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Speech by Dato’ Dr Mrs S T Kew
Master, Academy of Medicine of Malaysia at the AGM / ASM of College of Surgeons
14 MAY 2004
I would like to thank the College of Surgeons and the Organizing Committee of the ASM for inviting me here this morning. I would also like to congratulate the College of Surgeons – there are many things that the College can be justly proud of:
Indeed College of Surgeons is the largest College in the Academy in terms of fellowship and membership number: this has always been the envy of other colleges of the Academy.
Through the years, College of Surgeons has been very active in skills training, both basic and advanced – several workshops are held every year in the Klang Valley. In fact, this is the most active College in skills training.
College of Surgeons has also been very active in organizing local and international meetings in the various surgical subspecialties every year. This is
College of Surgeons is steep in tradition. You see the procession and the stage party this morning. It is remarkable to be able to successfully hold AM Ismail Oration on an annual basis without fail – last year we had Datuk Dr Hussein Awang, and this year, Prof Russell Strong as the AM Ismail Orator.
College of Surgeons has strong and close links with regional and international surgical fraternity. The College is a Member of Asian Surgical Association. Dr Chang Keng Wee, current President of ASA, is a Fellow of this College. I also
take note of the RACS travelling fellowship – something which continues to cement the close cooperation between the two colleges.
College of Surgeons has been successful in many arena. The challenge now is to make the College relevant in the face of rapid development in various surgical subspecialties. We can look upon the College as an unifying force, as it were, for the surgeons, whatever the subspecialties, i.e. a College that is able to represent the interest of the surgeons.
College of Surgeons needs to take the lead role in putting in place and streamlining the credentialling of various surgical subspecialties, working closely with other stake holders like Ministry of Health, Universities and Specialty Professional bodies. We already have the Academy specialist register, and we are moving towards the national specialist register. College of Surgeons needs also to take the lead role in training, in assessment and in certification of higher surgical specialist training in this country.
To this end, I would like to congratulate the people who have worked hard to make the Vascular Society of Malaysia a reality. I am happy to note the support and cooperation by the College of Surgeons to this new society.
On the home front, College of Surgeons and College of Physicians and the Academy have been through thick and thin in the College Land Development Project:
at least now we are hopefully seeing the beginning of the end of a long, long wait to have our own Academy building. Here, we need the support of all fellows and members. College of Surgeons, being the largest College in terms of fellowship & membership number, will have to play an important role. Together with other colleges
in the Academy, we hope to be able to raise about RM3 millions, over and above what we already have, and to see the project to a successful conclusion. This ASM will once again provide a forum for the College to bring together fellows and members: an
annual CME cum social event that is very much looked forward to. It is with great pleasure that I declare the Annual Scientific Meeting of the College of Surgeons open. It is also my pleasant duty to officially launch the Vascular Society of Malaysia.
News from the College of Anaesthesiologists
by Prof Ramani Vijayan
Consensus on Withdrawal and Withholding of Life Support in the Critically Ill
The College of Anaesthesiologists will be holding a national workshop on the above:
|Date :||25 September 2004|
|Venue :||Ballroom, KL Hilton, KL Sentral|
|Time :||4.30 pm|
|Chairperson :||Dato’ Dr K Inbasegaran|
|Target Audience :||Physicians, Surgeons, Anaesthesiologists, Intensive Care Nurses, Hospital Administrators and all those involved in managing critically ill patients.|
Given below is the draft consensus. Doctors who are interested in attending the national workshop are requested to RSVP to the Academy Secretariat before 15 August 2004.
One of the major advances in medicine occurred soon after the last World War when life supporting technologies were developed and continued throughout the 20th century. Intensive care units were developed which with life support technology could save many ill patients as well as allow major procedures in ill patients to be carried out. Before the mid sixties, the goal of medicine was to use whatever it takes to preserve life. However, it became apparent to most caregivers in the intensive care setting that significant numbers of patients would eventually die becauseof the underlying disease and all that these new technologies were doing, was to prolong the process of dying. In the nineties, the concept of a dignified death and the helping of the dying, became more acceptable. The medical community again, particularly in the West, learnt to accept that caregivers have to actively help patients to come to terms with terminal illnesses and minimise aggressive intervention such as CPR and ventilation in many of these cases.
