Saturday, December 11, 2010






· Ethics is linked to morality and judgments associated with it

· Everyone has his own moral values which has been nurtured over a period of time

· Every person’s moral values is unique and is normally determined by a number of factors including gender, culture, religious belief, environment and personal upbringing

· A medical student does not normally have an opportunity to exercise his moral judgment in dealing patient. Even if he does, that judgment does not influence the clinical management and care of his patient

· Ethical issues during period of studentship probably links to moral issues relevant to his personal conduct and its association to whosoever he in contact with. This may include issues such as truth telling, plagiarism, time-keeping, honesty, courtesy, empathy, respecting rights, communications and exploring insights of patients (MERCI checklist)

· Many of the issues of morality during the student days do not really matter to patient care

· The situation quickly changes as a student graduates

· Granting of a medical degree immediately empowers a student and unveils the cloak of uncertainty that has been covering him for at least 5 years

· He is now ready to make his own decision. Some of these decisions have to be made while he is at the front line of patient care, receiving patients at first point of contact and dealing with all the emotional issues surrounding a patient and his relatives

· This is the time when his moral judgments matter

· At the same time as he makes his judgments in his professional behaviour, his patients also judge him according to the scale of their moral judgments

· Judgment and evaluation of one’s moral standing can be gauged through a number of manifestations; from the way he dresses at work, the language he uses, gestures and body language, manner of interaction with peers and colleagues at work, note writings and phone calls and degree of urgencies in his actions. All of these carries significant weightage

· A patient who sees the first doctor on the scene who appears disheveled and unkempt would have a certain assumption and belief. Care of a sick person usually comes from an environment of clean and tidiness

· A houseman whose language lacks sufficient empathy and speaks in a language quite foreign to the patient he is in direct contact would transmit a certain message that can be adversely interpreted. Adverse interpretation may wrongly lack of interest and care, feeling of worthlessness, trust and confidence in the clinical management (remember the case of the doctor, declaring to his colleague that the hospital lacks fund, in full view of his acutely ill patient and his relatives). Casual statements such as “ I am only a houseman” or “My boss is not here and on holiday” would convey certain message to patients

· Patients normally take note the demeanor of the first doctor on the scene. Gestures and body language matter a great deal in transmitting sense of urgency and feeling of being taken care of. Most of these hidden issues relate directly to response to treatment and thus the speed of recovery from illness

· The environment within which a patient is being handled also carries significant value. Spilled bloods, and stained bed sheets, numerous indisposed used sharps would convey a situation of lacksidical approach to patient care, instill fear and reinforce negative values. A treatment room in full view of patient would also convey lack of sensitivity especially when painful procedures are carried out. An unnecessary large bandage over a small puncture mark would inevitably give a message that a big incision has been inflicted!

· A ward unguarded with laughter from doctors and health professionals would convey a sense of insensitivity and sometimes humiliation. This is especially true in situation of bereavement in an open ward

· A houseman is sometimes faced with ethical dilemma especially when his moral judgment may contradict that of his superiors. This can relate to issues in history-taking, physical findings and plan of clinical management. ( remember a case of a houseman who refuses to assist his consultant in a procedure as he feels that the procedure was unnecessary and unethical)

· Cultural and religious beliefs may also influence a houseman in his conduct. Care must be taken that these do not convey a negative connotation to his patient. Examples include statements such as “ I don’t work on certain days”, “ I am here now, even when I m not supposed to work”

· A houseman has to deal with colleagues (medical, nurses, support staff, administrators). His moral conduct will be transmitted to all those in contact with him. In an environment of close associates, judgments of others spreads quickly within an institution

· Ethical issues will also be relevant in dealing with those with financial interest in the clinical management of a patient ( insurance, pharmaceutical , companies dealing with equipments)

· Above all, the conduct of a houseman should exude a certain sense of flagship and icon for the medical profession, exhibit maturity and sensitivity that gives some reflection of humility between a care giver and those he cares for.


Dec 2010

Saturday, September 25, 2010

The Story of Hannah Part 3


Hannah is 2 yrs old. Not knowing what this fuss is all about, she gave a sweet smile to the approaching Nikon lens as her right hand struggled to hold the knife used to cut her birthday cake.

She finished the piece of her own birthday cake; no mess; no trouble. She wanted more!

By all accounts , she is disabled; she could only stand momentarily,briefly sits unsupported, say 2 words : "nak air " in her own little peculiar slang.

