VOL. 23 No. 2
Table of Contents
Message from the Master of the Academy of Medicine of Malaysia
Strategic Planning for the Academy of Medicine of Malaysia
The Academy of Medicine of Malaysia (AMM) is in a privileged position to articulate the vision and mission of the profession as it embraces all specialities in medicine. Since its establishment in 1966 it has played a pivotal role in ensuring the maintenance of a high standard of professional and ethical practice in the profession. The AMM enjoys the confidence of the Ministry of Health Malaysia (MoH), the Malaysian Medical Council (MMC) and the society. The amendment to the Medical Act 1971 for compulsory registration of specialists provided the AMM a critical opportunity to make itself more relevant. The AMM and the MMC have jointly established the National Specialist Register (NSR) and the AMM is currently administrating it on behalf of the MMC. The activity has further strengthened our relationship with the MoH and the MMC, and more importantly it has helped us to advance our objective to enhance the quality of health care in the country. The AMM has gained recognition as the specialist body for postgraduate education and represents the profession in specialty boards of the Ministry of Higher Education. Additionally, it engages with the MOH, the Universities and the specialist societies in formalising Subspecialty training in the country. The AMM is now in discussion with the MMC to manage the Continuing Professional Development (CPD) programme for specialists. The credit points acquired through the CPD activities will be aligned to the renewal of the Annual Practicing Certificate (APC) and revalidation of specialist status in the NSR. It is obvious that over the years the AMM is taking on increasing responsibilities.
Although there will be always be work-in-progress, the AMM has to be conscious of the rapidly changing health care landscape. As the country is moving towards a developed nation status, the medical profession will face significant challenges. In preparing for the future, the AMM must have clear goals and objectives. A new vision and mission for the AMM was developed during Prof Victor Lim's tenure as the Master; the AGM adopted it on the 8th August of 2010. It is pertinent that we rediscover and embrace our vision and mission as an organisation while working towards achieving important goals.
The vision of the AMM states "To attain an enhanced quality of life for all Malaysians through the highest standards of specialist care that incorporates promotive, preventive and curative interventions in a professional, ethical and socially just manner." The mission of the AMM is 'The Academy of Medicine is dedicated to promoting the highest standards of health care in Malaysia through – professional and ethical practices; placing the interest of patients above all else
Values in the Mission include
The vision and mission of the AMM serve as core elements of our strategic plan. Strategic planning allows an organisation to take a long range view of what and how it hopes to achieve its goals. The strategic plan serves as roadmap for us to make suitable changes to the organisation to achieve our vision. In preparing the strategic planning we need to examine the AMM's current structure, its governance, staffing, services it provides and resources.
Restructuring the AMM
Currently, 11 Colleges have been established with the AMM. While the Colleges are set up under the constitution of the AMM, each College is governed by its own bylaws. It allows individual Colleges to promote their specialty and be the sole professional body representing the specialty in matters of education and training or public interest concerning the specialty. The Colleges are generally board based and they represent various subspecialties of the discipline. The Colleges are carrying out their obligations responsibly. However, in the recent years the specialities and subspecialties divisions have rapidly evolved within the Colleges. These specialty and subspecialty divisions seek recognition and autonomy to promote their discipline, conduct education and training. This has resulted in the establishment of newly formed organisations which unfortunately is detached from the AMM. Increasing fragmentation of the profession may result in a weaker AMM. The profession must recognise this natural advancement and consider restructuring the AMM. The AMM must consider establishing Chapters within the Colleges to support the growth of new specialty and subspecialty divisions. Each Chapter must enjoy the privilege of being the singular body to represent the interest and expertise of the specialty. As the Chapter matures with increase in membership and functions it should be allowed to transform into a College.
