date : 31 October 2009 Venue : International Medical University Bukit Jalil, Kuala Lumpur Contact : Ms Danielle Ho / Dr Low Bee Yean Tel : 03- 2731 7358/7533 Fax : 03 - 8656 7299 Email : [email protected] / [email protected] Website : http://www.imu.edu.my 38th MMA Perak Installation 2009 Date : 31 October 2009 Venue : Royal Perak Golf Club Tel : 05 - 2436543 / 016-5209022 Contact : Ms Malar Email : [email protected] First Johor Medical Conference in Primary Care Jointly Organised by MMA Johor Branch and Monash University Date : 31 Oct - 1 Nov 2009 Venue : Monash Clinical School Johor Bahru Contact : Dr Kamarudin Ahmad Tel/Fax : 07-2364148 H.P. : 012 - 7761061 Email : [email protected]

NOVEMBER 2009 Seminar and Technical Workshop Mammalian RNAi and qPCR Date : 3 - 4 November 2009 (Seminar) : 3 - 5 November 2009 (Technical Workshop) Venue : International Medical University, Kuala Lumpur Contact : Ms Danielle Ho / Dr Leong Chee Onn Tel : 03 - 2731 7358 / 7528 Fax : 03 - 8656 7299 Email : [email protected] [email protected] Website : http://www.imu.edu.my Post Graduate Course on Paediatric Infectious Diseases “Paediatric Infectious Diseases” Date : 12 – 13 November 2009 Venue : Dewan Jemerlang University of Malaya Tel : 03 - 7949 2065/7949 2732 Fax : 03 - 7955 6114

Contact Email Contact Email

: : : :

Cik Natasha Alia bt Md Yusof [email protected] Prof M. T. Koh [email protected]

Occupational Health Course for Medical Practitioners Date : 13 - 15 November 2009 Venue : To be determined Tel/Fax : 03 - 4044 6030 Email : [email protected] / [email protected] Website : www.aoemm.com

University (UNU), Asia-Pacific Academy Consortium for Public Health (APACPH), World Health organization (WHO), The United nations Children's Fund (UNICEF) and Malaysian Public Health Specialists. Date : 23 - 25 November 2009 Venue : Dewan Kuliah UMS dan Pusat Pendidikan Perubatan Desa Sikuati Kudat Email : [email protected] For further info: http://www.ums.edu.my/conferences

DECEMBER 2009 Second Seminar on Postgraduate Medical Education in Malaysia Date : 14 November 2009 Venue : Grand Seasons Hotel, Kuala Lumpur Contact : Ms Alice Joseph/Ms Hema Tel : 03 - 4041 1375 Fax : 03 - 4041 8187 Email : [email protected] Reg fee : RM100.00 (MMA Members) and RM150.00 (Non MMA Members) AIDS After HAART Date : 14 November 2009 Venue : Hospital Sg Buloh Contact : Prof Suneet Sood Email : [email protected] or Contact : Dr Noor Sham Yahya Luddin [email protected] Contact : Puan Ruhi Tel : 03-6120 3420 Fax : 03-6120 3423 Website : http://mhr.uitm.edu.my http://medicine.uitm.edu.my Plantation Health Committee MMA “Introductory Plantation Health Seminar” Date : 14 - 15 November 2009 Venue : Jenderata Estate United Plantations Teluk Intan, Perak Contact : Ms Punitha Tel : 03 - 4041 1375 Fax : 03 - 4041 8187 Email : [email protected] Website : www.mma.org.my Target Group : Doctors, Estate Hospital Assistants, Plantation Management (Managers and Assistant Managers) Reg Fees : RM100.00 (MMA Members) RM150.00 (Non-Members) (2 breakfast and 2 lunches included) 25th Malaysia-Singapore Ophthalmic Congress 2009 Theme: “Ophthalmology Today and Tomorrow” Organised by MMA Ophthalmological Society (MMAOS) Date : 20 - 22 November 2009 Venue : Renaissance Hotel, KL Contact : Ms Begum Tel : 03-4041 1375 Contact : Dr Jelinar Mohamed Noor (Hon Secretary) Email : [email protected] College of O & G Teaching Conference Date : 20 - 22 November 2009 Venue : One World Hotel Bandar Utama City Centre Petaling Jaya Tel : 03-4041 7088/4041 7541 Fax : 03-4041 9722 Email : [email protected] [email protected] 2nd International Conference on Rural Medicine, ICORM 2009 Organised by Sekolah Perubatan UMS, Persatuan Perubatan Desa Sabah (PERDESA), Kementerian Sains Teknologi dan Inovasi (MOSTI), United Nation

