mma · dato’ pahlawan dr r. mohanadas [email protected] editor ... pengambilan ilmu perubatan...

beritaMMA Vol.45 • July 2015

ContentsMMA EXECUTIVE COMMITTEE2015 – 2016

President Dr Ashok Zachariah [email protected]

Immediate Past President Dr H. Krishna [email protected]

President–Elect Dr John Chew Chee [email protected]

Honorary General Secretary Dr Ravindran R. [email protected]

Honorary General Treasurer Dr Gunasagaran [email protected]

Honorary Deputy Secretaries Dr Ganabaskaran [email protected]

Dr Rajan [email protected]

SCHOMOS ChairmanDr Vasu Pillai [email protected]

PPS ChairmanDr Muruga Raj [email protected]

Editorial Board 2015 – 2016

Editor Dato’ Pahlawan Dr R. [email protected]

Ex-Offi cio Dr Ravindran R. [email protected]

Editorial Board Members Assoc Prof Dr Jayakumar [email protected]

Dr Gayathri K. Kumarasuriar [email protected]

Dr Juliet [email protected]

Publication AssistantMs [email protected]

The views, opinions and commentaries expressed in the Berita MMA (MMA News) do not necessarily refl ect those of the Editorial Board, MMA Council, MMA President nor VersaComm, unless expressly stated. No part of this publication may be reproduced without the permission of the Malaysian Medical Association. Facts contained herewith are believed to be true as of the date that it is published. All content, materials, and intellectual property rights are owned and provided for by Malaysian Medical Association and its members. VersaComm makes no guarantees or representations whatsoever regarding the information contained herewith including the truth of content, accuracy, safety, or the absence of infringement of rights of other parties. In no circumstances shall VersaComm be held liable for the contents, materials, advertisements contained in this publication. VersaComm has no infl uence over the contents of Berita MMA and all opinions, statements and representations made do not in any manner refl ect that of VersaComm or its employees.

Published byMalaysian Medical Association4th Floor, MMA House, 124, Jalan Pahang, 53000 Kuala LumpurTel: +603 4042 0617; Fax: +603 4041 8187, 4041 9929Email: [email protected] / [email protected]: https://www.facebook.com/malaysianmedicalassociationWebsite: www.mma.org.my© Copyright ReservedISSN 0216-7140 PP 1285/02/2013 (031328) MITA (P) 123/1/91

Consultant

12-A, Jalan PJS 8/4, Mentari Plaza, Bandar Sunway,46150 Petaling Jaya, Selangor Darul Ehsan.Tel: +603 5632 3301; Fax: +603 5638 9909Email: [email protected]

This Berita MMA is a publication only for the members of the Malaysian Medical Association. The Malaysian Medical Association does not warrant, represent or endorse the accuracy, reliability or completeness of the contents of Berita MMA (including but not limited to the advertisements published therein). Under no circumstances shall the Malaysian Medical Association be liable for any loss, damage, liability or expense incurred or suffered in respect of the advertisements and/or from the use of the contents in the Berita MMA. Reliance upon any such advice, opinions, statements, advertisements or other information shall be at the readers’ own risk and the advertisers are responsible for ensuring the material submitted for inclusion in Berita MMA complies with all legal requirements. The advice, opinions, statements and other information does not necessarily refl ect those of the Malaysian Medical Association. Nothing in this disclaimer will exclude or limit any warranty implied by law that it would be unlawful to exclude or limit.

ExCo4 Editorial

6 Address by YB Dr Ramli Mamat at the Offi cial Opening of the 55th MMA AGM

10 President’s Message

12 From the Desk of the Hon. General Secretary

Lead Article16 MERS Co-V

SCHOMOS20 Let Us Continue to be Relevant

PPSMMA22 Greetings from the PPSMMA

General 26 MMA 3rd Evidence Based Seminar on T&CM: Moving Towards

Professionalism

28 Is Confrontation the Way to Resolve Issues?

30 Do Not Resuscitate Order: Does It Need Resuscitating?

32 Ethical Professional Practice

33 Humour

MMA in the Press34 Medical Research Centre Says No Evidence of Different Dengue Strains

So Far

35 Malaysians Must Brace for Hot Spell, Haze

35 Healthcare Industry Urged to Improve Services

Book Review36 A Doc’s Life: 50 Years of Medical Memories

Branch News38 MMA Negeri Sembilan Annual Dinner 2015

40 MMA Kelantan Sharing Experince: The Kelantan Floods

Letter to the Editor 45 Loss of Art of Medical Sciences

Mark Your Diary

es

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Dato’ Pahlawan Dr R. [email protected]

Editor

’ P hl D R M h

The Editorial Board of Berita MMA 2015/2016 has seen some changes. We thank Prof Dato’ Dr N.K.S. Tharmaseelan and Datuk Dr Kuljit Singh for their services to the Berita over the past many years. They have also been regular contributors besides bringing in new advertisers. We welcome them to continue writing.

Dr Juliet Mathew and Dr M. Nachiappan are the two new appointees to the Editorial Board, and we look forward to their commitment and contribution. The Editorial Board will continue in its efforts to keep the Berita informative and interesting for its members. We welcome your suggestions, your writings in the form of articles, serious and light, sharing your hobbies, travel experiences, reports of conferences, humour and anything you feel would be of interest to other members.

Letters to the Editor on current issues are also welcome. Guidelines for submission have been published regularly, and will be repeated from time to time. However, I must mention, there is a caveat! The Editorial Board reserves the right to edit, publish or reject a submission, and this rule is no different from any other publication.

Our publisher, Versacomm Sdn Bhd has been a good professional partner in this venture, and hence they have been appointed for another two-year term ending December 2017. The Editorial Board wishes to put on record our appreciation to Ms Camen Ng of Versacomm for her excellent services to the Berita over the last three years. Her replacement at Versacomm for Berita MMA matters is Ms Intan Zalila Baharudin ([email protected]). The Editorial Board also thanks Ms Tamaraa Baisil, the Publications Assistant at MMA who is leaving this month. Her replacement is Ms Malar, therefore please send all material to Ms Malar, the email address remains, [email protected].

For this new MMA year, the Berita will retain its current format of a monthly newsletter of 48 pages, of which 10 to 12 pages will be for advertisements. This is necessary as the publication has to be self-sustaining as has been

done in the last three years. Further, like everything else, publishing and printing costs have been increasing each year. If necessary, advertisements may be increased to 15 pages. This will mean that submitted articles may appear the following month, so please bear with us.

On to the Humour column, it appears that most doctors are serious these days! We are trying to identify one with a sense of humour and who could contribute monthly to the Berita. Professor Dr A.A. Sandosham wrote the ‘Sandy’s Spice’ for many years. This was followed by Dato’ Dr S. Pathmakanthan, ‘SP’s Korner’ for about 20 years. I had the pleasure of meeting Dato’ SP last week at a reception in Ipoh. He still has his humour, but has ‘retired’. Prof Dato’ Dr Joginder Singh, a former Editor of the Berita MMA, whom I also met lately, felt our jokes were recycled and dry! For those who are acquainted with Prof Joe will understand that statement!

The Editorial Board would like to thank Dato’ Wira Dr LR Chandran, who has agreed, in the interim, to compile the Humour column for us. The invitation is open! Would any of our readers consider this invitation to lighten up your stressed-up colleagues by committing to the Humour column for a year, as a start?

On to health matters, as the Nation is striving hard to contain the dengue epidemic at home, the ugly face of MERS-CoV has reappeared, particularly in South Korea. With all the easy and affordable travel services available today, there is need for caution. Dato’ Dr Haji Abdul Razak Muttalif, the Director of the Institute of Respiratory Medicine of the Ministry of Health has kindly written the lead article for this issue. We thank him.

For your 2016 calendar, you may wish to note that, at Kota Bharu, supported by music, song and dance, and a letter of invitation from the Mayor of Miri, the 56th National MMA AGM goes to Miri, Sarawak. The dates are 27 to 29 May 2016.

Happy Reading!

Editorial



Address byYB Dr Ramli MamatExCo Kerajaan Negeri Kelantan at the Official Opening of the 55th MMA Annual General MeetingKota Bharu, Kelantan

Saya merakamkan ucapan terima kasih kepada Persatuan Perubatan Malaysia (MMA) cawangan Kelantan kerana memberi laluan untuk saya berucap di Majlis Makan Malam MMA Kebangsaan 2015 ini. Saya mewakili YAB Menteri Besar yang tidak dapat hadir kerana terpaksa ke Kuala Lumpur pada petang tadi diatas beberapa urusan penting yang tidak dapat dielakkan. Saya mengalu-alukan kepada semua para tetamu khasnya dari luar Kelantan ke negeri Serambi Mekah dan semoga majlis ini diberkati hendaknya.

Saya yakin, MMA sebagai sebuah badan bukan kerajaan (NGO) yang seiring dengan Kementerian Kesihatan Malaysia telah beraksi dengan jayanya dalam menjuarai pelbagai isu-isu kesihatan. Saya turut mencadangkan seandainya MMA juga dapat bekerjasama dengan pihak berkuasa tempatandan agensi kerajaan serta swasta bagi mewujudkan persekitaran yang bersih dan bebas daripada pelbagai penyakit berjangkit dan juga denggi yang semakin merebak kini.