While many specialties and subspecialties may be parked under a parent College, it is important to recognise that there will be fields of practice that spans a variety of disciplines and specialties. Recently the Chapter of Internsivists was inaugurated in the Singapore Academy of Medicine. The Fellows who specialised in Intensive Care Medicine were Fellows of College of Anesthesiologists, College of Physicians, Chapters of Respiratory Medicine and General Physicians. Similarly the Chapter of Palliative care may come from several Colleges. The organisational structure of the AMM has to continue to evolve to meet the demands of the profession. Perhaps the restructuring of the AMM can be discussed at the next AGM.
Restructuring the AMM Secretariat Services
The administrative staff of the AMM has consistently demonstrated exceptional loyalty, dedication and commitment. They have helped and supported the growth of the AMM. In the recent years the AMM has taken on some major responsibilities and they include:
In addition to servicing the AMM, the Secretariat also upkeeps the activities of 11 Colleges and several specialist societies as well as do event management. There is an urgent need to review the organisational structure and staffing of the administrative services of the AMM to achieve the strategic goals. It may necessary to have dedicated staff for the different units of activities.
Financial Sustainability of the AMM
A major challenge faced by the AMM is its financial sustainability. It needs adequate funds to carry out necessary activities to achieve its mission. The main source of income for the Academy has been profits from organization of congresses and subscriptions of members. The AMM must secure grants to maintain the NSR Secretariat, and monitoring of CPD credit points and revalidation. In addition the AMM must identify additional sources of income. The AMM has to consider appointing a Financial Officer to improve the financial management of the organisation.
Strategic planning is important because it outlines our goals and gives us a sense of direction. The most compelling reason for the AMM to engage in strategic planning is because of the rapidly changing landscape of healthcare. It is hoped that strategic planning will promote discussion and creative exchange of ideas among members of the AMM.
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40th Anniversary Celebration
of the Pathology Advocates
Pathology is a branch of medical science primarily concerning the examination of organs, tissues, and bodily fluids in order to make a diagnosis of disease. The College of Pathologists, Academy of Medicine of Malaysia is the sole professional body that represents their interests.
Pathology Diagnostic Laboratories
In Malaysia, the earliest pathology laboratories were found in the Institute for Medical Research (IMR) Kuala Lumpur (Founded in 1900) and IMR branches in Ipoh (1929), Penang (1923), Malacca (1940), Johor Baru (1940), and Sungai Petani (1941). They provided diagnostic services, facilitated medical research and training for scientific and technical personnel.
Major development of pathology laboratories occurred in the second half of the century which saw the establishment of pathology laboratories in the following institutions:
Today, there are more than a thousand pathology laboratories of varying sizes in every corner of Malaysia.
Training of Specialists in Pathology
In the old days, one aspired to be a pathologist had to be trained overseas, in particular, the United Kingdom, especially in the Royal Postgraduate Medical School, sited at the Hammersmith Hospital, London, where many of our senior pathologists were trained.
Our own local programme was first started in the University of Malaya in 1975. Initially a 2-year programme, the programme was converted to a 4-year programme in 1988 when Universiti Kebangsaan Malaysia also established the Master of Pathology programme. Universiit Sains Malaysia was on board in 1992. Specialty training in Pathology is also now available in Universiti Putra Malaysia and Universiti Teknologi Mara. Pathology specialties include: Anatomical Pathology, Haematology, Medical Microbiology, Chemical Pathology, Immunology, Forensic Pathology and Medical Genetics.
An aspiring trainee in pathology can also pursue alternate pathways to become a specialist in pathology by following training programme of the RCPath (UK) or RCPA (Australasia).
Research in Pathology
Initially research was mainly carried out in the IMR and its branches. Later, research was also carried out in the universities until today. In fact, undertaking a research project forms part of the requirement for the Master of Pathology programme. Research in pathology leading to an academic Master of Science or PhD or MD degree is available in the universities.