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

Nutrition Communication Workshop Date : 3 December 2009 Venue : International Medical University, Bukit Jalil, Kuala Lumpur Contact : Ms Danielle Ho / Ms Lee Ching Li Tel : 03 - 2731 7358 / 7249 Fax : 03 - 8656 7299 Email : [email protected] / [email protected] Website : http://www.imu.edu.my 40th Union World Conference on Lung Health “Poverty and Lung Health” Date : 3 - 7 December 2009 Venue : Cancun , Mexico Online Reg : www.worldlunghealth.org Rights and Responsibilities of Government Doctors Organised by Malaysian Medical Association and Ministry of Health Date : 5 December 2009 Venue : Auditorium, Ambulatory Care Centre Hospital Pulau Pinang Contact : Ms Azlin (SCHOMOS Secretariat) Tel : 03 - 4041 1375 Fax : 03 - 4041 8187 Email : [email protected] Asia Pacific Primary Care Research Conference 2009 Date : 5 - 6 December 2009 Venue : City Bayview Hotel, Melaka Website : http://www.afpm.org.my/appcrc2009.htm 7th Asian Angle Closure Glaucoma Club Meeting Organised by Malaysia Society of Ophthalmology & Malaysian Medical Association Ophthalmological Society Date : 5 - 6 December 2009 Venue : Crowne Plaza Mutiara Kuala Lumpur Contact : Majmin Tel : 03 - 42517032 HP : 017 - 8821680 Email : [email protected] Website : www.aacgc.org Occupational Health Course for Medical Practitioners Date : 11 - 13 December 2009 Venue : To be determined Tel/Fax : 03 - 4044 6030 Email : [email protected] / [email protected] Website : www.aoemm.com Calling all Medical Graduates from KMC Manipal, KMC Mangalore and Melaka Manipal Medical College to join Annual Alumni Meet Manipal Alumni Association Malaysia Annual Convention Date : 11 - 13 December 2009 Venue : Rennaisance Hotel, Melaka Contact : Mr Kulen Tel : 03 - 2282 7355 Email : [email protected] Website : manipal.org.my

Classified Advertisements ANNOUNCEMENT PUBLIC HEALTH SOCIETY OF MMA

CONGRATULATIONS

The Public Health Society of MMA has been in existence with the MMA since the last few years. It has engaged in public health activities and has worked very closely with other public health bodies, Ministry of Health and the public health departments of the various universities in Malaysia. In the recent years there has been a decline in membership from members of MMA who work in public health areas and other MMA members who have interest in public health issues. The PHS now needs to hold an AGM to elect its office bearers. Through this announcement, the PHS invites all MMA members/ Public Health Specialists who have interest in public health issues to inform the secretariat regarding their contact address to assist them to join the PHS.

For further information please contact: Puan Jalina at MMA House Tel: 03- 4041 1375 Email: [email protected] or Dr S. Elangovan H/P: 012-526 3293 Email: [email protected].

21

The MMA congratulates the following members:

DATO’ DR TEH LEI CHOO Darjah Setia Pangkuan Negeri (DSPN) DR SANTOKH SINGH DR REVATHY NALLUSAMY DR LIM LAY HOOI DR ANITA BHAJAN MANOCHA DR BALANATHAN KATHIRGAMANATHAN Darjah Johan Negeri (DJN) DR TAN CHONG GUAN Bintang Cemerlang Negeri (BCN)

The AGM will be held as soon as possible to elect the new committee. Your urgent attention to this matter is highly appreciated. Thank you.

On being conferred the recent award by the Yang di-Pertua Negeri of Penang in conjunction with his 71st birthday celebration.

Dr S. Elangovan Secretary, Public Health Society, MMA

SCHOMOS SEMINAR ‘RIGHTS AND RESPONSIBILITIES OF GOVERNMENT DOCTORS’ Anjuran Bersama Persatuan Perubatan Malaysia & Kementerian Kesihatan Malaysia Perasmian oleh:

YBhg Tan Sri Dato’ Seri Dr Hj Mohd Ismail Merican Tarikh Masa Tempat

: 5 hb Disember 2009 : 8.30 pagi - 5.00 petang : Auditorium, Ambulatory Care Centre, Hospital Pulau Pinang

Objektif: • Menyampaikan maklumat-maklumat penting berkenaan keperluan perkhidmatan dan kebajikan pekerja kepada para doctor; • Menyampaikan tugas dan tanggungjawab para doctor yang berkhidmat dengan kerajaan; • Membantu usaha Kementerian Kesihatan Malaysia untuk meningkatkan tahap perkhidmatan kesihatan di Negara ini. Yuran Pendaftaran: MMA Member: Percuma Non-MMA Member: RM50.00

Untuk keterangan lanjut, sila hubungi: Puan Azlin, SCHOMOS Secretariat, MMA Malaysian Medical Association 4th Floor, MMA House, 124, Jalan Pahang, 53000 Kuala Lumpur Tel: 03 - 4041 1135 Fax: 03 – 4041 8187 Email: [email protected]

Tarikh tutup pendaftaran: 30 November 2009

22

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PUTRA MEDICAL CENTRE

CIRCUS

P

UTRA MEDICAL CENTRE IS A 145 BEDDED HOSPITAL strategically located in the Centre of Alor Setar. We are expanding and growing with a 8th Level New Wing. In line with our expansion, we would like to invite applicants for the following Resident positions:-

“No one lives his life. Disguised since childhood, Haphazardly assembled From voices and fears and little pleasures, We come of age as masks Our true face never speaks.” Rilke II,11

• • • • • • • •

RADIOLOGIST OPHTHALMOLOGIST GENERAL SURGEON UROLOGIST ONCOLOGIST NEUROLOGIST GASTROENTEROLOGIST OBSTETRICIAN & GYNAECOLOGIST • PAEDIATRICIAN

“How would anyone know if you’re Sad or happy unless you are wearing a mask?” Mirrormask. No one recognizes the shadow In my bedroom mirror until I put on my mask. When I perform, the audience In the big top forget Their tiger-striped anger, elephant Trunk despair, lion-tamer anxiety. The tight rope tension in necks Disappear, All the Damocles fear Are sword-swallowed. Their joy cannon Balls to trapeze heights. I am a consummate performer, Everybody loves me. Every night My saw-dust dread is exchanged For star-dust dreams. Every morning I wake, vowing never again To be a clown. But then the Ringmaster cracks His whip, shouts, “The show Must go on!” by Dr Ng Kian Seng