Perkembangan ilmu perubatan pada hari ini adalah bermula dari semenjak berkembang tamadun sesuatu bangsa itu. Tamadaun yang tertua ialah bangsa India, Cina, Mesir Tua,

Babyloon, Syria dan Arab Islam hingga kepada tamadun dunia barat dari kurun ke empat belas hingga ke hari ini. Perkembangan perubatan Melayu adalah mengikut tamadun bangsa Melayu ia itu semenjak tamadun Empayar Seriwijaya Majapahit dan Melaka.

Yang banyak sekali mempengaruhi dan pengambilan ilmu perubatan Melayu ialah perubatan Hindu dan Buddha ia itu pengaruh agama Hindu dan Buddha yang dianuti oleh bangsa Melayu. Bila bangsa Melayu memeluk ugama Islam maka pengaruh perubatan Islam itu menambah lagi ilmu perubatan Melayu yang telah sedia ada.

Jika kita amati, Bapa perubatan yang sebenar yang banyak meninggalkan model perubatan ialah Ibnu Sina. Ia mengarang kitab Al Qanun Fi Tib, kilab Al Shifa’ dan berpuluh-puluh kitab lagi. Hampir 500 tahun kitab Al Qanun Fi Tib dan Al Syifa’ menjadi kitab pelajaran ilmu perubatan yang ulung sekali di seluruh Universiti Eropah, dipelajari oleh pelajar-pelajar dan mahasiswa-mahasiswa perubatan. Setelah 400 tahun dipelajari di dalam bahasa Arab asal naskhah-naskhah kitab itu, kemudian barulah di salin ke dalam Bahasa Latin. Banyak ulama dan tabib

exco • mma agm6


Islam yang mengembangkan kembali dengan luas dan dengan majunya perubatan.

Begitu juga dengan Kemasyhuran Al Razi dalam ilmu perubatan, kitabnya telah diterjemahkan ke Bahasa Latin, dan dipelajari di universiti-universiti Eropah pada abad pertengahan hingga sekarang ini seperti kitab Spiritual Physic. Al Razi ialah seorang ulama di antara yang terbesar sekali dalam dunia Islam dan seorang besar perubatan sepanjang zaman. Makna kata para cendikiawan Islamlah orang yang paling awal mempelopori ilmu perubatan yang sangat berjaya.

Teknologi dalam bidang perubatan telah pesat berkembang dan telah memberikan sinar dan harapan kepada jutaan pesakit yang menderita. Teknologi-teknologi baru dan terkini dalam bidang perubatan seperti teknologi MRI, Computer Tomography, Mata Bionik, Teknologi Iilzarov serta implikasi-implikasi yang terlibat samada dari aspek positif mahupun negatif. Teknologi moden membawa begitu banyak manfaat kepada pengguna. Dalam konteks bidang perubatan, teknologi mampu memberi rawatan yang lebih efektif dan cekap kepada para pesakit. Pesakit-pesakit yang serius seperti Tubercolosis, Polio, Leprosy dan lain-lain dapat diubati dengan perkembangan teknologi.

Saya mahu melihat bahawa Teknologi dalam bidang perubatan memerlukan penyelidikan demi penyelidikan agar dapat memenuhi keperluan semasa yang menuntut kecekapan dan kepantasan untuk menyelamatkan nyawa atau membongkar segala rahsia disebalik sesuatu penyakit bagi mendapatkan penawar. Antara kemajuan teknologi yang telah banyak membantu dalam bidang perubatan ialah teknologi radiologi. Pada tahun 1895 di Wuzburg, Jerman, seorang saintis yang bernama Prof Wilhelm Conrad Roentgen, ketika melakukan kajiannya dengan menggunakan Httorf-Crookes telah menemui sejenis sinar yang dinamakan sinar-x dan radiografi pertama di Malaysia telah dihasilkan di Taiping, Perak, selepas setahun tiga bulan penemuannya. Radiografi itu dihasilkan oleh Wray. Peralatan ini adalah yang pertama di Asia Tenggara maka perkembangan ini amat membanggakan rakyat Malaysia, namun sehingga kini saya tidak tahu apa perkembangan terkini dalam isu ini.

Perkembangan teknologi pengimejan juga yang tercipta di Negara kita boleh dikatakan agak perlahan dan digunakan hanya sebagai alat bantu dan proses diagnosis bagi pelbagai rawatan perubatan. Bagaimanapun, kini perkembangan bidang ini amat memberangsangkan dan kita berdepan dengan perubahan teknologi


mendadak yang turut mengubah gaya hidup manusia. Keadaan ini semakin cepat dalam tempoh 10 tahun akan datang. Dalam masa sama, dianggarkan penyakit gaya hidup mewah akan meningkat 50 peratus dikalangan penduduk negara membangun. Ini disebabkan kebanyakan negara membangun di rantau ini tidak memberi tumpuan khusus dalam menangani masalah kesihatan. Oleh hal yang demikian itu, kemajuan teknologi dalam pengimejan perubatan dapat memberi sumbangan besar kepada pengurusan pesakit.

Akhir kata, saya ingin menyampaikan penghargaan dan tahniah kepada MMA cawangan Kelantan yang mengambil inisiatif mengadakan majlis yang sangat bermakna ini dan sedikit sebanyak kita boleh berinteraksi serta bertukar pandangan. Terima kasih.

Editor’s Note: YB Dr Ramli Mamat is an Alumnus of The Faculty of Medicine, University of Malaya, who was in Family Practice in Kota Bharu for 19 years before embarking into politics, and is a classmate of Dr H. Krishna Kumar.

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exco • president’s message10


“The time of the singing of birds is come, and the voice of the turtle is heard in our land”. This quote from the Song of Solomon refers not to the almost mute reptile, but to the much more melodious turtledove. In this day and age, though, many of the voices come to us through Twitter, Facebook and other channels of the so-called “social media”.

Recently, the newspapers reported on a controversial post on Facebook. A doctor, upset because a patient had refused medical advice, then presented with complications, vented her frustrations in a Facebook post. This post was shared widely and comments proliferated. The Ministry of Health became involved. Since I am told the matter is now under investigation, I will leave it to one side for now and discuss the risks to doctors of social media.

Perhaps the thing that many doctors fear most about social media is the possibility that disgruntled patients might post uncomplimentary versions of their interactions with the doctor. No matter how good a doctor you are, no matter how right your diagnosis and treatment, you will never be able to make every patient happy. Perhaps there was an undesirable outcome, through nobody’s fault. Perhaps the patient felt they had to wait too long. Perhaps they thought your bill too high. In the past, they would most probably do no more than grumble to friends and relations. Now they turn on their tablets or computers and put their unhappiness and your name out there for the world to see.

What can you do if this happens? Very often, the best thing to do is nothing. The famous Internet advice is “Don’t feed the trolls”. No matter how wronged you feel, no matter how right you are, getting into a fi ght on social media rarely works out well. Doctors are handicapped in this sort of fi ght because you cannot put sensitive or confi dential information out into public, even in response to uncomplimentary comments. Occasionally, the comments head into the territory of the defamatory, and in such cases, your legal advisor might help you to decide if a letter to the malefactor is needed. Occasionally, too, the operators of the site may remove a post if it is pointed out to them that it breaches the law or violates their terms of use. Similarly, if a patient puts your name and place of practice on his post and praises you to the heavens, please do not engage. It might be construed that you are encouraging him to advertise you. Generally, then, do not engage with your patients on social media. I might go so far as to say that even being friends on social media with your patients is dangerous.

What about promoting yourself on social media? The rules are complex. Many sites are not hosted here, so local laws may not apply. Until new legislation clarifi es what you may or may not do on the Internet, the safest path is to stick

to the traditional guidelines. Do not hold yourself out as the best in a particular fi eld, do not offer guaranteed outcomes, do not offer bulk discounts on Groupon or similar sites. Conduct yourself in cyberspace as you would in real life.

Finally, of course, we come to the sort of interaction that got the young doctor into the spotlight. We put something up on our personal Facebook page or on Twitter, documenting our interaction with a diffi cult patient. Perhaps there is a picture or two attached to the post. Of course, the picture is anonymised, and no names are used. Is this acceptable? In all but the rarest circumstances, probably not. Let me say when it might be okay.

If your Facebook account security settings are so tight that your friends (and only your friends) can do nothing but view and comment on your posts (no sharing), perhaps it might be acceptable – if all your friends are doctors. Photos, even anonymised, can only be posted if the patient gives explicit consent. Even if you do not name names, people know who you are and where you work. The cases we complain about are often quite extreme or unusual, so the details may suffi ce to identify the patient despite all.

I think that if you know anything about Facebook (and by extension other social media sites) you will know that it is almost impossible for all these conditions to apply. Remember, social media sites are, by defi nition, for sharing. Remaining private is diffi cult. Therefore, it is best not to share anything about your practice or patients on the Internet, except perhaps as anecdotes of the “Well, I once saw…” type, which give no names, places or dates. It should go without saying that photos are verboten.