But you could hear her shrieks when the neighbour's bird sings it's usual morning melody.

Points to her own nose, mouth and ears awkwardly with her functioning right arm, slow, and writhing, almost like a shadow play

She even pretended to use a mobile phone, perhaps pretending to locate her mum; and we know no mobile companies would volunteer to locate.

Paediatricians say that she's 6 months delayed, at least.

Humanists say that she has progressed by leaps and bounds as no one expects her to be a delight to anyone; the way she was 8 months ago.

These must all be the grace of Allah, who knows that little Hannah's physiology, biochemistry and bodily functions are as sophisticated as bodies belonging to the Kings of Kings.

Only that she couldn't say to people surrounding her " Treat me like you wish to be treated".

She couldn't say it - for now at least. She will prove us wrong again , I am sure.

Good for you little girl.

Happy Birthday Hannah!

Saturday, August 14, 2010

Trip to South Africa


Just recording my recent trip to Johannesburg South Africa. It was a trip sponsored by the Malaysian Paediatric Association to attend the International Paediatric Association Congress. I represented Malaysia as the President of our Association.

It was a long trip and as soon as we arrived in the early hours of the morning, we were sufficiently warned that this place isnt safe.So, travel with 'official' taxis and don't venture out alone. This is Africa - they said.

Such friendly advice is exactly the sort of thing I love to go against.

"Official" taxis means paying almost RM200 ( USD70 ) for a 15 km trip! I decided to break the rules and travel the local ways.

That meant going into one of the local vans, wait for 14 others to fill it up and contribute RM2 per person ( USD 30 cents ) to the person closest to the driver and hey presto! off we went., Initially to Alexandra and changing taxi to Midrand where my cheap hotel is.

One needs a few important tips when travelling like a local. Foremost, learn a few local phrases to win the local hearts. that means learning some Zulu phrases. "how are you" becomes " Unjjaani" and you answer "Ghia pila Unjjanif for Im well thank you".

I found the locals exceptionally friendly despite their angry-looking demeanor, and skin complexion slightly darker than mine.

Its that angry-looking that our guides had warned us " Beware of African" Little did they know that behind these looks, are exceptionally warm hearts, one of whom , a girl barely 17 yrs of age who made way for my 2 huge suitcases and allowed the suitcases to sit on her lap. One lady volunteered to carry one of them to the next taxi, even she was already late for work. Of course there were those who had learnt that foreigners are to be swindled and made offers to help , hiding some evil intents. By then you can 'smell' their intentions, and seek help from others; many were ever so ready to assist, like Clive, Anastasia, Salphina, and many others whose name escape my memory.

That reminds me of the mystery of the VAT Refund. Sounds friendly enough. "you dont have to pay for the tax - we pay you back" full of non African smiles , charming voice and sluggishly friendly. That was at the modern airport. they offerred to give me back 400 rands but using local cheque and to be cashed at the airport. At that point the smiley lady said" Sorry, we take 100 rands as our commission; you take the rest, better than nothing eh?" thats a whopping 25% commission or is it "con mission '. That was an official policy apparently.

I can clearly recall, being robbed in Belgium and kicked by locals in Austria!

Beware of Non Africans ? - or am I being racist now?

"Salanigha seth" and "Ghia Bonggo " for now.

Tuesday, June 15, 2010

Thoughts on Medical Education






The future lies in what the present leadership plans. As such prediction of future of Malaysian medical education scenario can be accurately done by judging the trends over the last few years, reflecting the thinking of medical education leadership in the country. The needs of medical education have and will never change i.e. to produce competent clinicians to serve the health needs of the population.

Published data has shown that Malaysia has done extremely well in improving the state of health of its population, marked by impressive data on indicators such as Infant and Maternal Mortality and the indices to the Millennium Development Goals.

The dramatic improvement of our health care indicators must surely be partly attributed to the rapid increase in the number of doctors serving the population, flooding the system from various training establishments. 24 medical faculties are now actively training doctors for the country, compared to 3 medical schools for a period of 16 years from 1963 to 1979. This exponential increase is made possible through the Private Higher Education Act 1996 which allowed the setting up of private higher institutions and medical schools, in addition to faculties attached to public universities. Currently the numbers of private medical faculties outnumber public faculties by 1.4:1. The numbers of newly graduated doctors have more than doubled for the last 4 years. 978 provisional registrations were given to house officers in 2006, 1426 in 2007 and 2516 in 2008. When combined with the number of medical graduates trained and recognized in 370 medical schools overseas, the estimated number of new doctors can exceed 3000 per year as newer local faculties start graduating their medical students, competing for housemanship training in less than 50 approved training centres nationwide. This surge of numbers of new doctors poses a new challenge to medical education. Housemanship is a period of practicing new skills acquired during basic medical training and is seen as an essential continuation of formal medical education from higher learning institutes. Without a parallel increase in number of housemanship centres and the availability of suitably-trained trainers, the competencies, readiness and experience of fully registered doctors entering the career pathway in Malaysia may be seriously flawed, posing a risk to the quality of health delivery.