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Nursing Supervisor Training Manager SRN Nurses & Midwives Cardiac Technician Finance Manager Nursing Manager

• • • • •

MSQH Coodinator Operation Theatre Manager Housekeeping Supervisor Management Trainee Medical Equipment Technician

Please send CV, Certificates, Testimonials and Photo (n.r) to: E-mail: [email protected] For enquiries contact: Mdm Shanti Kandaiyah: 017-5081658 Mdm Gan: 012-5820528 Tel: 04 - 7342888 Fax: 04 - 7348882 Website: www.putramedicentre.com.my

www.adeg.com.sg

The medical practitioners need to be armed with basic knowledge on aesthetic dermatology which are not taught in medical school so that they will be able to advise their patients on various skin rejuvenation procedures and also carry out some of the more simple procedures ADEG workshops are designed to equip medical practitioners(GPs and specialists) to gain basic and practical knowledge on evidence based skin rejuvenation procedures on Asian skin. For detailed formation on ADEG workshops, please visit www.adeg.com.sg Please sign up for the workshop to be held in Kuala Lumpur immediately if you wish to gain knowledge on aesthetic procedures.

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

DERMATOLOGIST PHYSICIAN NEUROSURGEON ENT, HEAD & NECK SURGEON o DENTISTS o DIETITIAN/NUTRITIONIST o RESIDENT MEDICAL OFFICERS (Attractive Incom & Incentive for Self-Drive MOs)

THERE ARE ALSO VACANCIES FOR:

KL ADEG Aesthetic Dermatology Workshops Who Should Attend & Why Attend:

Please send completed form to: Email: [email protected] or fax: +65 62548966 or Mail form and cheque made payable to ADEG Pte Ltd to : 290, Orchard Road, #11-20, Singapore 238859.

• • • •

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23

CLINIC FOR SALE IN KULAI Good Location in Taman Indahpura Doctor Retiring Contact: Dr Lau H/P: 016 - 764 3066

Clinic or Equipment for SALE Fully equipped for surgery with Facilities for O.T and G.A at Mentakab, Pahang.

Contact: Dr Subra – 019-2774455 IMMEDIATE VACANCIES Medical Officer in A & E • 2 Positions • Basic remuneration (RM7,500.00 + EPF) negotiable. • Must be registered with MMC & possess current APC.

Please contact Mr. Selva Raj Tel: 03 - 3324 3288 Ext 230 or Email resume to: [email protected].

"CLINIC FOR SALE" Medical Clinic at strategic location in SEA Park Section 21, PJ for takeover, reasonably priced.

Call: 016-949 7333 017-266 8289

KPJ Healthcare Berhad is a public listed healthcare group owned and managed by Malaysians providing Premier Healthcare Services. Since 1981, our network has expanded with full-facility of hospitals in Malaysia, Indonesia, Bangladesh and Saudi Arabia. We are supported by Services and Companies in creating excellent workplace and providing community value and ensuring fiscal responsibility. Celebrating 28 years of excellence and gearing up for the next phase of our corporate growth, we invite resourceful and committed professionals with the right attitude, skills and experience to join our team

MEDICAL OFFICER Requirements: • MBBS or equivalent from recognized institutions • Registered with the Malaysian Medical Council • Malaysian citizens or hold Permanent Resident Status • At least 3 years working experience Interested applicants are invited to submit full resume complete with working experience, copies of certificate, contact number, current and expected salary and recent passport-sized photograph (n.r.),on or before 15 October 2009 to: H R S e rv i c e s K P J I P O H S P E C I A L I S T H O S P I TA L 26, Jalan Raja Dihilir 30350 Ipoh, Perak Te l : 0 5 - 2 4 0 8 7 7 7 F a x : 0 5 - 2 4 0 8 7 4 5 or via e-mail [email protected]

CLINIC FOR SALE GENERAL PRACTICE WORK IN AUSTRALIA We are looking for General Practitioners to work in two new multidisciplinary Medical Clinics in Adelaide, South Australia. The Clinics are operated by Adelaide Unicare and the University of Adelaide, a public university, established in 1874, and the third oldest university in Australia. It is a member of the elite “Group of Eight” Universities in Australia. Benefits include: • Assistance with registration and visa requirements; • Assistance with relocation: travel, accommodation and suitable schooling etc.; • A good, safe lifestyle close to the city centre; • Brand new purpose built facilities; • High remuneration with a 2 to 5 year contract; • Ideal for husband/wife team; • Working within a coordinated and integrated “one-stop” primary healthcare model; • A population approach to healthcare service delivery; • Practice nurses, allied health professionals and diagnostic services on site; • Student training, teaching and research; • Opportunity for academic appointment; • Opportunity for further training; • Commencement late 2010/early 2011. Candidates must satisfy Australian Medical Board requirements and assessments to work as a Doctor in Australia.

MOH registered clinic in populated surburb of Ipoh. Ready for immediate takeover, Doctor retiring.