GOALS OF MEDICINE AND INTENSIVE CARE
The primary goal of medical treatment is to benefit the patient by restoring or maintaining the patient's health as far as possible, maximising benefit and minimising harm. If treatment fails, or ceases to give a net benefit to the patient (or if the patient has competently refused the treatment), that goal cannot be realised and the justification for providing the treatment is removed. Unless some other justification can
be demonstrated, treatment that does not provide net benefit to the patient may, ethically and legally, be withheld or withdrawn and the goal of medicine should shift to the palliation of symptoms.
The goal of intensive care is to treat reversible life threatening conditions so that patients can recover and continue to enjoy a reasonably good quality of life. In many of the developed societies and broad consensus has emerged during the past 30 years that it is appropriate to withhold or withdraw life support therapy in many clinical situations. The consensus did not come about easily. There had been much debates and controversies within the medical community. It had also raised numerous societal, ethical, religious, legal and economic issues in the last two decades. Up to 90% of Western critical care unit deaths in the present day result from caregivers limiting or withholding therapy. In many of the consensus guidelines, there is no moral difference between the decision to withhold or to withdraw life support as the intention is the same.
In Malaysia, the medical profession is still a little behind in accepting many of the concepts that lead to the limitation or withdrawal of intervention in certain categories of patients. However, with the rapid growth of both public and private health care, there is also an increase in the demand for intensive care which is becoming very expensive to provide. Although economic factors are not a criteria for limiting therapy,
it is also justifiable for the medical community to have a consensus as to the kind of patients who will truly benefit and those who will not benefit from intensive care therapy.
Scope of guideline – This consensus statement is directed at adult patients who are critically ill and are being treated by various means in critical care or intensive care units. The consensus statement is not directed at children and patients undergoing palliative therapy in homes or nursing homes. There is also a category of critically ill patients who may be receiving life support therapy in conventional wards due to a lack
of intensive care beds, and this consensus statement can also be applied to them.
Definition – Life support treatment or life prolonging treatment refers to all treatment which has the potential to postpone the patient’s death and includes cardiopulmonary resuscitation, artificial ventilation, specialised treatments for particular conditions such as dialysis, vasoactive drugs, antibiotics when given for a potentially life-threatening infection and artificial nutrition and hydration. It will also include pacemakers when used to treat life threatening arrythmias .
Artificial nutrition and hydration refers specifically to those techniquesfor providing nutrition or hydration which are used to bypass a pathology in the swallowing process. It includes the use of nasogastric tubes, percutaneous endoscopic gastrostomy (PEG feeding) and total parenteral nutrition.
PRINCIPLES OF WITHDRAWAL OR WITHHOLDING LIFE SUPPORT
Withholding or withdrawal of life support is the process by which various medical interventions are either withdrawn or withheld with the expectation that the patient will die of the underlying disease. Palliation is the prevention or treatment of pain, dyspnea and other kinds of suffering and providing basic care for patient comfort and must be provided to all patients in whom withdrawal of life support is being considered. Both these closely related processes must be supported by ethical principles in medicine.
The principles of withholding or withdrawal of life-support should be based on the basic principles of medical ethics. These are:
Preservation of life which is frequently tempered by the second principle.
Relief of suffering – This covers distressing symptoms such as pain, distress caused by anxiety, etc.
“First do no harm” – Non maleficence
Respect the autonomy of patients – Patients have the right to informed choices in treatment and have the right to refuse or accept a given mode of treatment.
Concept of a just allocation of medical resources – This is a concept that it must be good for the majority in society. Allocating scarce and expensive re s o u rces like intensive care for potentially non-salvageable patients limits the amount that can be spent on potential survivors. Increasing medical costs also make some form of rationing inevitable. Intensive care is extremely expensive and economic considerations form part of the consideration in ethical discussion regarding intensive care management.
To be truthful to the patients and family or surrogates as to the prognosis of their loved ones.
CATEGORIES OF PATIENTS TO BE CONSIDERED FOR WITHDRAWAL OR WITHHOLDING OF LIFE SUPPORT
A patient with imminent death
A patient facing imminent death has an acute illness whose reversal or cure would be unprecedented and will certainly lead to death during the present hospitalisation within hours or days, without a period of intervening improvement. This is a patient who is clearly not responding to therapy, and is reasonably unlikely to survive with continued therapy. Futility will be determined by prolonged multiple organ system failure. Further intensive care management with four or more organ systems failure is futile as shown by most studies and reports.
A patient with terminal condition
A patient with a terminal condition has a progressive, unrelenting terminal disease incompatible with survival longer than 3-6 months. Life support treatment should be provided to treat superimposed, reversible condition only with clear and achievable goals in mind.