As for the young lady whose Facebook post prompted this article, let me say that we are observing what happens. Without wishing to prejudge the matter, I think that it is often the people who care the most about their patients who get the angriest when patients do not listen. Though the doctor needs to realise that what she did might not be right, draconian disciplinary measures that might affect her career or even her passion for the profession should be avoided. Temper justice with mercy.

Social Media and Doctors Dr Ashok Zachariah [email protected]@gmail.com

President

~~~No matter how wronged you feel,

no matter how right you are, getting into a fight on social media

rarely works out well

~~~


16th Medical Association of South East Asian Nations (MASEAN) Mid-Term Meeting

The host of this meeting was the Brunei Medical Association and held in Bandar Seri Begawan, Brunei Darussalam from 1 to 3 May 2015.

The Associations from MASEAN countries represented in Brunei were: 1. Brunei Medical Association2. Myanmar Medical Association3. Philippine Medical Association4. Singapore Medical Association5. Medical Association of Thailand6. Vietnam Medical Association7. Malaysian Medical Association

Absent8. Cambodia Medical Association9. Indonesian Medical Association10. Laos Medical Association

The MASEAN Secretariat is managed by the Singapore Medical Association.

The theme for this meeting was “Challenges in Training Our Future Healthcare Workforce”.

Dr Ravindran R. Naidufl [email protected]. General Secretary

From the Desk of theHon. General Secretary

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1 May 2015

Brunei Medical Association hosted the representatives to a welcome dinner in Badi’ah Hotel (venue of the meeting).

2 May 2015Meeting started with the roll call by Dr Lee Yik Woon (Singapore Medical Association) who is the MASEAN Secretary General. He welcomed all the National Medical Associations (NMAs).

This was followed by presentation of country reports by all the medical associations. This basically constitutes the updates, issues and challenges by each country.

Welcome dinner

Presentation of country report


SELAMAT HARI RAYA TO ALL OUR MUSLIM MEMBERS

1. MASEAN acknowledges the discrepancy in the demand and supply of junior doctor manpower within its member countries; however there is still a shortage of specialist manpower across all member countries.

2. Member countries are facing different challenges in the training of doctors, each member has introduced its own training guidelines and programme according to the needs of the country, with the ultimate aim of ensuring quality medical education.

3. Member countries acknowledge that medical curriculum has become outcome-based and competence-based, more structured and requires workplace-based assessments.

4. Member countries recognise the need to harness new technology in teaching healthcare workforce.

5. Member countries recognise the challenges to the introduction of Electronic Health Records (EHR); including the need for training doctors in EHR.

6. Increased political and leadership in member countries are required to support long-term human resource development.

7. Member countries recognise that the retention of healthcare workers in areas where the defi cits are most acute and greater balancing of the distribution of healthcare workers geographically within the member countries.

3 May 2015

A half-day social tour with lunch was organised by the Brunei Medical Association for all the delegates who attended the MASEAN meeting.

Boat cruise

Together with Philippine members

Dinner with Minister of Health

Meeting in session

After lunch we continued the day with a Scientifi c Symposium presented by all the associations. Subsequently the business part of the meeting followed with the adoption of minutes of the 16th MASEAN Conference 2014, adoption of Position Statement of the 16th MASEAN Conference and followed by updates on fi nance issues and schedule of future meetings.

The MASEAN Conference is held every alternate year and the same with the Mid-Term meetings. The 17th MASEAN Conference will be hosted by the Medical Association of Thailand from 6 to 8 May 2016 in Pattaya. Malaysia will host the 17th Mid-Term Meeting in 2017 and Vietnam will host the 18th MASEAN Conference.

At night, we were invited to a dinner with the Minister of Health as the Guest of Honour.

Position Statement on “Challenges in Training Our Future Healthcare Workforce” accepted at the 16th MASEAN Mid-Term Meeting 2015 in Brunei


lead article16

Dato’ Dr Hj Abdul Razak [email protected]

Senior Consultant Chest PhysicianLife Member MMA, Wilayah

’ D Hj Abd l R k M

Middle East Respiratory Syndrome (MERS)

MERS is a viral respiratory illness caused by the novel coronavirus MERS-CoV (subfamily Coronavirinae, genus Betacoronavirus, lineage C). The exact origin of this novel coronavirus is still unknown.

Early studies indicated that MERS-CoV may be related to a zoonotic virus found in bats, but more recent evidence suggests that the virus may be more strongly linked to camels. The disease was fi rst reported in Saudi Arabia in 2012, within camels being a likely source of infection in humans; strains of MERS-CoV that match human strains have been isolated from camels in Egypt, Qatar, and Saudi Arabia. Human-to-human spread is most likely from airborne transmission of respiratory secretions and from close personal contact.

Sporadic or index human MERS cases have occurred in Jordan, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates, Lebanon, Iran, and Yemen; cases from individuals with recent travel from endemic areas have been reported individuals Europe (United Kingdom, Spain, France, Germany, Italy, the Netherlands), Africa (Tunisia, Egypt, Algeria), Asia (Malaysia, the Philippines, South Korea, Thailand), and North America (United States). Therefore, it is essential that clinicians obtain a thorough and detailed travel history from patients.

The reported median incubation period of MERS infection is 5.2 days, but periods of up to 12 days have been reported. The initial presentation usually includes fl u-like symptoms, including fever, chills, rhinorrhea, fatigue, and myalgia. Respiratory symptoms, including shortness of breath and dyspnea, may become predominant later in the course.

Dust/dirtContaminated

CamelsFresh excretaMeat preparationMilkingClose contact

Structures/CavesBat roostsBaboon/cat contact

PalmsDatesSap/DrinksShadeContact (climbing)

CatsFresh excretaPetsClose contact

InsectsAttract bats

BatsExcretaSalivaParturition

HumansAerosolInhalationIngestion?Self-inoculation

Partu

BaboonsFresh excreta

WindStirs up dust

HOW A ZOONOTIC MERS-COV INFECTION MAY BE INDIRECTLY ACQUIRED FROM A PRIMARY OR

SECONDARY ANIMAL HOST

Photo credit: Centers for Disease Control and Prevention, US

~~~Transmission has

occurred via close contact with infected

persons, including from patients to healthcare

personnel

~~~


In more severe cases, patients who developed acute respiratory failure may require mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Gastrointestinal symptoms including anorexia, nausea, diarrhea, and abdominal pain have been reported. Several patients with severe illness have developed acute renal failure requiring haemodialysis, lymphopenia, thrombocytopenia, and/or multi-organ failure with coagulopathy. Older age and comorbidities including diabetes, end-stage renal disease, and chronic cardiac and pulmonary conditions have been associated with more severe presentation and higher risk of mortality.

Physical examination fi ndings associated with MERS-CoV infection are similar to those presenting with any fl u-like illness, including the following: fever, rhinorrhea mostly clear, pulmonary fi ndings such as rhonchi and rales (some patients may have a normal auscultation) and tachycardia mostly secondary to fever.

MERS-CoV has been shown to spread from person to person via close contact but without sustained community transmission. Potentially at-risk individuals include caregivers and close contacts of people with suspected or confi rmed MERS-CoV infection. Transmission has occurred via close contact with infected persons, including from patients to healthcare personnel.

For diagnosis, World Health Organization (WHO) recommends collecting multiple specimens from different sites and times in suspected cases of MERS, including nasopharyngeal and oropharyngeal swabs, sputum, serum, and stool or rectal swabs after symptom onset. Evidence shows that lower respiratory tract specimens such as bronchoalveolar lavage (BAL), sputum, and tracheal aspirates contain the highest viral loads, and these are recommended. Some cases have been confi rmed only in sputum after negative or equivocal results on polymerase chain reaction for MERS-CoV in nasopharyngeal and oropharyngeal specimens.

EducationTravellers who develop fever, cough, shortness of breath, or myalgia during their trip or within 14 days after returning to Malaysia, are strongly encouraged to seek medical attention. The WHO advises that people observe the following tips to help prevent respiratory illnesses:

• Wash hands often with soap and water for 20 seconds; if water and soap are not available, use an alcohol-based hand sanitiser

• Cover nose and mouth with a tissue when coughing or sneezing

• Avoid touching eyes, nose and mouth with unwashed hands

• Avoid close contact with sick people, such as kissing and sharing drinking cups or dining utensils

• Clean and disinfect frequently-touched surfaces, such as utensils and doorknobs

• Respiratory protection that is at least as protective as a fi t-tested NIOSH-certifi ed disposable N95 fi ltering face piece respirator or NIOSH-certifi ed and US-FDA cleared disposable anti-viral mask that can kill the MERS virus.

• If a respirator is unavailable, a high quality face mask (US-FDA cleared anti-viral mask is a recommended option) should be worn.

• Monitor healthcare providers for 14 days after the last known contact with the sick patient.

• Healthcare providers should stay home when sick!

Photo credit: AFP Photos/Fayez Nureldine

Treatment and ManagementManagement of MERS-CoV infection is supportive; this includes hydration, antipyretic, analgesics, respiratory support, and antibiotics if needed for bacterial superinfection. Experience during the Severe Acute Respiratory Syndrome (SARS) outbreak showed inconsistent results when antiviral therapy was used. A recent study demonstrated activity of mycophenolic acid against the novel MERS-CoV; its potent in-vitro activity may allow it to be used as monotherapy. Ribavirin and interferon alfa have synergistic in-vitro effects against the virus, but their role (if any) in the treatment of MERS remains unknown. One small observational study of fi ve patients with MERS-CoV infection receiving ribavirin in combination with interferon alfa 2b in Saudi Arabia failed to show any benefi t. These patients were all critically ill and on mechanical ventilation, and the median time from admission to therapy was 19 days, perhaps too late to demonstrate any benefi t.