Contact: 012-5809189 (Between 5pm - 8pm)

DERMATOLOGIST WANTED Every Monday to Friday 2.00pm – 4.00pm in Seremban. Contact: 012 – 395 8848

MEDICAL OFFICERS needed in NCI Cancer Hospital in Nilai. Call: Stephanie: 06-8500999 Ext. 2333 or Email resume to: [email protected]

To apply, email your CV and contact details to Mr Ivan Lee at: recruitment.ivan @gmail.com Enquiries to 0129 117 260. • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

24

Report

Introductory Plantation Health Seminar We would be also discussing the problems faced by the medical team and the management in maintaining good health among the plantation workers. There would be a question and answer section at the seminar which we hope will benefit all participants. by Dr J. R. Prushothaman Committee Member, Plantation Health Committee, MMA

he Plantation Health Committee headed by Dr Ravindran Naidu is planning to be more dynamic this year. We just had our first committee meeting on the 6 September 2009 and we have confirmed our first Plantation Seminar to be held on the 14 and 15 November 2009 with the first day being lectures and the second day will be hands on training like A Walk Through Survey, Line Site Visit, Crèche Visit and a demonstration on the correct technique of spraying chemicals and personal protective equipment. The venue has been confirmed and it will be held at Jenderata Estate, United Plantations, Teluk Intan, Perak.

T

The Plantation Seminar will be useful for all doctors especially V.M.O (Visiting Medical Officers) as well as for the Estate Hospital Assistants (EHA). The Estate Managers and Assistant Managers would also benefit in attending such seminars. The Management would be aware of all the regulations and laws that govern the health faced by their workers and the correct role of the V.M.O and Estate Hospital Assistants.

The topics of discussion are as follows: 1. Role and Responsibilities of Visiting Medical Officers 2. Role and Responsibilities of Estate Hospital Assistants 3. Chemical Regulations 4. Noise Regulations ( Oil Palm Mill) 5. Estate Sanitation and Health and Minimum Housing Act 6. Common Diseases in the Plantation 7. Personal Protective Equipment The Plantations such as United Plantation, Sime Darby, National Land Finance, FELCRA, FELDA and many more would benefit from this seminar. The plantation industry in Malaysia has been one of the major economy frontiers since the yester years of British Colonization. After rubber and coconut, currently oil palm has been a major booster for the Malaysian economy. Hence, getting involved in health issues of our Plantation workers would indirectly improve our Malaysian Economy. If any doctors and visiting medical officers have any doubts, problems or topics that they want to be addressed, please do not hesitate to write to the Chairman, Plantation Health Committee MMA. We would appreciate any feedback from the members. 

MEDICAL PROTECTION SOCIETY

An exciting and prestigious role with an international education team MPS is the world’s leading indemnifier of health professionals covering more than 260,000 doctors and dentists worldwide. As part of our commitment to improved professionalism, quality and safety, MPS is embarking on a significant expansion of the risk management and educational services we provide members. There is an opportunity for Malaysian doctors with an interest and expertise in communications and risk management to join our world class medical faculty to become a trained presenter. Presenting risk management and communications programs to your medical and clinical colleagues as a MPS faculty member is an exciting and prestigious opportunity that can enhance your reputation as a professional expert.

Successful candidates must: 

Be a medical graduate with significant post graduate experience



Have experience in training, education and/or presenting



Have extensive experience in one or more of the following areas; medical education, communication skills training, formal post graduate psychological or counselling training and risk management or medicolegal experience linked with a medical protection organisation or healthcare facility



Be based in Malaysia.

Both local (overnight) and international travel may be required.

Presenter positions would suit either full time or part time clinicians looking for regular weekend or mid week work.

Doctors who are interested in applying should review the position description on www.medicalprotection.org/uk/careers All applications must include a letter detailing how they meet the minimum requirements, necessary experience and profile description outlined in the position description.

Applications must arrive by 23 October 2009 Applicants who are shortlisted will need to be available for a video or teleconference w/c 26 October 2009 and a selection interview in Singapore on 13 November 2009. All travel costs to this event will be met by MPS in accordance with standard policies. We are an equal opportunities employer. PROFESSIONAL SUPPORT AND EXPERT ADVICE

MPS_MAL_FACPD_MMA_0909

Applications should be forwarded by email to [email protected] or mail to: Faculty and Education Support Coordinator, MPS Educational Services Asia Pacific, P.O. Box 1013, Milton, Queensland Australia 4064

CME Update

26

“Limbal Stem Cell as Potential Therapy to

Blinding Corneal Conditions” by Dr Bakiah Shaharuddin Universiti Sains Malaysia

T

he surface epithelium of the eye comprises of conjunctiva at the p e r i p h e r y, l i m b u s a t t h e t r a n s i t i o n zone and the cor neal epithelium. Cor nea is a s t r u c t u re a t t h e f ro n t o f t h e e y e w h i c h a l l o w s l i g h t t o p a s s t h ro u g h t o re a c h re t i n a , which then transmits signals to the brain. To p e r f o r m t h i s f u n c t i o n , c o r n e a m a i n t a i n s i t s t r a n s p a re n c y b y p h y s i c a l l y b e i n g d e v o i d of any blood vessels.

and the epithelium are continuously eroded and exposed the corneal nerves. The eye would be inflamed and the conjunctiva epithelium may replace the corneal epithelium bringing together heavy vascularization, inflammation and its milky coloured surface. Painful red eyes, secondary glaucoma and total blindness are conditions suffered by these patients which reduce their quality of life. The principle of treatment for limbal stem cell deficient conditions include the use of amniotic membrane graft, conjunctival-limbal autograft and penetrating keratoplasty. Amniotic membrane grafting on its own usually fail to regenerate the epithelium. Conjunctival-limbal autograft needs a large size graft taken from patient’s other healthy eye which would render the donor eye of developing secondary limbal stem cell deficiency. If an allogenic source is used, the cont’d...pg 27