Cardiopulmonary resuscitation should not be instituted in such patients with terminal, irreversible illness whose death is expected and in whom resuscitation represents a violation of the right to die with dignity.
A patient with severe and irreversible condition impairing cognition and consciousness but death may not occur for many months This category includes patients with permanent vegetative state or severe dementia. Permanent vegetative states is usually diagnosed in patients with severe cerebral injury after a month of assessment for non traumatic injury and three months following a traumatic injury. In many of these cases who are nursed in wards, the decision
is often not to initiate CPR or other resuscitative measures in the event of a downturn in the patients condition.
A competent patient who has stated his/her wish not to initiate or who has stated his/her wish to have life support withdrawn
This will include patients who, when competent, have given clear wishes before the present episode of illness in the form of a written Advanced Medical Directive (AMD). The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. The medical team however, has to be very certain that this is indeed the case and in the case of doubt should disregard previous wishes.
A patient who is brain dead
Brain death is now recognised as death in many countries including Malaysia and it is perfectly legitimate and legal to withdraw all forms of life support from such patients once a diagnosis is made. Organ support is only continued in the event where consent for organ procurement is needed.
OTHER DECISION–MAKING AIDS IN WITHDRAWAL OR WITHHOLDING
Scoring systems – Recently, various scoring systems have gained increasing importance as decision-making aids. Among the multitude of predictors available, the best known is perhaps the APACHE (Acute Physiological and Chronic Health Evaluation) which is now available in version III. There are also others such as SAPS (Severe Acute Physiological Score), TISS (to indicate the number of interventions), Trauma scores and many more. Regardless of the accuracy of these predictors of outcome, these can only aid decision-making. They should
not replace conscientious medical decision-making taking other factors into account.
Quality of Life – Patients in intensive care who are unlikely to regain some form of meaningful life as we know it pose a particularly challenging problem. Quality of life has to be taken in the context of other factors mentioned above as well as the possibility of further rehabilitation and family support. Most intensivists have resisted managing such patients in the ICU as there is no meaning in prolonging the life of these individuals. At the same time, it will be an easier decision not to admit these patients to an intensive care unit rather than taking them out of one.
STEPS IN DECISION-MAKING TO WITHDRAW OR WITHHOLD LIFE SUPPORT
Medical consensus – It is essential that the primary physician and the intensive care team have agreed on a consensus before any decision is taken. In certain cases, more than one primary team may be involved and it is essential to have the consensus of all the caregivers. In the event of absence of medical consensus, active treatment is continued. A further time period of active treatment is set and subsequent review of management plan. The primary physician in our context refers to the specialist or consultant under whose department the patient is admitted.
Nursing consensus – Nurses play a key role in intensive care and are in continuous contact with patients and relatives. The sense of sympathy for the patient is often stronger and it is essential that they also support the decision to withhold or withdraw therapy.
Communication – In the unfortunately rare event that the patient is fully rational, awake and competent, the communication should be with the patient. More often in the intensive care setting the discussion is with the relatives. A clear and honest medical opinion should always be given to the family. To avoid any seeming conflict of opinion, it is best that a single resource person deal with the family, while the others can be present. The physician orchestrating discussion with either the family or patient, must be someone who is involved in
the active care of the patient. This key person must be someone who has been frequently communicating with the family and has a rapport with them. This task should be done by a senior medical staff and should never be left to the most junior doctor in the unit.
The family should be given time to come to terms with the impending loss of the their loved ones. They should be allowed to ventilate their feelings and be as often as possible with the patient.
Time limited goals should be established by the clinical team and this must be based on clinical judgement and best medical evidence. Families will usually agree to discontinuation of life support systems after a reasonable trial of therapy has demonstrated failure.
In the event of disagreement between the physician and the patient or family, the assistance of an individual consultant and a patient representative is often helpful to reach resolution amongst all parties. An institutional committee such as an ethics committee, may be involved if disagreements are not resolvable. In dealing with the family, they should not be rushed as the mental shift from hope and cure to accepting the inevitable will not occur quickly. All explanations should be kept as simple as possible (in a manner easily understood by lay persons). Facilities for discussion such as a private counselling room, must be made available and the designated staff should help them with any clarifications if needed. The decision and processes taken, must not be conflict with the laws of the country. Although active termination of life i.e. euthanasia or assisted suicide may be acceptable legally in some countries, it is unlawful here.