The Malaysian Society of Pathologists (MSOP) was established in 1975. In 1999, it merged with the Chapter of Pathologists of Malaysia to become the College of Pathologists, Academy of Medicine of Malaysia (CPathAMM). Besides this main body that represents the general interest of the pathology profession, there are also other specialist pathology associations that champion the interest of the respective specialty field, such as the Malaysian Society of Haematology, the Malaysian Society for Infectious Diseases and Chemotherapy, and the Malaysian Association of Clinical Biochemists.
This year, the CPathAMM celebrates its 40th year of existence. The College plans the 2015 Annual Scientific Meeting to be held on 13th - 14th June 2015 at the Berjaya Time Square Hotel, Bukit Bintang, Kuala Lumpur, the 2015 Annual Dinner where founder members of the MSOP would be invited, and the publication of a commemorative book scheduled to be released on 18th November 2015, a day when pathologists of many parts of the World celebrate the International Pathology Day.
Meeting website: https://2015cpath.wordpress.com/
You are all invited to join us in celebrating the occasion.
College of Pathologists
Academy of Medicine of Malaysia
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College of Physicians, Academy of Medicine Malaysia Annual Scientific Meeting 2015
"Fulfilling the Duties of a Physician to Relieve and Comfort"
10th-12th April 2015
By Dr Richard Lim, Dr Bahariah Khalid
The field of medicine has indeed evolved by leaps and bounds from the days of sepsis being the primary cause of death in an era where life expectancy was barely above 50 years of age. Today we have progressed so much in terms of pharmacology, surgical techniques, medical technologies and molecular science. In countries where there is access to these modern medical advances, people do indeed live longer and better. Life expectancy throughout the world is steadily increasing and in patients with chronic illnesses such as end-organ failures and certain metastatic cancers, hope to continue living has never been greater. However, as we move towards having greater technologies and more aggressive life-prolonging therapies, it is important as physicians, we do not get ahead of ourselves to forget the wisdom of our great teachers of medicine with words of caution to always realise the limitations of medicine and not to lose sight of our primary focus and duty as a physician, namely, to relieve and comfort the patient before us.
With that in mind, the College of Physicians, Academy of Medicine of Malaysia, had chosen the theme "Fullfilling the Duties of a Physician to Relieve and Comfort" for our annual scientific meeting (ASM) held on the 10th - 12th of April 2015. The aim was to serve as a call to all physicians to remember our responsibility to always ensure a patient's comfort and well-being particularly in situations where modern medicine has failed to cure the patient.
Rather than to abandon a patient by saying, "there is nothing more that can be done", physicians still have a huge responsibility to support the patients and their loved ones through the most difficult time of their disease trajectory. Restraining a physician from saying "there is nothing that can be done" is indeed crucial as it is an unavoidable circumstance. A patient may be in his or her last days of life and the understanding that there IS still much that can be done in terms of relieving pain and distress, addressing psychosocial issues and communicating effectively to help navigate the patient and the family through this final phase of life requires enhancement.
ASM 2015 was the first for the College of Physicians almost entirely dedicated to promoting the field of Palliative Medicine and end of life care. It also incorporated a half day pre-conference workshop. On the 10th of April, it began with the pre-conference workshop which was in fact an MRCP PACES communication skills workshop and the scenarios highlighted during the workshop were all related to issues in palliative care, end of life care discussions and advanced care planning. Participants were privileged to gain exposure in these scenarios and had guidance from actual MRCP examiners including Dato' Dr (Mrs) Kew Siang Tong, Dr. Letchuman R and Prof Dr Roslina Abdul Manap.
On the 11th of April, it began with the opening plenary session by the keynote speaker, Assoc Prof Dr Cynthia Goh from Singapore who spoke on the theme of meeting itself, "Fulfilling the duties of a physician to relieve and comfort." Assoc Prof Goh very eloquently spoke on the origins of palliative care, some if its history and the importance and role it plays for the physician.