The regeneration of corneal epithelium relies heavily on the stem cells which are located at the limbus, the circumferential structure area around it. Limbus also separates cornea from the conjunctiva which is highly vascularized and is slightly opaque. The stem cells are also protected by being deeply buried and hidden by pigments which are abundant at the limbal area. The stromal component of the limbus is also richly innervated and vascular, to allow proliferation and maintenance of the stem cells niche. In limbal stem cell deficient conditions which in majority are due to chemical injury, the limbus could be totally damaged S t r u c t u re s o f t h e e y e

Day 20 Autologous

graft

c u l t u re d

with

amniotic

membrane

transplantation • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

re a d y

for

Limbal stem cell deficiency in the right eye of patient with chemical injury

CME Update (cont’d) cont’d...from pg 26

risk of graft versus host disease is also a risk. Penetrating keratoplasty does not replace the stem cells thus it bears the same complications and a high risk of graft rejection. This makes the procedure prone to failure. Limbal stem cells transplantation addresses the problem of treating the limbus while keeping the eye ‘quiet’ for the possibility of a more definitive procedure i.e penetrating keratoplasty, to be performed to clear the scarred central part of the cornea, at a much later date. By keeping the inflammation at bay, patient would benefit from a pain-free condition. Limbal stem cells are part of the ‘adult somatic stem cells’ which have limited potential of differentiation or specialization. The sources of limbal stem cells could be derived from patient’s own tissue from a healthy eye which is autologous in nature, from a living relative (allogenic), or from a cadaveric source. Other autologous sources could be other epithelial derivations from other types of stem cells i.e embryonic or mesenchymal origins. In a method of ex-vivo expansion, a limbal tissue explant may be obtained from a small biopsy from the other healthy eye. In the laboratory, the limbal explant was cultured using a cryopreserved human amniotic membrane for two weeks.

27

After a successful process of tissue expansion, patient is transplanted without the need for use of anti-rejection drugs, as the original source of tissue is patient’s own cells. Most patients would experience the benefit of this transplant after 3 days of surgery whereby alleviation of the pre-existing painful red eyes is the first sign of recovery. Continuous improvement in visual acuity may be observed during 12 to 18 months of follow up. Stabilisation of the limbal area by this method will result in a marked improvement to the subsequent second surgery which is normally undertaken to clear the scarred central part of the cornea. In this instance, penetrating keratoplasty, a surgery performed by removing the central cornea of the patient and replace it with a cadaveric donor cornea will fare more favourably. The method described above, the “Newcastle method” was carried out in a clinical trial at the Royal Victoria Infirmary in Newcastle upon-Tyne. They have recruited 10 patients whom were sufferers from chemical injury to the cornea. In their clinical trial, all the patients had subjectively reported considerable alleviation of eye pain. Most patients had also improved their visual acuity at least 4 lines tested by Snellen Chart. Following this success, the ophthalmology/limbal stem cell team at Newcastle University will recruit more patients into their clinical trial next year. 

28

CME Update

COLOUR BLINDNESS by A. Prof. Dr Andrew Tan Khian Khoon

What Is Colour Blindness Colour blindness is not a form of blindness at all, it is a condition whereby the person with this condition finds it difficult to discriminate between different colours, especially when many type and shades or hues of colours are presented at the same time. The commonest type of Colour Blindness is Red-Green colour deficiency, which is usually an inherited condition; other less common forms include blue-yellow colour deficiency. It is estimated by various studies that worldwide, 2 to 8% of men are affected by this Fig. 1: condition. A recent study done in Singapore by Chia A. et al in 2008 found that among 1249 secondary school students between the age of 13 to 15 years old, 5.3% of boys and 0.2% of girls were found to have colour blindness.

Ishihara Colour Blindness Test Booklet

Fig 2: Ishihara Plate

Clinical Features Contrary to popular belief, people with colour-blindness seldom see things in black and white or shades of grey, they are still able to see colours, though they may have a hard time distinguishing between colours, say between red and green, or blue and yellow, especially when they are presented with a mix of many colours.

What Causes Colour Blindness Colour blindness happens when photo-sensitive cells (photoreceptors) in the retina do not function properly. Usually, people with colour blindness are born with it, it is usually a sex-linked (X-linked recessive) chromosomal disorder, which means it affects male much more than female. A male with the colour blindness gene will be manifested as colour blind, whereas a female with only one colour blindness gene will not be colour blind (as female has 2 X-chromosomes), but instead will be a carrier and pass the disease to her sons, a female will only be colour blind if she has 2 colour blindness gene, one on each of her Xchromosomes. Red-Green colour blindness usually results from diseases of either long (L) or middle (M) wavelengthsensitive visual photo pigmentation. It is the most common single locus genetic disorder.