Rapid development of effective therapeutic options is a high priority since no antivirals are approved for the treatment of coronavirus infection nor vaccines available for prevention. Infection control and the local health department should be notifi ed immediately if a case of MERS-CoV infection is suspected. Proper infection-control measures, including standard contact and airborne precautions, should be implemented while managing patients with suspected MERS-CoV infection.

lead article18


schomos20

Dr Vasu Pillai [email protected]@yahoo.com

ChairmanNational SCHOMOS

We are in the middle of Ramadhan. Selamat Berpuasa and Selamat Hari Raya to all Muslim members, and Greetings from SCHOMOS to all.

SCHOMOS had a smooth Annual General Meeting (AGM) on 29 May 2015 in the beautiful city of Kota Bharu. Thanks to MMA Kelantan for successfully organising 55th MMA AGM. Around 134 SCHOMOS members attended the SCHOMOS AGM where many issues concerning the welfare of members were raised. Representing the new Committee, I promise that we will do our best to raise those issues with the relevant authorities and work towards achieving solutions. I would like to share some good news with you all!

Reduction in Life Membership Fees for House Offi cers

One of the important highlights of this AGM was the resolution to reduce Life Membership fees for house offi cers to RM1,500 and this was passed by an overwhelming majority on the fl oor. There were many senior members and Past Presidents of MMA who supported the resolution. Now, once the resolution has been approved by the Registry of Societies (RoS), we hope more junior members will join as Life Members. Each State SCHOMOS representative will defi nitely be entrusted with the great task of spreading this information and propagating the benefi ts of becoming MMA members.

Let Us Continue to be Relevant


~~~Representing the new Committee,

I promise that we will do our best to raise those issues with the relevant

authorities and work towards achieving solutions

~~~

Deal with AirAsia – Corporate Deal on Premium Flex Rates for All Flights

The previous SCHOMOS ExCo had succeeded in striking a deal with AirAsia. Now all MMA members will be entitled to discounted premium fl ex rates on all AirAsia fl ights. As published in the May 2015 issue of Berita MMA, there are many perks in this deal such as the fl ight can be postponed without penalty up to two hours before departure, free premium seat selection, free meal combos, and free 20kg baggage allowance among others. And best of all, this benefi t is extended to immediate family members as well.

There is a tedious process involved in registering each member for this deal as each member will be given an individual username and password.The State MMA Chairman has been given this enormous task of fi lling-up the details of the members (full name, email address, and contact numbers - mobile, offi ce and fax). Sadly, many members have yet to update their contact details (email and mobile numbers) thus we were unable to register everyone.Therefore, those who are interested and in urgent need to use this deal may kindly contact your State Committee to get registered. Mind you, the deal is exclusive for members only. So, spread the news to your colleagues and encourage more doctors to join as members. Once you get your username and

password, you have to log on to the corporate AirAsia website: http://www.airasia.com/my/en/login/go-corporate.page. Then there you go, you can start enjoying the perks.

SCHOMOS Facebook

This was started by one of the SCHOMOS Past Chairperson, Dr Rosalind. We thank her for the effort in maintaining the site all these years, and we promise to continue her efforts. We hope more members will join the page, highlight issues, and provide suggestions whenever possible.

Lastly, let us work together for the welfare of our members!


Dr Muruga Raj [email protected]

ChairmanNational PPS

Greetingsfrom the PPSMMAIt has been about a month now that my team and I have taken over the reins of the PPS chariot. At times it is a nightmare when I think of all the hot issues concerning the PPS, but my team and I are confi dent that we will be able to handle the pressures and demands of this job.

As a start, we met up with the MMA ExCo during our PPS ExCo meeting on 28 June 2015. We had a good meeting and various suggestions were put forward to our MMA ExCo for the benefi t of all PPS and MMA members as a whole.

We also suggested a discussion with the Volunteer Corp (VoC) of MMA to see if we could form a ‘Disaster Rescue Team’ so that whenever a disaster occurs, MMA will be there to help.

We have asked our Secretary to invite all the third party administrators, FOMEMA, the pharmaceutical division, and pharmaceutical association for a friendly dinner separately so that we can get to know each other and deal with our issues in a friendly manner. We will update you all in the next bulletin about our meetings and I shall make it a point to keep everyone updated on our activities through the PPS Facebook page.

We have a good team as the main Council and PPS will work together with them to produce the best for all MMA members.

PPS has also suggested that more privileges be packed in our MMA Members Card so that it might be more meaningful to our members. There is more to come, so hang on, and let us work together.

I would also like to thank all our members for trusting my team and I in running PPSMMA for the year 2015 to 2016 term. We promise to do our best.

~~~We have a good team as the main

Council and PPS will work together with them to produce

the best for all MMA members

~~~

ppsmma22

We have a good team as the main Council and PPS will work together with them to produce the best for all MMA members.

PPS has also suggested that more privileges be packed in our MMA Members Card so that it might be more meaningful to our members. There is more tocome, so hang on, and let us work together.

I would also like to thank all our membbers ffor ttruuststiningg mymy tteaamm ana dd II iin runu ining PPPPSMSMMAMA fforor tthehe yyeaear 2015 to 2016 term. We prp omise to do our best.

members

PPS meeting with ExCo at MMA

MMA 3rd Evidence Based Seminar onTraditional & Complementary Medicine:

Moving Towards Professionalism

This seminar was held at the Grand Seasons Hotel in Kuala Lumpur on 16 May 2015. It was offi ciated by YBhg Datuk Dr S. Jeyaindran, the Deputy Director-General of Health (Medical), Ministry of Health (MoH).

In his opening address, Datuk Dr Jeyaindran congratulated the MMA for planning and executing this seminar for the benefi t of the medical community and practitioners of Traditional & Complementary Medicine (T&CM). He informed us that the T&CM Act, barring any last minute issues, will be enforced by the end of the year. To date, a total of 13,500 T&CM practitioners have registered under this Act. In addition, there were eight institutions of higher learning, approved under the Ministry of Higher Education, that were conducting courses in T&CM. He stressed that the MoH was committed to harmonising the co-existence of T&CM with Allopathic Medicine.

Presently the MoH is collaborating with India and China on T&CM in the areas of practice, research, regulation, education and training. From India, an Ayurvedic practitioner seconded under the Indian Technical and Economic Cooperation (ITEC) Programme is at Hospital Port Dickson providing services in the practice of Shirodhara. While from China, the MoH is awaiting the arrival of practitioners in Herbal Oncology and Acupu ncture-Assisted Anaesthesia.

The session started with Dr Anil Kumar Kukreja, who provided information on the beginnings and concept of evidence-based medicine and emphasised the need for professionalism in line with the theme of the seminar.

This was followed by Dr Goh Cheng Soon, Director of Traditional & Complementary Medicine Division, MoH. She highlighted the Malaysian strategy which has been inked in the National Policy of Traditional and Complementary Medicine (Revised 2007). Presently there are 16 hospitals and public healthcare centres where T&CM coexists with Allopathic Medicine practice. The MoH has plans for further expansion of T&CM services in the future.

Dr Anil Kumar [email protected]

Committee on Evidence-Based Complementary Medicine, MMA

Life Member MMA

~~~Shirodhara is one

of the healing techniques of Panchakarma mentioned in

Ayurveda, the 5,000 year-old Indian

system of medicine and art of living

~~~


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We then heard from Prof Peter RP Diakow, Head of Chiropractic Department in International Medical University (IMU), who presented the topic “Whacking, Cracking and Chiropracting”. He provided inputs on the origin of Chiropractic Medicine and its applicability to patients suffering from musculoskeletal disorders. In the year 2016, IMU is commencing a Master course in Chiropractic.

Asst Prof Ibrahim Usman Mhaisker, MD (Hom.) took the fl oor with his presentation on “An Overview of Latest Research in the Field Of Homeopathy”. He highlighted that homeopathic medicines contain nano-particles and presented a number of clinical papers that have confi rmed the benefi ts of Homeopathy.

From the National Pharmaceutical Control Bureau (NPCB) we had Datin Shantini Thevendran who spoke on “Regulatory Control for Herbal/Traditional Medicines and Health Supplement Products in Malaysia”. Datin Shantini provided information on the phases of registration, and the classifi cation process which depended on the type of claim made by product manufacturers, i.e. general, medium and high claim, each with their own defi nition.

Dr Dyanan Puvanandran, Head of Policy and Development Section in T&CM Division of MoH, then took the fl oor with his presentation on “Moving Towards Integrated Health Care in Malaysia”. He highlighted the World Health Organization’s (WHO) perspective on T&CM and also spoke on the “Regional Strategy for Traditional Medicine in the Western Pacifi c”.