Professor Goh originally from Hong Kong, moved to Singapore in the 1980s and is the pioneer in the field of Palliative Medicine in Singapore. She holds many national and international positions with both academic and leadership roles in palliative medicine and currently is the most senior consultant in palliative medicine at the National Cancer Centre in Singapore. The college was indeed fortunate to have her to deliver the keynote speeches whom we hoped managed to inspire and excite all participants about the role of palliative care.
Following the keynote lecture, the conference was then officiated by the honourable Minister of Health, Malaysia, Datuk Seri Dr. S Subramaniam who addressed the conference in a rather candid but sincere and heartfelt manner as he talked about his own personal experience with caring for his late father. The official opening of the conference was accompanied as well by the launching of the "Handbook of Palliative Medicine in Malaysia". This handbook, the first of its kind in Malaysia was produced by the College of Physicians in collaboration with the Malaysian Hospice Council. It was written and compiled to disperse basic information on palliative care management and practical skills to help physicians in their local settings to address symptoms and suffering of patients at the end of life. The book also addresses key ethical and psychosocial issues in caring for patients with advanced incurable illnesses. It was distributed to all conference participants free of charge with the hope that greater knowledge and awareness in palliative care will evolve in Malaysia. An electronic version will be made freely available soon on the College of Physicians' website as well as the Malaysian Hospice Council Website.
Among other topics discussed at the conference included expert views on how to care for patients in end-stage renal disease, geriatrics, neuromuscular disorders, chronic lung disease, managing cancer pain and end of life care management in the intensive care unit. Other sessions include topics to address the holistic needs of patients, psychologically, socially and spiritually. There was an interactive session by Dr Tan Seng Beng on Hope and where a family member of a patient who had died in the care of a palliative care team related her experience, her sadness and also her joy that her mother had left her life fulfilled.
One of the highlights of the ASM was the panel discussion on ethics at the end of life and for that the panellist included Prof Dato' Dr Khalid Yusof our renown cardiologist and College of Physicians council member, A/Prof Cynthia Goh from Singapore, Prof Ghauri Aggarwal, Head of the Chair of the Sydney Institute of Palliative Medicine, Australia, and Ms Sharon Palani, a very dynamic and experienced lawyer from the Medicolegal Society. This panel discussion was moderated by Dr Ednin Hamzah, CEO of Hospis Malaysia, who highlighted many pertinent issues regarding care of patients towards the end of life such as patient's right to information and autonomy to make decisions in their care, issues on capacity and who does the law recognise deemed of having legal power of attorney when the patient in question is incapacitated. The panel also touched on issues of advanced care planning and living wills and touched upon the nations' current stand on euthanasia. The discussions were interesting as there was interaction by an interactive voting system which allowed members of the audience to provide opinions.
It was indeed a very impressive turn out with approximately 380 participants showed up to this conference despite another popular conference being held elsewhere at the same time. This illustrated the amount of interest amongst our medical fraternity regarding issues discuss and following this, we are looking forward to many other opportunities to conduct more activities like this one. We hoped to encourage and welcome frequent CME activities in palliative care and end of life care be it in hospitals or national level and more can be done to address the needs of the sickest and most vulnerable of our Malaysian population. This shall be a step to organise a national committee to address ethical issues and towards developing a consensual national guideline on caring for patients at the end of life.
In accord to the WHO resolution in 2014 on "strengthening of palliative care as a component of comprehensive care throughout the life course", palliative care is fundamental to improving the quality of life, well-being, comfort and human dignity for individuals. Malaysia was a co-sponsor to the development of this resolution and it is imperative that we "walk the talk".
As the chairperson, I would like to thank my organizing committee who were mostly in sub-specialty of palliative medicine and geriatrics. I greet `kudos' to all of you for a job well done. Our envision of hope is that this conference ignited some sparks that will lead to greater things in the near future and throughout the nation, and that doctors will always know how to relieve and comfort their patient.