Fig. 3: Farnsworth-Munsell 100-Hue Colour Vision Test Kit

Besides this inheritable form of colour blindness, damage to the retinal cells may also cause colour blindness, which may affect different spectrum of colours, these aetiological factors may be: ageing, diseases and drugs (e.g. certain drugs used in treating arthritis), in extreme cases, these other disease may lead to total blindness, whereas inheritable red-green colour blindness does not lead to blindness. Diagnosis Eye doctors usually test for colour blindness using some coloured plates with numbers or figures made up of many dots of different colours, known as the ISHIHARA CHARTS. cont’d...pg 29

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

CME Update (cont’d)

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cont’d...from pg 28

There are also other tests available for assessing the extent of colour blindness for industrial or professional use, such as 'Lantern Test' and '100 Hue Test'. More sophisticated electro diagnostic tests like Electro-retinogram (ERG) or ElectroOculogram (EOG) are also useful in diagnosing this condition. Treatment Colour blindness cannot be cured, nor prevented - except by genetic counselling. (Though possibility of using genetic engineering to repair/modify the colour blindness gene may be a possibility in the future). Diagnosing colour blindness early in life may prevent learning problems during the school years, since many learning materials rely heavily on colour perception. Other forms of remedy for colour blindness include special lenses which are colour filters, available either in contact lens or spectacle forms. Other ways to work around this disability include organising and labeling items of different colours to avoid confusion. Remembering the order of things rather than their colour may also help (e.g. the red light is always at the top a traffic light, followed by yellow and green.)

Remember proper counselling and career guidance early in school life is very important for sufferers of colour blindness, as they may not be suitable for certain jobs, e.g. pilot, navy or other jobs where discrimination of colours is of ultimate importance and cannot be compromised, otherwise, people with colour blindness can venture into most career. Recently, there were various experiments done in the United States in laboratory animals that suggested gene therapy in adult animals may be useful in treating colour blindness, which will greatly give hope to people affected by this condition in the future. Researchers from the University of Washington (Mancuso K. et al, 2009 September 16) had described experiment whereby a third type of cone pigment (opsin), was added to dichromatic retinaes in adult monkeys to produce trichromatic colour vision behaviour which apparently does not require an early developmental process. This provides a positive outlook for the potential of gene therapy to cure adult with colour vision disorders. Other promising studies to date include that done at the University of Florida (June 2008) in which cone targeted therapy was done using Adeno-assisted virus (AVV) vectors. 

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Branch News

MMA WILAYAH ACTIVITIES 1

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by Dr Koh Kar Chai Chairperson, Wilayah Persekutuan

As is the norm every year, come the ‘Puasa Month’, there will be a dearth of activities as our Muslim brethren go into a month long fasting period and prepare for the ‘Hari Raya Aidilfitri’ celebration at the end of it. During this celebration week, many Malaysians will go off on a holiday. Thus, most of the Pharmaceutical companies will hold back on their CPD activities for fear of a poor participation of doctors. The first activity that we at MMA Wilayah embarked upon, immediately after the festivities was the ‘ K L E a r, N o s e & T h ro a t S y m p o s i u m f o r P r i m a r y C a re Physician’. This event was held on the 27 September, 2009 under the auspices of MSO-HNS (Malaysian Society of Otorhinolaryngologists, Head & Neck Surgeons), MMA Wilayah, MMA Selangor and PMPASKL.

1. Participants signing in early in the morning. 2. Even the Course Director needs to sign in. 3. Our doctors in deep concentration 4. Dr Shailendra, Dr Loganathan, Dr Yap Yoke Yeow, Dr Kuljit 5. Dr Rahmat Omar 6. Dr Balwinder, Dr Yeo Sek Wee 7. Dr S. Shailendra, Dr Kuljit, Dr Pua Kin Choo (President of MSO-HNS), Ms Darleena, Dr KC Koh

A presentation on the C o n s e n s u s G u i d e l i n e s o n t h e M a n a g e m e n t o f U p p e r R e s p i r a t o r y Tr a c t I n f e c t i o n was also done at this event. This guideline was drawn up by ENT Specialists from the MSO-HNS and Primary Care D o c t o r s f rom MMA Wilayah. It was initiated about two years back and finally presented this year.

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It was felt that since this Consensus Guideline is meant for the use by Primary Care Doctors, an input is required from this group of medical practitioners. Hence, the role of MMA Wilayah in the formulation of this Consensus Guideline by the provision of input by our Wilayah Primary Care Doctors. Funding was available in the form of an educational grant from a local Pharmaceutical company, for which we are grateful to have, since it requires a certain amount of financial allocation to embark on such activities. It has been the norm for Multinational Pharmaceuticals to be involved in such ventures, with most of our local Pharmaceuticals taking a back seat. Hopefully, with this Symposium, we will see more similar activities being initiated by our local Pharmaceuticals. We were pleasantly surprised with the overwhelming response by our doctors in the Klang Valley. Apparently, the Pharmaceutical Company involved in handling the RSVPs had to turn down some doctors who wanted to attend the event as the lecture hall

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

couldn’t accommodate the number of doctors who had replied to the invitation. At the end of the day, our doctors left the venue armed with additional valuable information on the management of URTIs in the Primary Care setting, as well as some interesting knowledge on certain ENT disorders. 

Don’t forget to mark your diary for the 5th PRIMARY CARE SYMPOSIUM on the 9 and 10 January, 2009. Website: www.mmawilayah.com

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Branch News

Briefing to the Private Sector on

Influenza A (H1N1) Penang, 5 September 2009

by Dr Saraswathi Bina Rai Penang

nother briefing on Influenza A (H1N1) was held in Penang (for the 3rd time this year in the state) to the private sector. The idea was mooted by the State Health Director, Dato’ Dr Teh Lei Choo following a request by a private practitioner in Penang to have such a session. There had been two such briefings before this year and both were held on a Sunday but the attendance was never as envisaged. The State Health Director planned the date with the Chairman of Penang Branch MMA and PMPS President and a Saturday morning was agreed upon – 5th September, 2009. It was very timely indeed as over the week prior to the event, there were some changes in the management of Influenza A (H1N1) and we were able to update the participants accordingly.