Shirodhara is one of the healing techniques of Panchakarma mentioned in Ayurveda, the 5,000 year-old Indian system of medicine and art of living. Dr Gopesh Mangal, MD, PhD (Panchakarma) elaborated how Hospital Port Dickson (where he is based) used this practice to manage insomnia, stress, anxiety, headache, and depression.

Over the last ten months, he has treated 1,458 patients at Hospital Port Dickson and Hospital Cheras. He then detailed the technique of practising Shirodhara and quoted 290 articles that provided the evidence behind this science.

Traditional Malay Postnatal Care has been in practise for generations. Dr Suhaila Ismail of the T&CM

Unit at the Kepala Batas Hospital, Penang, provided an insight to the concepts, practises and ‘pantang’.

Another topic, “Nutritional Therapy as Adjunctive Cancer Therapy” was presented by Dato’ Steve Yap, President of Federation of Complementary & Natural Medical Associations Malaysia (FCNMAM). After defi ning the concepts of Nutritional Therapy, he went on to discuss the rationale behind this practice. He highlighted various spices and herbs that have a positive effect on our health and how therapeutic nutrition can prolong lives in cancer patients.

Prof Dr Ab Aziz Al-Safi from Universiti Sains Malaysia (USM) presented a paper on “The Effects of `WET CUPPING THERAPY’ on Cardiovascular Disease Risk Factors”. He went on to describe the procedure of the technique and reported the results of the study done at USM on `wet cupping therapy on anthropometrics, biochemical, hemodynamic parameters and microvascular endothelial function on healthy individual.’

In his closing remarks, YBhg Datuk Dr Athimulan, the seminar’s Organising Chairman and Chairman of the Evidence Based Committee on T&CM, MMA, thanked the speakers for their diverse range of topics and the participants which totalled 102 in all, comprised of both Allopathic and T&CM practitioners.

He opinioned that with the current boom in the Herbal and Dietary Supplement industry and the signifi cant trend towards increased use of complementary and alternative medicines or natural health products, making them a major component of total consumer healthcare spending, all practitioners need to provide evidence of safety, effi cacy, good quality traditional medicinal products coupled with the need for integration and maximisation of their potential as a source of healthcare.

akow, Head nternational d the topic cting”. He

hiropractic nts . In aster course

(Hom.) took An Overview

hUnit at the Kepala Batas Hospital, Penang, provided

IsConfrontation the Way to

Resolve Issues?

W ell, yes, confrontation is the way to go. Surprised to hear it coming from within the realms of MMA, when it has been repeatedly accused of being non-confrontational? Actually, confrontation has been the manner adopted by many responsible offi ce bearers of MMA when there are important issues affecting us doctors that needed to be resolved.

However, confrontation does not mean that you need to take it to the media and shout it out for all and sundry to take notice of. Yes, it is agreed that at times that it is necessary, but most of the confrontations done have been within four walls across the table and this was where many issues were resolved amicably, except for the times when those meeting across the table were unable to make decisions on the ground, especially in matters with political intervention.

Our members are mostly unaware of all the numerous meetings with occasional heated interactions which at times even involve the slamming of tables and throwing of fi les. Being the gentlemen’s (of course with ladies’ as well) association that we are, which is befi tting our noble profession, the marching of doctors to Parliament House and holding nationwide strikes are unheard of.

Dr Koh Kar [email protected]

MMA WilayahLife Member


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I concede that there have been times when there were calls to assembly at MMA House as well as marches and strikes but they have all come to naught either due to the issues having been resolved amicably or sensing that we may not achieve the desired outcome, all calls to action were not answered.

Therefore, is using the media to voice our grouses and perceived injustices against the medical profession the right way to go? The media, whether mainstream or alternative, is a very effective tool when used properly. Readers come in many types and the way they assimilate information is therefore varied. The way we form media statements should be balanced and contain unshakeable elements, be it mere opinions or facts. Shout in the media if you must, but we must not come across to the reader as being misinformed writers or face the risk of undesired backlash.

Has MMA achieved anything by its own brand of confrontation or is it still considered a toothless tiger? I would say that MMA’s tiger still has the bite, though it does not roar much. Depending on where you stand within the medical profession, you may or may not have benefi tted from your membership with MMA. But on the whole, the standing of our medical profession has been maintained by MMA throughout the years.

The reason why medical doctors are setting up other medical associations to look after their needs should not be questioned. As our society progresses with time, there will be others within the medical profession who feel that they require an association which will look after their specifi c needs. It has been happening throughout the years and will continue to be so. Just look at how many humanitarian aid organisations there are in Malaysia, even though natural disasters in our country are few and in between compared to the rest of Asia.

On calls by certain members that we need to elect offi ce bearers who will look after their specifi c needs, do understand that what is facing each member at a certain point in time may not be what is ailing another member. For an issue that is being opposed by a

member, it may be welcomed by another. Of course, there is the hope that the elected offi ce bearer will take on the issue in the manner prescribed by a certain member, but do understand that the person needs to be well-balanced in order to represent the workings of MMA.

It will be pure politics if a member is elected to offi ce on the premise that he or she will grapple with just

the single issue that is current and is not able to manage matters on a whole.

Even then, this is nothing new as there have been instances in MMA’s history where the members have rallied to put in a President from the ranks of those in the public sector

because they needed to look into the promotion and salary raises of Government doctors, and also instances like now when they feel that a General Practitioner (GP) is needed to handle issues plaguing the GPs in the country (the run of MMA Presidents who are and were cardiologists was just a matter of coincidence).

The forefathers of MMA had created SCHOMOS and PPS for the very reason that MMA represents all sectors in the medical profession. Societies and committees were set up to look into different aspects of the medical profession in this country and it has worked well, except that we do not have adequate members who are dedicated enough to do real work within the societies and committees and many a times, the appointed Chairperson is the one to take the fall when things do not happen according to the expectation of our members.

MMA needs its members to offer their expertise and time where it is needed so that our association will stay relevant and also retain its bite.

This is a rally call to all members to start getting involved with the association, not just to be offi ce bearers but to come in and support the association where it is needed. Holding offi ce is but an illusion if it is perceived as a position of power and glory. Being in the offi ce makes you answerable to the members who come from various sectors within the healthcare profession.

~~~Confrontation does not mean that you need to take it to the media

and shout it out for all and sundry to take notice of

~~~


Do Not Resuscitate Order:Does It Need Resuscitating?

The term Do Not Resuscitate (DNR) or Do Not Actively Resuscitate (DNAR) has always been, and will continue to be practised in many hospitals and healthcare facilities in Malaysia. However there is a lack of standardisation in the implementation of DNR orders. Many hospitals in Malaysia have yet to set a standard guideline with proper documentation for the implementation of a DNR order. This may lead to serious medico-legal implications to the healthcare provider and the practitioner if incorrectly practised. Moreover, the lack of communication between healthcare practitioners with the next of kin or family members of patients subjected to a DNR would result in them feeling that the DNR order was unjustifi ed or unfair. Besides, there is a debate on who is able to make a DNR decision on behalf of a patient in a hospital setting. Does the decision lie solely on the attending consultant, senior registrar or junior doctor? If the decision has been made, what is the appropriate documentation of DNR orders that is required?

DNR is a legal order to withhold cardiopulmonary resuscitation (CPR) if a patient’s heart or breathing stops. Therefore, on a strict manner, the term does not only prevent intubation but also any form of act to restart a failed heart via CPR or electrical shocking. It does not prevent the administration of fl uids or medication on a dying patient. Therefore a patient with an applicable DNR or DNAR request should be actively managed medically until the point where either his or her breathing or heart has seized working. Some have argued that DNR is associated with the anticipation of poor prognosis with a low survival probability and subsequent less aggressive care(1,2). There is often a stigma attached to patients who have been given the DNR orders. However this is a

misconception as DNR has shown to not be a sign of defi nite death. In a study conducted by Salottolo et al. (2015), only 22% of the patients with DNR orders succumbed to death(3). It was also discovered that for ages equal to and greater than 65, severe injury and number of comorbidity are the main factors involved in establishing a DNR.

Documentation should be clear, standardised, easily read and obtainable at times of emergency when a decision to resuscitate arises. Failure of appropriate record-keeping may lead to a wrongful DNR in a patient who should have been resuscitated and vice-versa. Besides, how long does a DNR order last for in a hospital setting and in the community? Does it need to be renewed on each admission? The answer to the above is not simple, and would therefore require in-depth studies and clear guidelines for all healthcare professionals and patients in order to allow a lawful order of DNR.

The Resuscitation Council United Kingdom (RCUK) has suggested for several minimum requirements that should be taken into account when recording DNAR decisions as documented in Table 1. Therefore, the majority of healthcare professionals in the UK have adopted two standard DNAR forms across the country, each for adult patients and paediatric patients under 16 years of age(4) respectively.

Therefore the authors would like to suggest several pointers with regards to the standardised production and record-keeping of DNR in public or private healthcare facilities nationwide:

• DNR orders should only be decided and signed by an attending consultant or specialist caring for the patient.

Dr Hardip Singh [email protected]

Resident Medical Offi cerUniversiti Kebangsaan Malaysia

Medical CentreMember MMA Wilayah

&Prof Dato’ Dr N.K.S.