MANAGEMENT PLAN FOR WITHDRAWAL OF LIFE SUPPORT
While the medical team puts its plan for withdrawal into operation, the exact mechanics of this, need not be told to the family or patient. It is however, important to emphasise that the patient will be comfortable and will not be in distress or pain, etc, during the process. There should be great sensitivity to cultural norms and dignity to the dying patient. There should be five main objectives for ensuring a good end of life care;
Receiving adequate pain relief and relief of any other distressing symptom such as dyspnoea.
Avoidance of prolongation of dying.
Active sense of control over events.
Strengthen relationship among loved ones.
Relief of “burden” amongst caregivers and the loved one.
THE PLAN FOR WITHDRAWAL WI LL GENERALLY HAVE THE FOLLOWING COMPONENTS
All basic support such as pain control, hydration and nutrition, patent airway and freedom from breathlessness, must be ensured to keep the patient comfortable.
All life support must be continued until the patient and his family had enough time together.
Removal of life sustaining therapy are removed in an escalating fashion after ensuring the patient is both pain free and free from any form of discomfort.
Support therapies such as inotropes and other medications are withdrawn first. Usually, in a patient with multi organ failure, this alone may sometimes result in death.
Relief of pain and discomfort – At this stage, most ICU patients are already receiving some form of sedation and analgesia. These drugs are continued, often at higher doses.
Opioids are the most useful drugs for relieving pain in terminally or critically ill patients. Morphine is the most common opioid and there is no maximum dose when used in these situations. In patients who have not previously received opioids, it should be titrated and rapidly increased until symptoms of pain and dyspnoea are relieved. Benzodiapines should be used to treat anxiety until during the dying process. In the event where relatives wish for their loved ones to pass away at home, the caregivers may assist with the necessary arrangements for the patient to be transported home. This will depend on the local logistics and practices.
DISCONTINUATION OF MECHANICAL VENTILATION
Withdrawal of mechanical ventilation is probably viewed as more problematic than withdrawal of other interventions. Discontinuing mechanical ventilation does not differ morally from forgoing dialysis or cardiopulmonary resuscitation.
There are two strategies for the withdrawal of mechanical ventilation
Terminal weaning i.e. gradually reducing the ventilator rate, positive end-expiratory pressure, oxygen levels or tidal volume while leaving the endotracheal tube in place.
Extubation after appropriate suctioning.
There is no significant difference in patient comfort between the two methods. However, the endotracheal tube should generally be left in place while ventilatory support is reduced for the patients with difficulty in clearing their secretions or protecting their airways. Regardless of the method, frequent assessment of the patient’s comfort during and after withdrawal of the ventilator is most important. Intravenous opioids and benzodiazepines should be used liberally to relief dyspnoea and other discomfort. The alarms on the monitors should be disabled. The family should be allowed to be with the patient if they choose to. The physician should be present to ensure the patient’s and family’s comfort during withdrawal of mechanical ventilation.
Withdrawal of life support is lawful at the patient’s request at common law and in a few countries by legal statute. It is more common to withdraw life support because the therapy is perceived to be of little benefit or not in the patient’s best interests or the therapy is futile. In Malaysia, there is very little case law and no legislation to direct the decision of whether to withdraw life sustaining therapy on grounds of futility or the patients best interests although these are available in the UK and in the US. The decision to withdraw therapy, usually places responsibility on the doctor/doctors in charge of the patient. Much weight is, however, placed on the wishes of the family or legal guardians.
Today, the medical technology available has made it possible for many patients in intensive care to be successfully treated and given an acceptable quality of life. At the same time, the intensive care teams and other caregivers have recognised that in many cases, one should be aware of the limitations or futility of trying to achieve a cure and turn towards allowing the patient a dignified and peaceful death. This paradigm change in thinking amongst doctors, has taken many years and is here to stay. Although these are difficult decisions, discussion amongst doctors and other caregivers on this issue should constantly be encouraged to allow acceptance of a consensus on limitation or withdrawal of life support therapy.
American Medical Association Guidelines on Withholding or Withdrawing Life sustaining treatment. June 1994.
BMJ Guideline on End of Life; BMJ Publishing Group October 14th 2000.
Recommendations for end of life care in the Intensive care unit; The Ethics Committee of the Society of Critical Care Medicine; Critical Care Medicine 2000 Vol 2; 9; No 12 Pg 2332-2349.
Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J of Respir.Crit Care Med; Vol 155.No 1. Jan 1977; 15-20.
Ethical issues in Anaesthesia - Edited by Michael Vickers, Wendy Scott; published by Butterworth Heinemann 1994.