A

To ensure all the private doctors were aware this time around, flyers were sent through MMA and PMPS to all their members; letters were sent individually to the private hospitals; In addition emails were sent to about 400 private doctors, dentists (Yes, we decided that dentists too should be informed) as well as to the private hospitals. Not all doctors are members of MMA or PMPS but we tried to reach as many as possible. We were quite confident that most of the private doctors were aware of this briefing but the decision to attend is a personal choice. The Penang Branch of MMA was represented by Dr Praveen, the Vice-Chairman; Dr Patrick Tan, the President of PMPS was present as well (in between his surgeries); the State Health Department was well represented by the Director - Dato’ Dr Teh Lei Choo, Dato’ Dr Rosenah - the Consultant Physician, and the District Health Officers. Yours truly wore the hats of MMA Penang Branch and the State Epidemiology Unit – the unit to receive all brickbats. There were three presentations – Dato’ Teh took the lead and gave an overall situation of the disease. This was followed by an excellent presentation on the Medical Management of Influenza

• MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

A (H1N1) by Dr Chow Ting Soo, the Infectious Disease Physician in the State. She was able to share her experience on the many cases that she had handled at the Penang General Hospital. The 3rd presenter was Dr Chan Kwai Cheng, the Infectious Disease Pediatrician at Penang General Hospital. Her topic was on the Pediatric Management of Influenza A (H1N1). Each participant was given a CD on the lectures presented – compliments of the State Epidemiology Unit. The session was chaired by Dato’ Dr Lim Yu Hoe, Consultant Physician at Penang General Hospital. He had been given the task of taking the role as the State Liaison Officer for Flu A. Personally, I believe it’s an excellent move. Penang is a great place to work as there always has been great cooperation between the private sector and Government and between the Health and Hospitals and this has never been an issue here. However, we do need someone to champion our cause and Dato’ Lim may be the most apt person. He pointed out that patient education was not effective enough and each and every health personnel had a role to play in this. The public was still not interested and there is lack of knowledge. It is every health practitioner’s task to treat, prevent and to allay anxiety and he stressed upon these simple but crucial messages. There were hitches at the start of this briefing that was held at the Auditorium of Hospital Pulau Pinang. The air-conditioning went on strike and the hall projector refused to work (as always: Murphy’s Law). Anticipating the worst, we had brought our own LCD and notebook as well, so were able to rectify the situation, and started right on schedule. Hence, albeit a tilted screen and a few stiff necks it was a very fruitful morning and it’s a pity that more doctors did not attend. I believe it is their loss. At the end of this very stressful morning, sitting at home with a book, I texted my appreciation to all those involved in this organisation and made this happen. Maybe the reply from the Health inspector from the Epid Unit sums its all: “Satu Pasukan, Puan”. One team! Yes, it’s nice to be a part of this team! 

Branch News

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MMA PERLIS PAIN WORKSHOP by Dr Hari Ram Ramayya On 1 August 2009, two events were organised by MMA Perlis. The first was a Pain Workshop held at Putra Palace Hotel at 2.00pm. The speakers were Mr. Jaya Prakas Rao, General Surgeon, HTF, Mr. Yeap Ewe Juan, Orthopaedic Surgeon HTF and guest speaker was Dr Mary Suma Cardosa, Consultant Anesthesiologist, Hospital Selayang. The Workshop was attended by about 30 doctors including GPs and ended at 6.00pm.

MMA PERLIS DINNER 2009 The 3rd Annual Dinner and Installation Night was also held at Putra Palace Hotel on the same night. The guest of honor was Perlis Menteri Besar, YAB Dato’ Seri Dr Md Isa b. Sabu. The night was graced by about 100 members and two outstanding service awards were conferred to Dr Khairul Shakir former Branch Secretary and Dr Hasna Hamzah, former Branch Treasurer for their contributions in establishing the Perlis branch. The awards were given out by YAB MB. “Chain of Office” was handed over to the new Chairman, Mr. Yeap Ewe Juan by Dr Hari Ram. The night ended at 10.30pm and was a great success. 

Occupational Health for Health Care Professionals –

Caring for the Carers Publisher ISBN Number Editors Cover Pages Contents

: : : : : :

Malaysian Medical Association 978-983-99128-3-8 Dr G. Jayakumar & Assoc. Prof. Dr Retneswari Masilamani Hard 300 pages 22 Chapters (Contributors from: Malaysia, Singapore , Japan, India, Australia, United States of America, United Kingdom, UAE, Egypt and South Africa)

TO PLACE ORDER: Contact: Ms. Hema @ Tel: 03- 40411375 Email: [email protected] Cost: RM88.00 (inclusive of postage within Malaysia) Cheque payable to: Malaysian Medical Association