TharmaseelanSenior Consultant Obstetrics

and Gynaecologist

~~~Documentation should be clear, standardised,

easily read and obtainable at times

of emergency when a decision to resuscitate arises

~~~

general30


• There should be a standardised content for a DNR form applicable to all healthcare facilities nationwide.

• The DNR form must clarify that it is strictly only to withhold CPR if a patient’s heart or breathing stops whereby all other treatment should continue.

• The decision of a DNR must be communicated and explained to next of kin and family members.

• It must be made mandatory for a signed DNR form to be placed at the front or at a visible section of the clinical notes used during the current admission.

• There should be a stipulated time frame for the validity of DNR (for instance two weeks) and it should only be valid for a current admission.

• It must be mandatory for all healthcare professionals to document and record a pre-stipulated DNR which the patient has consented to in the community or in the patient’s living will.

• There should be a clear guideline on whether the next of kin is able to request or consent for a DNR when the patient is in no capacity to exercise his or her autonomy.

The Malaysian Medical Council (MMC) must be applauded for its initiative in producing the Brain Death Guideline (MMC Guideline 008/2006) which precisely states its pre-conditions, criterions, considerations, including the need to have two registered healthcare specialists for the certifi cation of brain death. However, there are still no formal national guidelines in Malaysia to defi ne DNR orders; at best they are only hospital-based. As a result, there is a lack of standardisation and agreed consensus between different hospitals and healthcare facilities nationwide. Given that Malaysians are of a rich multicultural and multi-ethnic background, considerations should be taken from the various religious and cultural beliefs of the nation for the allowance of DNR.

Similarly, the MMC was ethically correct to have considered the views of various religious bodies for its Brain Death Guideline. A Malaysian DNR Guideline, similar to that of the Brain Death Guideline, will provide a blueprint and minimal standardisation of care among all healthcare providers to patients requiring DNR. A guideline will pave the way for improved patient-centred healthcare and safety in keeping with the words of Thomas Jefferson, “I like the dreams of the future better than the history of the past”.

REFERENCES

1. Hakim RB, Teno JM, Harrell FE Jr, Knaus WA, Wenger N, Phillips RS, Layde P, Califf R, Connors AF Jr, Lynn J. Factors associated with do-not-resuscitate orders: patients’ preferences, prognoses, and physicians’ judgments. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med. 1996;125(4):284-93.

2. Chen JL, Sosnov J, Lessard D, Goldberg RJ. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J. 2008;156(1):78-84

3. Salottolo K, Offner PJ, Orlando A, Slone DS, Mains CW, Carrick M, Bar-Or D. The epidemiology of do-not-resuscitate orders in patients with trauma: A community level one trauma center observational experience. Scand J Trauma Resusc Emerg Med. 2015; 23 (1):9

4. Recommended standards for recording “Do not attempt resuscitation” (DNAR) decisions. Resuscitation Council United Kingdom. Available at http://www.resus.org.uk/pages/dnarrstd.htm

An example of a Do Not Resuscitate Order by NHS Scotland

Table 1 : RCUK requirements for DNAR Documentation

• Effective recording of DNAR decisions in a form that is recognised by all those involved in the care of the patient.

• Effective communication and explanation of DNAR decisions where appropriate with the patient.

• Effective communication and explanation of DNAR decisions where appropriate and with due respect for confi dentiality with the patient’s family, friends, care providers or other representatives.

• Effective communication of DNAR decisions between all healthcare workers and organisations involved with the patient.


The practice of medicine should be executed on the foundations of ethical professional practice. Professional means a member of a profession.

In practice, it denotes the standards of education and training that prepare members of the profession with the particular skills and knowledge to perform the role as a professional. Those who are specialists will have to perform at a much higher level, as expected of them. As doctors and specialists, we are assumed to perform within the set norms for the standard of care in medical practice. In addition, we patently need to adhere to acceptable ethical standards too.

Ethics is a branch of philosophy dealing with values pertaining to human conduct which takes into consideration the righteousness and wrongness of actions; the goodness and badness of the motives; and the ends of such actions.

It is for the professional who on entering the practice, to be invested with the responsibility of adhering to the standards of ethical practice and conduct set by the profession. Some of these standards are codifi ed but moral and ethical values may not be clearly defi ned or delineated as there are many grey areas that we may need to traverse and navigate with thought and care.

Some may have or believe in their own set of ethical values which may not necessarily be in line with the thinking and beliefs of the rest in the profession. Each individual has his or her own ingrained visions and beliefs which defi ne their own ethics and moral values when practising medicine. Race, gender, cultural and religious values may sometimes impinge upon and affect the generally acceptable standards of ethical professional practice.

Professional ethics encompasses the personal, organisational and corporate standards of behaviour expected of professionals in medical practice. Professionals exercise specialist knowledge and skills but medicine is not an exact science. Thus, medical professionals would exhibit various differing ways in managing a case. Whilst the profession may dictate the best mode of performing a certain procedure, ethics would seek answers as to why that is the best way and whether it is justifi able by moral and ethical standards.

Thus many medical organisations, academies and councils have chosen to formulate ethical professional practice, so as crystallise these ideas, thoughts and beliefs into setting the standards and paving the way for rational decision making. This would be for the benefi t of patients and doctors.

But these ethical and moral values certainly needs to evolve with changing times and changing attitudes that affect the way society views these ethical and moral dilemmas. Perplexingly, in some countries, it appears that moral values are becoming more and more narrowly conservative, being heavily infl uenced by religious values. These add to the conundrum facing doctors in medical practice.

The face of medicine is fast changing due to the rapid advances in research and treatment modalities, along with the gargantuan technological advances being made. Occasionally, market forces seem to infl uence how medicine is practised. Professionals seem to be swaying away from the basics, as we become more and more reliant on machines, gadgetry, wizardly diagnostic inventions and sophisticated non-invasive interventions to manage patients. But are they really vital, or to be followed in a standardised manner to manage patients? Is it fair for the patient to be pounded with a series of investigations or experience highly-sophisticated surgery when simpler methods would suffi ce? Some patients faced with astronomical bills howl that they were not told of the need and necessity of this trail of investigations.

Some of the ‘unnecessary’ practises espoused have been due to doctors having to practise defensive medicine in view of rising litigation. But these are added burdens to the patient. If in fact the allegations that insurance-covered patients and cash-paying patients make a difference in care provided are true, it adds to the moral dilemma facing doctors practicing in such a hospital.

As professionals, we need to keep patients’ interest above all else. The primary obligation will be to cause no harm. When professionals provide this specialised service to the public, it should be governed by generally acceptable moral and ethical values according to the general expectations of all, most importantly the patient.

Prof Dato’ Dr N.K.S. Tharmaseelan [email protected]

President/CEO Asia Metropolitan University Life Member MMA

n yy A

Ethical Professional Practice

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During Pharmacology Viva:

External Examiner: What are the side effects of NSAIDS?

Medical Student: Sir, Nausea, Vomiting.

External Examiner: What are the side effects of Opiates?


External Examiner: What are the side effects of Antidepressants?


External Examiner: in anger Tell me the drugs which don’t cause Nausea and Vomiting.

Medical Student: Sir, Antiemetics.

Indian MotherMadam Rani came to visit her son Raj for dinner, who lives with a girl, housemate Sharon.

During the course of the meal, Madam Rani couldn’t help but notice how pretty Raj’s housemate was. She had long been suspicious of a relationship between the two, and this had only made her more curious.

Over the course of the evening, while watching the two interact, she started to wonder if there was more between Raj and his housemate than met the eye.

Reading his mom’s thoughts, Raj volunteered, “I know what you must be thinking, but I assure you Sharon and I are just housemates.”

After a week, Sharon told Raj, “Ever since your mother came to dinner, I’ve been unable to find the silver plate. You don’t suppose she took it, do you?”

Raj said, “Well I doubt it, but I’ll email her, just to be sure.”

So he sat down and wrote:

Dear Mom,

I’m not saying that you ‘did’ take the silver plate... but the fact remains that it has been missing ever since you were here for dinner.

Love,

Raj

Several days later, Raj received an email from his mother which read:

Dear son,

I’m not saying that you ‘do’ sleep with Sharon, and I’m not saying that you ‘do not’ sleep with Sharon. But the fact remains that if she was sleeping in her OWN bed, she would have found the silver plate by now under the pillow...

Love,

Mom

A woman went on vacation, leaving her husband behind. Before she left, she told him to take extra special care of her cat. The next day she called her husband and asked if the cat was all right.

Her husband said: The cat just died.

She burst into tears and said: How could you be so blunt? Why couldn’t you have broken the news gradually! Today, you could have said that it was playing on the roof; tomorrow, you could have said that it fell off and had broken its leg; then on the third day, you could have said that the poor thing had passed away in the night. You could have been more sensitive about the whole thing.By the way, how is my mom?

Husband: She is playing on the roof.

Patient: Doctor I am fustrated with my life. I want to commit suicide.

I can’t take it anymore. Every night my wife goes to a pub and sleeps with anyone who proposes to her!

Psychiatrist: Relax, take a deep breath, calm down & now tell me...

...

...

...

...

...