In a preemptive effort to ensure quality in medical education, a National Board of Accreditation; the Lembaga Akreditasi Negara (LAN) was established in 1996 almost at the same time as the passing of the Private Higher Education Act. Although the initial reason was to oversee the educational approaches of private medical colleges, this mission has evolved into a more ambitious plan of overseeing the standards of education of all universities and colleges in public and private sector. In 2007, LAN was replaced by the Malaysian Qualification Agency (MQA) through the Malaysian Qualification Act of 2007. The aim was to establish a far ranging desire and authority of monitoring standards of educational programs and institutions. At the same time, a common criterion for accreditation of medical schools was established. The standards are contained in the ‘Guidelines on Standards and Criteria in the Accreditation of Basic Medical Education Programme in Malaysia’,revised and approved by the Malaysian Medical Council in August 2007 together with the establishment of “ A Joint Technical Committee for the Accreditation of Medical Programmes” responsible to oversee all matters pertaining to accreditation of medical schools either locally or abroad. As can be seen, within 10 years of liberalizing the education system, a firm criterion for ensuring quality medical education was established in the country. This augurs well for the future of quality medical education provided the judgments made by the various technical committees involved in accreditation of medical schools are free from factors beyond what is stipulated in the published referenced documents.

A quick check in our medical schools will reveal that all local medical schools have been visited by our national accreditation teams. Some have been reprimanded for taking in more students than what has been stipulated based on the permitted ratios; others have had their annual intake suspended for breach of rules. Well financed public medical schools have not been spared. Some have had to extend the duration of training for their students when accreditation teams discovered that their declared program fell short of the training requirement.

Such firmness of accreditation teams gives a sense of confidence to the public that a credible system is indeed in place to ensure that medical schools in Malaysia adhere to a set international standard. I have, in my travels visited many medical schools worldwide and I am privileged to state here that the schools in Malaysia are certainly under stricter scrutiny compared to some overseas institutions that we send our students to over the past years. If this trend continues there is some guarantee that Malaysia will be able to compete in medical education with most established medical schools in the world.

Another check reveals that Malaysian medical schools are not short of innovations and are certainly at the ‘edge of technology’ in their approach to medical education .Accreditation requirements of ‘outcome-based’ makes medical schools scramble to make that loud pronouncement. Fanciful clinical skills lab are mostly in place, despite wide availability of patients in clinics and wards who are ever so ready to be involved in training and teaching of medical students.. Assessment system becomes trendy and fashionable. There are now talks of using the ‘Virtual Curriculum”, simulated patients, and open book assessments. Various types of MCQs, OSCEs, MEQs, SAQs , BAQs and SEQs are made available, all in line with international ‘norms’, making everyone feels good and comfortable.

However the the basic question remains. Are our medical students getting sufficient guided training and exposure to clinical medicine through clinical apprenticeship, role modeling and learning hands-on from experienced medical teachers in these medical schools?

Such data is difficult to obtain. I’d like to define ‘seasoned medical teachers’ as those medical specialists with more than just a fleeting moment ‘teaching and educating’ but have spent their lifetime practicing holistic clinical medicine; keenly witnessed by their students. A quick check reveals that more than 60 % of top level and senior specialists we have in the country are in the private sector, shielded from direct involvement of training medical students, due to the nature of their jobs and the expectations of their clients. Most , if not all of these specialists are renowned public figures in medicine and surgery ,and had formerly served in the public sectors, medical schools or public hospitals , swarmed by numerous medical students eager to get even the tiniest trickle of skills and experience they posses. Their move to the more lucrative private sector virtually cuts them off from passing on their wisdom and skills to students. Many of them feel uneasy in the beginning , a bit of guilt sometimes, but with passing of time, a set routine is established and calls for them to contribute voluntarily or otherwise to teaching of students is often drowned by other pressing needs; to attend to patients who their superiors and share holders now call ‘clients’. Clients as they are; they are always right and must be attended to at a moments notice.