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College of Anaesthesiologists Activities
Reported by Dr Patrick Tan Kee Seng
On 26th April 2015, the College of Anaesthesiologists in collaboration with the Malaysian Society of Anaesthesiologists had conducted two interesting talks at Hilton Hotel, Kuala Lumpur before the commencement of the Annual General Meetings of both organisations. It was attended by 36 participants. Dr Teoh Ming Keng, Head of Medical Service of Medical Proctection Society Asia, spoke on "A Safe and Happy Anaesthetic Practice". Dr Mohamad Namazie Bin Ibrahim, Chairman of the MMA Fee Schedule Committee, spoke on "Evolution of the Anaesthetic Fees".
The practice of anaesthesia in the current litigious environment compels the Anaesthetists to adopt a different approach to patient care. Knowledge and skills in Anaesthesia are not enough to achieve satisfaction in providing patient care. The Anaesthesiologists must acquire skills in the ability to communicate with patients and portray empathy and compassion when interacting with patients and their relatives. The practice of obtaining an informed consent is not merely obtaining signatures, but it involved a process which assists the patient to understand what ever he or she is going to go through to allow him or her to make an informed decision. When the outcome of patient care is not favourable, saying "sorry" and showing empathy and compassion towards patients and their relatives will usually avoid litigation.
With the privatization of healthcare services, how much is the work of the Anaesthesiologists worth? The Anaesthetic fee was formulated based on a fixed percentage of the surgeon's fee. However over the years the fee structure had evolved where the fee is based on the type of surgery and patient involved. This appears like a varying percentage of the surgeon's fee based on the minimal varying complexity of the anaesthetic. This fee structure had not taken into consideration the medical risks involved, complexity of the surgery and anaesthetic and the duration of surgery and anaesthesia. The future of the anaesthetic fee formulation is to adopt the "relative value system", which will take into consideration all these consisting of the complexity of surgery and anaesthesia, patients' risks factors and duration of surgery and anaesthesia, including other factors like extreme of age and positioning of patient for surgery (prone).
These two important aspects involving the anaesthetic practice will continue to be amongst the challenges faced by all Anaesthesiologists in general and specifically those in private practice. Where do we go from here?
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The History of Palliative Care in Sabah
Datuk Dr Ranjit Mathew Oommen
MBBS, MS(Gen Surgery),FRCS Ed,Dip. Pall. Care, Med(Wales)
Consultant Surgeon, Jesselton Medical Centre, Kota Kinabalu, Sabah, Malaysia,
Consultant, Home Care Program of the Palliative Care Association, Kota Kinabalu,
Hon Consultant, Palliative Care Unit, Queen Elizabeth 1
By 1991 the Department of Surgery at Queen Elizabeth Hospital, Kota Kinabalu was operating on a large number of patients with advanced cancer. Even after major surgery, and often adjuvant therapy, the disease recurred in a large percentage of patients. They came back in pain and distress and as health care professionals we found that there was little we could do for these patients. It was heart breaking to send these patients home to suffer and die. At that time we weren't aware of any other options. A lot of effort and funds were being spent on patients undergoing major surgery for advanced cancer but there was little gain in improving quality of life.
real name) when
he presented with
The story of Encik Paulus (not his real name) best demonstrates our situation. He was a middle-aged man who underwent a major liver resection in 1991 for a solitary lesion. He returned after less than a year in pain and distress. The tumour had metastasized and he now had gross ascites (fig. 1). Besides pain control and treatment for the ascites, he also required social and spiritual support. He also had a young family who were in turmoil. At the time, we had no facilities to look after him at home. However, we could only keep him in the hospital for a short period of time before he wished to return home to spend his last days with his family.
We were encountering many patients with similar plights to Paulus. We felt morally obliged to look for ways to extend our care of such patients to not only offer them major surgery, but to also support them if their cancer was not curable and to allow them to die with dignity.