WHICH PUB? :D

Humour


The Malay Mail – 30 June 2015

Medical Research Centre Says No Evidence of Different Dengue Strains So Far

KUALA LUMPUR: T he Institute for Medical Research (IMR) has found no evidence of different strains of dengue so far, although there have been reports of patients exh ib i t i ng d i ff e r en t symptoms, said its director Dr Jasbir Singh Dhaliwal.

He said however, a more thorough s tudy was being conducted to identify the symptoms that occured in patients who were susceptible to the disease, which was

currently on the rise.“Aside from dengue

virus research, a lot of research on dengue vector control has been conducted at IMR.

“At present, there is no specif ic treatment, and a vaccine against dengue is still under evaluation. Therefore the method of preventing dengue fever is being focused on controlling its vectors, which are the ‘Aedes aegypti’ and ‘Ae albopictus’ (mosquitoes),”

he told Bernama today.He was commenting

on Health Minister Datuk Seri Dr S. Subramaniam’s statement which said that the country may be facing the biggest ever outbreak of dengue fever, with more than 40,000 cases and 157 deaths reported since January this year.

Dr Subramaniam was quoted as saying that many new cases of dengue fever reported this year were of types they had never seen before, in addition to the differing symptoms of the virus.

In this regard, Dr Jasbir said innovative methods and concepts of vector control were being developed , including creating fogging chemicals that could seep into the walls outside the house.

“The chemical will stick to the surface which has been sprayed on, and kill adult mosquitoes when they rest on the surface. Preliminary assessments in large-scale fi elds have been successful,” he said.

He said the chemical called ‘Deltamethrin’ had been formulated in paint, and was in the process of obtaining approval from the authorities to regulate it as a treatment

by painting the walls of a home.

Other innovat ions include the ability to forecast the epidemic b y d e v e l o p i n g a mathematical model based on environmental data and analysis, using neural networks.

Meanwhile, Malaysian Med ica l Assoc i a t i on P re s iden t Dr Ashok Zachariah Philip said that the dengue virus had now mutated into a new type.

“This mutation is a normal process — every one or two years, the type of dengue virus will change, but this time the virus is more virulent and has a severe impact on patients,” he said.

He hoped that the Ministry of Health would continue to help health practitioners obtain ‘test kits’ for dengue at low prices, so that they could detect the disease at an early stage.

“The Government is experienced in the process of overcoming the epidemic, and people should clean up their surroundings to reduce the risk of becoming breeding grounds for mosquitoes,” he said. — Bernama

The Institute for Medical Research Director Dr Jasbir Singh Dhaliwal said a more thorough study was being conducted to identify the symptoms that occured in patients who were susceptible to dengue, which is currently on the rise. — Picture by Malay Mail

featuresxx mma in the press34


features xxmma in the press 35

KUALA LUMPUR: M a l a y s i a n s m u s t brace for hotter days ahead as the country is now experiencing the south west monsoon. Malaysian Meteorological Depa r tmen t (MMD) director-general Datuk Che Gayah Ismail said the monsoon season will bring about hot and dry weather and the dry spell is forecast to last until September. “There will be little rain, mostly only early in the morning at the coastal areas, as well as areas south of Selangor,” she told Bernama here, today adding that weather conditions can worsen and lead to haze if there was indiscriminate open b u r n i n g . A r a n d o m observation here today saw

weather conditions quite hazy but Che Gayah said it could be because there was no rain over the past few days. She further said that the condition was not due to the volcanic activities of Mount Sinabung in North Sumatra although volcanic ash was moving towards the central of Peninsular Malaysia and its altitude when passing the Peninsular was above 6,000 feet. According to the latest satellite image on ASEAN Specialised Meteorological Centre ( A M S C ) , t h e r e n o hotspots were detected in Peninsular Malaysia but two each in Sabah and Sarawak was detected. A check with the Department of Environment showed that all 52 areas monitored

nationwide for air quality today showed good to moderate Air Pollutant Index.

Meanwhile, Malaysian Medical Associat ion President Dr Ashok Philip said the current hot spell can cause dehydration if they sweat and do not drink enough water. He said this can occur even if they stayed in the shade, but the condition will be severe when people are exposed to direct sunlight. “As dehydration progresses, the affected person will start to feel weak, dizzy and disoriented or confused, as blood pressure starts to drop and body temperature rises. “In order to stay cool and avoid heat related problems, drink enough water,” he told Bernama

in an email reply today, adding that those who suffered from dehydration should move to a cool place and start sipping water. “Please remember not to leave anyone unattended in a parked cars with the air-conditioner off and the windows up – temperatures can quickly rise to more than 50 degrees Celsius due to the greenhouse effect,” he said. Dr Ashok also advised those who are fasting to drink regularly throughout the night and “top up” their fl uid intake before starting the fast. He said although such action may cause a little inconvenient, as it can lead to frequent visits to the toilet, that’s the price of staying cool and healthy. – BERNAMA

PETALING JAYA: Malaysian healthcare i n d u s t r y m e m b e r s have been challenged to improve services.

In giving the thumbs up to medical tourism, M a l ay s i a n M e d i c a l Association President Dr Ashok Philip said the healthcare sector should keep improving its services to meet patients’ needs.

He said more private medical centres were being accredited by the Malaysian Society for Quality in Healthcare and

the Joint Commission International.

“Because of that , foreign patients have a fair amount of confidence,” he said in a telephone interview.

He was responding to Prime Minister Datuk Seri Najib Tun Razak’s announcement on Tuesday that medical tourism would be made a priority for Malaysia.

Malaysia had 770,000 medical tourists last year, bringing in around RM700mil in revenue.

The number is expected

to rise to 930,000, with an estimated revenue of RM1bil, he said.

Dr Ashok said the country was attracting medical tourists in a big way and had many repeat customers, especially from Indonesia.

Asked i f medical tourism might worsen the brain drain in public healthcare, Dr Ashok ag reed that pr ivate hospitals generally roped in more specialists from the public sector.

And for this reason, the Heal th Minis t ry

encouraged more doctors to go for alternative ways of getting their Master’s degrees.

H owe v e r , Fo m c a secretary-general Datuk Paul Selvaraj is worried that with increasing demands from medical tourism, the pr ivate sector would keep taking specialists from the public sector and this would cause a longer waiting period for patients there.

“The focus should be on improving healthcare for Malaysians fi rst,” he said.

New Straits Times – 1 July 2015

Malaysians Must Brace for Hot Spell, Haze

The Star – 2 July 2015

Healthcare Industry Urged to Improve Services

book review36

Dr Teoh Soong Kee, ed. A Doc’s Life. Ipoh, Perak. Desktop Systems: 2015

The newly published book consists of a compilation of 50 years of medical memories by Dr Teoh Soong Kee. It offers an excellent overview of the contextual underpinnings of a life of a doctor. It commences with an initial write-up (done in 1964) on why he chose to be a doctor while studying at Penang Free School. The arduous journey takes him through to the Grant Medical College in Bombay (now Mumbai), India, where he commenced his medical studies under a Colombo Plan Scholarship. He gives a frank and candid view of life as a medical student. There are pockets of amusement-tinged stories while he was a medical student. An extract of it is quoted by him, “They (local students) laughed at my lack of body hair. While most of them would shave twice a day, I needed to shave only once a week. I would remark that less hair was a sign of higher stage in evolution!”. As much as he crafted a name for himself during his academic years (with a well-balanced academic and extra-curricular activities) and a highly successful career, he steers clear of self-aggrandisement.

Elsewhere, Dr Teoh, or often referred to as SK, traces his life journey through early and late careers namely as a houseman in Penang, medical offi cer in Perlis, lecturer at University of Malaya, and till now as an Obstetrician and Gynaecologist at Ipoh. He shares the experiences in his life that laid the foundation to his path of success or were the turning points that got him through, not just in terms of shaping his career but also in the making of himself as a person. He recounts many varied and interesting clinical scenarios as well as his engagement in Malaysian Medical Association and in the international arena as an anti-smoking advocate. He puts his thoughts down with opinions, analysis, humour and life events.

One of his fi nal chapters deal with his grit and determination to withstand the onslaught of sickness and treatment that came along with it. The people who supported him including his life partner are dealt with appreciation. The spiritual view point on health is put on record in the tail end of the book.

One aspect that many Malaysians are not aware and given credit by the writer is in the form of a fi tting tribute to Dr Wu Lien-Teh, who was the fi rst Malaysian Chinese nominated for the Nobel Prize in Medicine in 1935.

~~~He recounts many varied and interesting clinical scenarios as well as his engagement in

Malaysian Medical Association and in the international arena as

an anti-smoking advocate

~~~

*All proceeds from the sale of this book will be channelled to charity. For inquiries on the book, kindly contact Dr Teoh Soong Kee via email: [email protected]. A hardcopy of the 130-paged book is priced at RM20.00 each.