This trend is not set to change, sadly. For as long as the public sector remains unattractive and unsympathetic to the plight of medical educationists ,calls on loyalty to the nation alone is not sufficient for experienced medical teachers to stay in the public sector , serving , teaching, setting assessments, vetting and researching. Even the most ethical and experienced medical teachers, like all others, have young families to raise, humble worldly lifetime ambitions to fulfill and time-honored targets to meet. Loyalty is most often assured if most of these minor worldly pursuits could be achieved through hard work and fair compensation. One begins as a fierce loyalist, and an idealist only to realize that this does not pay off except through accelerated presenile ageing, unbearable tolls on physical appearance and worst of all, for some; having to beg for scholarships to ensure decent education for their own children!

Our system has so far failed to recognize the pain and endurance of being a good medical teacher, a healthcare provider and in addition a renowned researcher, all in a single unfortunate soul surviving on a 24-hour day and night cycle of borrowed time. This oversight can indeed be costly; for if it continues, role modeling by senior medical teachers will be a thing of the past and be sorely missed .Gone will be the days when students see their senior physicians in the wards, in body and spirit talking and counseling patients, and witnessing the fine art of medicine and absorbing the richness of doctor-patient relationships. Seniors will simply not be there to be ‘exhibited’.

Medical teachers in research-intensive medical schools have several added perils. Foremost, is the need for them to excel, fitting in with the lofty institutional visions and complying with the ‘decree’ that they have to compete and surpass everyone in the world that their Vice Chancellors have come across during their kilometers of travels. They are expected to lay golden eggs, regardless of the feeds they receive. Golden eggs, brings golden rewards, and in turn ensure continuity of academic leaderships and the fine trimmings associated with it. Many medical schools have now started to give financial rewards to publication with Impact Factor, the proportion of which increases with the numerical value of the latter. Of course, to balance it all, many have started rewarding teaching excellence but through methodologies unfamiliar to clinicians. Many ask their medical educators to provide evidence of what kind of teaching they do and judgments will be made if the teachings faintly resemble that of a senior physics professor or a learned academic from social science. While research publications can certainly be evidenced, the thought of video taping daily teaching ward rounds or 8 hours worth of orthopedics surgery is too much to expect from these noble souls! As such, experienced medical teachers who teach and guide students in the busy wards, spending countless hours on their feet in operating theatres, have little to show as evidence; hence receive little recognition, except perhaps from God.

It appears that in order to remain visible in an academic hierarchy and be considered worthy, one has to conform to the well established performance index. If that index excludes the work of a senior clinician, then medical education, apprenticeship and role modeling will be left in the hands of the young, inexperienced mass of postgraduate students prowling the wards, or worse, to the far-too-many house officers in a single clinical department. Other academics may be in their cool and comfortable rooms, writing their next academic manuscript.

The future of this sort of medical education is bleak.

Monday, March 1, 2010

The story of "Hannah" - part 2

She is now 16 months old and has taught many of us useful lessons.

To her doctors, she taught them the virtues of not condemning their patients with hideous labels , such as 'cortically blind', 'spastic' and 'poor prognosis'. As she can now see, touch and wink naughtily, even from her squinting left eye. Lift both her arms in response to encouragements of " Who's Hannah?". Bears weight on both her 'spastic' legs and miserable-looking buttocks. She could , and by God she would!

To the nurses, she taught them that her unwillingness to swallow, wasn't from laziness. But that's the way she'd register her silent protest. Why pumped milk and nestum down her throat with big syringes when a simple finger feed would make her learn the art of chewing ?

To the other babies in the nursery,many of whom were recuperating from jaundice and hospital-acquired infections, she taught them that having good looks might make someone celebrate your birthday in hospital, but not enough to make them find you a home. For; as long as you cant control your own head or chew your own food, words spread that you are considered 'special' ( read 'spastic' ) and you can continue to bask under the phototherapy lights until state agents fetch you to welfare homes. Homes for the homeless.

Friday, January 29, 2010

The story of "Hannah"

She's nameless. As of the hospital tradition, even those with names are called " B/O - Baby of "someone".

That name lasts until the baby is discharged from hospital.

But for "Hannah" , she remained B/O for a long time. Dont know why mum could not think of a good name, as any mothers would. Hannah was a name through a popular vote; by nurses. And to this day, she remains Hannah.