Following the lead of Dato' John Cardosa and Dato Seri TP Devaraj, in 1992 we organised a statewide campaign for the early detection of cancer in Sabah. With the help of NGOs as well as the government, we worked to increase awareness and promote earlier presentation of patients with cancer. At the same time we also set up an interim committee for palliative care services and started discussions with the local doctors and nurses regarding the need for this service.
The beginnings of the
"Hospice in the Home"
program in an outhouse of
the Sabah Cancer Society.
After much lobbying, a Hospice at Home program was set up in collaboration with the Sabah Cancer Society. An interested nurse was employed and sent for training. Both international and local experts were excited about our project and on invitation came to share their experience, offer training and provide inspiration. Volunteers from various organizations were primed, recruited and trained. The home care program started to function in 1993 from the outhouse of the Sabah Cancer Society (fig. 2). This entire program was initiated and supported by the Department of Surgery at Queen Elizabeth Hospital.
All patients were registered under the Department of Surgery. The program soon grew in strength and numbers.
The need eventually arose for a specialized unit to care for these patients and to support the home care program to provide seamless care. A proposal was presented to the Director of State Medical Services at the time. With his support, the first Palliative Care Unit (PCU) in Malaysia was established at Queen Elizabeth Hospital in 1995. The unit was still managed under the Department of Surgery. In 1998, for better functioning and control, the home care program branched out from the Sabah Cancer Society and registered itself as the Palliative Care Association of Kota Kinabalu. The PCU doctors and other volunteer doctors and nurses all provided expertise in palliative care and assisted the nurse coordinators of the home care program. Together, they worked as a team. All the necessary equipment including syringe pumps, complex hospital beds and oxygen concentrators were acquired and loaned out to patients. The aim was: to take all the facilities of the hospital to the home of the patient; to train and support the primary carer; and to accompany the family as their loved one made their final journey.
The palliative care unit and the home care program have been the stimulus for the development of palliative care in the rest of the state of Sabah and throughout the country. This has been facilitated by yearly training programs held in Kota Kinabalu and frequent visits by eminent national and international speakers in the field. The media has also played a part in creating awareness of the need for palliative care.
Some of the nurses, driver and
other administrative staff who
help make up the team that
provide the home care program.
In 2010, palliative care services began coordinating efforts with the Paediatric Oncology Unit to provide hospital and home-based care to the paediatric population. Over the years, it became apparent that there was a need to extend palliative care services to noncancer patients who also had incurable diseases and were dying. Although we initially did not have the resources to provide for noncancer patients, both the palliative care department and association developed and we were finally able to accept referrals for non-cancer patients in 2013. These mainly consisted of end-stage renal failure patients who were not for dialysis, and also patients with lung and/or heart failure. To identify potential patients and to assist with smooth transition of care, the palliative care department has a representative in the heart failure clinic and we also work alongside the cardiac team. Currently approximately 12% of the total number of patients cared for by palliative care services are non-cancer patients.
With regards to monetary support, the Palliative Care Unit was funded by the Ministry of Health. Being an NGO, the Palliative Care Association and the home care program, had to find it's own funds. An annual black tie fund raising concert was started in collaboration with the Sutera Harbour Resort. Each concert raised sufficient funds to run the home program for a year. Many independent donors also made contributions throughout the year. Most recently, in May 2015, we had our 15th successful annual fundraising concert themed "With Open Arms" by Deep Creek Road, a popular band from Melbourne, Australia.
Currently, the palliative care services in Kota Kinabalu consist of:
It has been a long road but now we can do major cancer surgery and provide other advanced treatment knowing that even if the treatment is not curative, our care will still be complete. We can accompany our patients through the final phase of their lives, providing adequate pain and symptom control, social and spiritual support and allow them to die with dignity.
Palliative care in the community
An achievement even at end of
life – Patients taking part in The
Borneo International Marathon
pushed by volunteers.
Letting go moving on –
Music for the soul by a volunteer
Training the primary carer to care
Daycare - massage for the patients
Pain control with
syringe pump –
ready to go home
Nebulizer at home
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