Book Review:A Doc’s Lifeby Dr Teoh Soong KeeReviewed by,Assoc Prof Dr Jayakumar [email protected] Director of Faculty & International Collaboration Perdana University Graduate School of Medicine

This book does not hone the skills or revolutionise the understanding of a clinician nor is it intended to be. A medical student and a rookie doctor will fi nd this book extremely motivating. Nostalgia may be frowned upon by the avatars of philosophy. However, I am inclined to think many medicos will fi nd the book nostalgic as they fl ip the pages. As quoted in André Brink’s novel, An Instant in the Wind, ‘The land which happened inside us, no one can take away from us again, not even ourselves.’ Any medico looking out for an anecdote or to break the ice with their consultant, this book might just do the trick.



book review 37

Quotes from Dr SK Teoh’s A Doc’s Life

Medical School in BombayI was fortunate enough to be sent to Grant Medical College (in 1965) a prestigious Medical College in the bustling city of Bombay, it was the second oldest Medical College in India, founded in the 1850s.

The RM Bhatt Hostel in which I stayed was built more than 50 years ago. The metal beds were often infested with bed bugs…we had to dip a powerful insecticide TIK 20 or use a blow torch to kill the bugs and destroy the eggs!

Some examiners had the ambition of failing as many students as possible… one slip from the student and out he went … and the remark … I like your face and I would like to see you again!

Opposite the College was a popular Indian Christian Restaurant (Carmellos) where we could eat beef and pork at reasonable prices. We found out the Bombay Duck was not a duck but a fi sh!

Not far from the College was the famous red light area of Bombay. It covered 10 streets with about 500 small houses, each identifi ed by a red coloured lamp and a number. Among the wooden buildings was a popular Chinese Restaurant called ‘Luk Kok’!

Medical Offi cer at PerlisThere was only one hospital in the whole of Perlis, with about 120 beds in fi ve wards. The Pengarah of the State Health Services was Dr Ahmad Adnan, who was also the Medical Superintendant of the Hospital, and the Consultant Obstetrician! There were 5 MOs to cover the whole hospital.

There was an interesting MO who would prescribe 10 to 15 medicines for even the most common conditions. He became very popular!

During the monsoon season fl oods were common. There were days when cars could not leave the houses, when the fl ood waters will even fl ood the toilets!

SpecialisationI had wanted to be a paediatrician as I was interested in children and got along well with them. However, the diffi culty of setting intravenous drips in small children turned me off. O&G seemed to be the next alternative as the speciality deals with unborn children and babies.

MenstruationIn almost all cultures, there are taboos about the women’s menstruation. Terms like “curse”, “kotor”, “lah sum” (dirty) are commonly used. Some religions forbid menstruating women from praying. One culture even discourages a menstruating woman from cooking.

Unusual DeliveriesI was called to assist in a delivery where the mother was pushing in second stage and yet the baby’s head was still hidden by the vagina. I just slit the imperforate vaginal septum and the baby came out crying. I was told to look into the sky for a shining star, as this could be another virgin birth!


It was “WOW“ indeed if one word is needed to describe the Annual Dinner of MMA Negeri Sembilan 2015. The event was organised by the state’s Select Committee and had a large gathering of doctors, including General Practitioners from both the Private and Government Sector, who came together for a wonderful time of relaxation and enjoyment.

This auspicious event was held on 9 May 2015 at 7.30pm at the Royal Sungei Ujong Club Seremban, Negeri Sembilan. The event was graced by our Honourable Guest, Deputy Director General of Health, YBhg Datuk Dr S. Jeyaindran and his wife, Datin Sunita Jeyaindran. Also in attendance was the State Director of Health, Dr Abdul Rahim Bin Abdullah and other dignitaries. The National MMA was represented by Dr Krishna Kumar and ExCo members. The Organising Committee ushered in the honourable guests into the main hall with the wonderful accompaniment of ‘dholl’ music.

The function started with the singing of the National Anthem followed by a speech by our Organising Chairman Dr Andrew Solamadan (Chairman of MMA Negeri Sembilan) and Datuk Dr Jeyaindran. Dr Andrew Solamadan thanked all Committee Members and guests present, and detailed the various activities carried out over the past two years. Excerpts of his speech and the glittering event were highlighted in The Star newspaper on 16 May 2015. The speech by Datuk Dr Jeyaindran touched on privatisation of Malaysian Medical Council, Continuing Professional Development (CPD) points, Annual Practicing Certifi cate (APC) renewal, the role of MMA, and much more. Datuk Dr Jeyaindran then presented token of appreciation to all MMA Negeri Sembilan Committee Members (2014-2015) prior to a group photograph session.

MMA Negeri Sembilan Annual Dinner 2015

Dr Selvaganapathi Ganeson [email protected]

Deputy Secretary / Treasurer MMA Negeri Sembilan

S l thi G

branch news • negeri sembilan38


The function continued with a sumptuous dinner and some entertainment. A live band named ‘Rockwell’ mesmerised us with their musical talentand the stand-up comedy act by Mr Gajendheran Nadaesan provided much laughter. The guests were thrilled by the many lucky draw prizes available. Datin Sunita Jeyaindran, accompanied by Mrs Rachel Sharmilla Andrew, presented ‘FOCUS A e-Learning’ portals to representatives from Rumah Kebajikan Kanak-Kanak Seremban as part of our social outreach programme. Datuk Dr Jeyaindran immediately announced a donation of RM5,000 to the orphanage.

The guests were excited to see the newly crowned Miss Malaysia Universe Vanessa Tevi Kumares who

was appointed as the “Thalassaemia Ambassador” for MMA Negeri Sembilan. A sash was presented to her by Dr Andrew Solamadan and his wife. This has been an annual project in collaboration with Hospital Tuanku Jaafar, Seremban to raise the awareness of Thalassaemia amongst the public and to empower the kids and their caregivers.

The event offi cially ended with the opening of the dance fl oor. All those who attended were happy, satisfi ed and requested that we organise the dinner function on an annual basis if possible.

~~~The speech by Datuk

Dr Jeyaindran touched on privatisation of Malaysian Medical

Council, Continuing Professional

Development (CPD) points, Annual Practicing

Certificate (APC) renewal, the role of

MMA, and much more

~~~


By,Dr Joginder Singh Rakhra [email protected] Life Member

The fl oods in Kelantan last year were devastating, and the worst recorded in history. Property damage was massive, but worse still was the human suffering. All were caught by surprise by the speed the fl ood water rose. There was no time to save property, only a desperate attempt to save lives.

There was no water and electricity. As a result none of the banks or ATMs were working, as all in Pasir Mas town were totally under fl ood water. All the Government Health Clinics and GP Clinics were also under water, and the ill and injured patients had nowhere to go. My clinic is hardly 100 meters from the Kelantan River, where the river water overfl owed like the Niagara Falls, only this was dirty, muddy with logs, trees and cows fl oating down stream! Despite this, the muddy water fl owed past my clinic and wreaked havoc in low-lying surrounding kampung areas. Yet thankfully, mine was the only clinic spared from devastation!

Amid this very wet, miserable and gloomy weather were the sick and injured. They came in lorries or tractors, the only vehicles that could traverse the submerged roads. Most did not even have money, as money had already been spent on important essentials such as drinking water, candles and food. After consultating with my wife, we decided to keep the clinic open, despite having no electricity or water. Three of my staff were willing to assist, despite their homes being under water. We decided to provide free medical services to all the needy, without any distinction whatsoever. I collected rainwater to be used in the toilets and lighted candles at strategic places. I rifl ed through my garden and collected all the garden fl ood solar lights,

Sharing Experience: The Kelantan Floods

branch news • kelantan40

No electricity and water, clinic in darkness, only candle lights

Clinic during fl oods


which came in very handy in my examination room.

Initially, I planned to provide free services for two days. I called up Pejabat Pengarah Negeri Kelantan and made my intentions known. I also informed the District Offi ce’s Bilik Operasi and the Pasir Mas District Health Offi cer that emergency medical services were available free of charge. Seeing the response and noting that the other clinics were still under water, I extended the free service by another two days. The second day I managed to buy a generator, and we had lights, fans and well water! I did not create any unnecessary campaign or publicity to attract attention to this initiative, other than to notify the above-mentioned Government offi cials. I saw all types of cases including those who sustained deep cuts in their feet, for which I did toileting and suturing under solar light. I am indebted to my wife and clinic staff, who despite the very diffi cult working conditions, managed to serve the public.

I am happy to state that many of the patients were extremely grateful for the free services provided. Some were even taken aback when told by the clinic staff that there was no charge. Some even commented that instead of taking advantage of the situation and charging double, this clinic was actually offering free services!

Suturing under solar lightPatients in semi darkness using solar lights

Preparation for Disaster Relief

• Adequate torchlights and batteries.

• Adequate candles.

• Adequate solar-powered fl ood lights.

• Adequate solar-powered portable fans.

• Electric or diesel generators.

• Adequate stock of petrol and diesel for single or triple phase generators (observe safety measures for fi re and explosion hazard when handling the generator and storing the diesel and petrol).

• Adequate stock of vaccine injection of Tetanus Toxoid (vaccines to be transferred for proper refrigeration during power outage i.e. fridge with adequate ice blocks or attached to a generator).

• Adequate stock of essential medications.

• Adequate stock of dressings, suturing materials, local anaesthetics.

• Adequate drinking water for taking oral medications.

• A bore well (very useful as no water was available for almost ten days after the fl ood had subsided).

• Insure your clinic and equipment.

• Floods to be included i

mma · dato’ pahlawan dr r. mohanadas [email protected] editor ... pengambilan ilmu perubatan...

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