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SP’s Korner

SP’s Korner by Dato’ Dr S. Pathmakanthan Ipoh, Perak

This is my 200th contribution to this Korner. There was a time in September 1985 when I got this queer urge of propagating humour in a written form. I was then encouraged by friends and colleagues. I particularly like to single three of them – Dato’ Dr Joginder Singh and the late Dato’ Dr Lim Say Wan both of whom were Editors of Berita MMA during that period and Dato’ Dr Abdul Hamid. And for some of the early years, I had to progress against some prevailing odds to keep the budding voice of humour growing in a conservative and mundane society where mirthology is strictly controlled by theology and ethnicity. After a span of 25 years, some humour is still taboo and can only be nervously mentioned in isolation and in “silence” in our “fragmented but one” society. TALK, TALK!! A husband, proving to his wife that women talk more than men, showed her a study which indicated that men use, on the average, only 15,000 words a day, whereas women use 30,000 words a day. She thought about this for a while and then told her husband that women use twice as many words as men because they have to repeat everything they say. He said,“What?” WHAT IS IN A NAME – ANATOMY The pastor asked if anyone in the gathering of the Church Hall would like to express “Praise for answered prayers”. A lady stood up and walked to the podium. She said,“I have a Praise. Two months ago, my husband, Marvin, had a terrible motorcycle wreck and his scrotum was completely crushed. The pain was excruciating and the doctors didn’t know if they could help him.” You could hear a muffled gasp from every man in the congregation as only they can imagine the pain that poor Marvin must have experienced. “Marvin was unable to hold me or the children.” She went on. “And every move caused him terrible pain. We prayed as the doctors performed a delicate operation and it turned out they were able to piece together the crushed remnants of Marvin’s scrotum and wrap wire around and through it in places to hold it in place.” Again, the men in the gathering were unnerved and squirmed uncomfortable as they imagined the terrible surgery performed on Marvin. “Now,” she announced in a quivering voice,“thank God, Marvin is out of hospital and the doctors say that with time his scrotum should recover completely.” All the men sighed with obvious relief. The Pastor rose and tentatively asked if anyone else had something to say. A man stood up and walked slowly to the podium. He said,“Hi, I’m Marvin.” The entire congregation held its breath. “I just want to thank you all and also explain to my dear wife again that the word is STERNUM.” GOVERNMENT A small boy was asked by his teacher, “What is the size of the Government?” “About 5 feet 2 inches,” he replied promptly. “No, no, no,” said the teacher, “I mean how many members the government has? How did you get 5 feet 2 inches anyway?” “Well,” replied the boy. “My father is 6 feet tall and every night he puts his hand to his chin and says,“I have had it up to HERE with the Government!!” • MALAYSIAN MEDICAL ASSOCIATION • SEPTEMBER 2009

HOW STUPID CAN YOU GET Bob walked into the Royal Ipoh Club Long Bar at around 10.00pm. He sat down next to Vella at the bar and looked up at the TV. The 10.00pm news was on. The news crew was covering a story of a man on a ledge of a tall building preparing to jump. Vella looked at Bob and said,“Do you think he’ll jump?” Bob said,“You know, I bet he’ll jump.” Vella replied,“Well, I bet he won’t.” Bob place a RM10 bill on the bar and said,“You’re on!” Just as Vella placed his money on the bar, the guy on the ledge did a swan dive off the building, falling to his death. Vella was very upset, but willingly handed his RM10 to Bob saying, “Fair’s fair. Here is your money.” Bob replied,“I can’t take your money. I saw this on the 5.00pm news and so I knew he would jump.” Vella replied, “I did too. That really must have hurt!! I didn’t think he’d do it again!!” Bob took the money. REAL DISPUTE – PRE – DNA STORY A young boy comes running down the street looking for a cop. He finds one and then begs, “Please, officer, come back to the bar with me, my father’s in a fight.” Well, they get back to the bar and there is three guys fighting like you wouldn’t believe. After a while the cop turns to the kid and says, “Okay, which one is your father?” The kid looks up at the cop and says, “I don’t know, officer. That’s what they’re fighting about.” LYRICS OF INDIA Surinder’s granduncle was booked into an SIA flight to Bombay. But as this was his first time in an airplane, he made a few preparations that were out of place. When the stewardess came around to take orders for the in-flight meal, the granduncle declared loudly, “I have brought my own lunch. Make sure you don’t charge me for food and drinks!” So, as everybody was given their in-flight meal, the granduncle began spreading out his own home-cooked meal. The man sitting next to him was an American history researcher, who was curious about the food. “Excuse me, what is that drink?” he asked. The granduncle picked up the yogurt-based lassi drink and said, “Milk of India!” The granduncle took out several pieces of chapattis and started feasting. “And what is that dish?’ asked the curious American. “Wheat of India!” replied the granduncle proudly. Finally, the granduncle took out some desserts. He offered some to the American. “What is it?” asked the American. “Sugar of India!” replied the old man. After the meal, everyone was settling down when there was a loud “Pooooooooot” from the granduncle. “What was that?” asked the American in disgust. The old man replied coolly,“That’s air of India!” MINI – BITES (1) You know that children are growing up when they start asking questions that have answers. (2) “If stupidity got us into this mess, then why can’t it get us out?” - Will Rogers (3) “Any government that robs Peter to pay Paul can always depend upon the support of Paul.” - Rings a bell, eh! (4) The more you observe politics, the more you’ve got to admit that each party is worse than the other. - Will Rogers (5) An amateur golfer is one who addresses the ball twice: once before swinging, and once again after swinging. (6) “We don’t want to go back to tomorrow, we want to go forward.” - Dan Quayle (7) Terrorists pollute the nation’s water supply with truth serum. Society is rocked to its foundation as everyone including lawyers and politicians start speaking honestly. Doctors were status quo. Marvin murmurs:- “Two is company. Three is bad control.”