I refuse to get to know minute details of her early life, for fear that this affects judgement.

But what i know is, at 14 months, she is the longest resident baby in the hospital.A close friend of her's, had been taken away not so long ago , so I was told. Gone, in the authoritative hand of welfare from this 1 nation of ours. Gone, as the nurses told me , to somewhere; a home, they would not place their stray cat into. Surely that's an unkind exaggeration.

Hannah turn for placement was next on the agenda and she patiently waited.

There were of course those with better luck and charm. Although nameless and a B/O, their looks make them attractive. Bookings are often made when they were even in their mother's womb. Documents made ready as they were born .A home not so long after. Different home to the owner of the womb that she'd lived for 9 months. Its OK . That was the deal.

Hannah was different.

By all counts and professional judgments, Hannah is considered abnormal. In as much as her sweet smile tries to compensate, there is no way it could hide her bad squint; or her spastic legs, or that awkward-looking ams;that head lag. Its a text book description that is really a short form of the dreaded word 'handicap'. To some, this means 'special'.

Special as she may seem to be, she is still doomed by hypocrisy of the day.

Wouldn't 'special' mean that she is entitled to at least a decent meal? After all, she does have some teeth!

Or to a loving cuddle?

Or being spoken to?

To rubber teats and bottles?

Nay; nothing of the sort. Sorry Hannah!. We call you special so that we be considered compassionate. We get into the good books of our 1nation- a caring society.

How could we give you things the authorities consider 'unfriendly'?

Bottles, teats, infant formula?. These are unfriendly objects Hannah! - dont you know that? These can never come near our beloved 'baby-friendly' place. We will lose our hard earned , world-certified accolade. "The Baby-Friendly Hospital"

Friday, January 1, 2010

Global Reconciliation Summit Amman Jordan

It was November 2008 when I last visited Jordan to attend the first Reconciliation Summit, organized by Monash University and the RMIT Melbourne.

The Global Reconciliation Summit held in Dec 2009 was a follow up conference , but with a distinct difference

1) Almost 200 delegates participated, most of them were from various areas of conflict in the world- Sri Lanka, Serbia, Kosovo, Croatia, Turkey, Cyprus, Brazil,Palestine and Occupied Territories and Israel.

2) The delegates were from a variety of background - medical doctors, artists, playwrights, movie writers, journalists, and philosophers

3) Delegates shared their experience dealing with people traumatized by conflicts and their efforts on reconciliation

4) One clear message was, victims and perpetrators of violence and conflict each share similar suffering.The victim suffers from the obvious pain, while the perpetrators suffer from his undignified action of inflicting pain on his fellow human being. One common problem is that they dont share that mutual feeling as hatred is fanned , often by those with deeply vested interest in the continuing conflict.

5) Successful reconciliation efforts are often facilitated by readiness of common people on either side to accept and share mutual feelings of respect. This takes time and requires perseverance

6) I was asked to give some thoughts on the situation in Malaysia

7) I presented a paper entitled "Community-Engagement Projects as a Tool for Teaching Ethics in Medical School - Our Experience "

8) My arguments were as follows : That we in Malaysia must strive to preserve racial harmony especially among professionals by designing a training program that specifically adresseses ethical issues. Failure to do this might enhance highly polarized professional doctors as their primary academic background were not necessarily similar. Promotion of mutual understanding and respect among students can be developed through specific community engagement projects .

9) We in the Medical School Universiti Sains Malaysia regularly conduct the Community and Family Case Studies (CFCS) - a community-engagement project led by medical students of mixed ethnicity. CFCS is an essential component of our training of doctors and involve medical students being 'adopted' by members of the community for a period of 5 weeks during the 2nd and 3 rd year of the medical study.

10) Students identify medical and health -related problems in the community that they are adopted and implement intervention programs that deal with the problems identified

11) They work in groups with mixed ethnic groups and naturally getting engaged with fellow students from other cultures in a highly close setting. They also, at the same time understand the community they live in and appreciate the ethical issues at the most micro level

12) I came to realize that being a medical doctor, we are in the position to appreciate that the differences we notice between individuals are merely 'skin deep'. Having operated and opening up the abdomen of people from colours and creed across the globe, one does not fail to realize that as the outer skin is retracted, everything else is the same inside : the colour, function , smell and suffering! Understanding that , may just slightly facilitate reconciliation!

Happy New Year folks