John Edward Ruarn; Thomas Alfred Raffin; Stanford University Medical Center Committee on Ethics; Initiating and Withdrawing Life Support – Principles and Practice in Adult Medicine; NEJM; Jan 7th 1988; Vol 318; Pgs 25-30.
John Luce; Making Decisions about the Forgoing of life sustaining therapy; Am J. Resp Crit. Care Med; 1997;Vol 156 pp 1715-1718.
Statement on the Limitations of Life Sustaining Therapy in the Intensive Care Unit; Intensive Care Committee of the Hong Kong College of Anaesthesiologists; 9th January 2002.
R.J. Young; A. King; Legal Aspects of withdrawal of Therapy. Anaesth and
Intensive Care 2003: 31:501-508.
News from the College of Pathologists
Heading towards a National Accreditation Scheme for Medical Testing Laboratories
by Prof Looi Lai Meng
Further on the Memorandum of Understanding signed in late 2002 between the College of Pathologists (CPath) and the Department of Standards Malaysia (DSM) of the Ministry of Science, Technology and Innovation, activities towards the realization of a National Accreditation Scheme for Pathology Laboratories have been progressing rapidly. A Steering Committee chaired by Professor L M Looi and comprising Professor Victor Lim, Dr Halimah Yahaya, Dr Roshida Hassan, Dr Jamilah Baharom, Dr Rohani Md Yasin, has met several times with the Accreditation Division of the Department of Standards to plan the schedule for development of such a scheme. To date, the following key events have been jointly organized by DSM and CPath and have been successfully carried out:
A Public Forum on Laboratory Accreditation, at the Quality Hotel, Shah Alam on 15 December 2003. This forum was to increase awareness of the need for Laboratory Accreditation and to explain the rationale for the adoption of ISO15189 as the standards for Pathology Laboratories.
An Introductory Course on “Medical Laboratories – Particular requirements for Quality and Competence (ISO/IEC 15189)” for Lead Assessors, at the Quality Hotel, Shah Alam. 16 – 18 December 2003. This was conducted by Mr Phil Barnes, Programme Manager for Medical Laboratories, International Accreditation New Zealand (IANZ).
A Training Course (ISO/IEC 15189) for 20 Lead Assessors (comprising pathologists and DSM nominees), at the Department of Standards, Putrajaya, 22 – 26 March 2004 by Dr Max Robertson (IANZ) and Mr Shaharul Sadri Alwi (DSM).
A Workshop on Traceability and Uncertainty of Measurement, at the Putrajaya Convention Centre, 30 – 31 March 2004, by Dr Max Robertson (IANZ) at the DSM.
Formation of the Technical Working Group, chaired by Professor Looi and comprising Members of the Steering Committee from CPath and members of DSM,
to develop the Specific Criteria for the DSM standards in accordance with ISO 15189, on 3 April 2004.
Formation of 6 Medical Expert Panels (on Histopathology, Cytopathology, Haematology, Chemical Pa t h o l o g y, Medical Microbiology and Virology) chaired by various members of the Steering Committee, on 3 April 2004. These panels, comprising pathologists, scientists and medical laboratory technologists, will develop the Specific Technical Requirements for the various specialities of Pathology to supplement the ISO 15189 requirements.
To enhance the efficiency of collaboration with DSM, CPath has been successfully registered with the Ministry of Finance in April 2004, and can now officially bid for projects with the Government.
CPath has officially signed a contract with DSM on 4 June 2004, to provide the professional input towards development of the National Accreditation Scheme. This project, costing RM500,000, will include field training for lead assessors, training of technical assessors and finalization of the Specific Criteria and Specific Technical Requirements for the National Scheme. We aim at the launch of the Scheme by December 2004.
Commitment towards the development of this scheme by CPath members has been steadfast and most encouraging. Many members, though not directly being trained as
assessors, have been contributing through Committees formed to develop Guidelines on Laboratory Practices (e.g, Retention of Pathology Records and Materials; Laboratory Design and Safety, etc) which will have important bearing on Laboratory Accreditation Standards for Malaysia.
Dr Max Robertson conducting the lead assessors course at DSM.
Calendar of Events
05 – 06 August 2004 (Thursday – Friday)
4th INTERNATIONAL ADVANCED ENDOSCOPY WORKSHOP
“EXPLORING NEW DEPTHS”
|Venue||Selayang Hospital, Selangor, Malaysia|
|Secretariat||Day Care Endoscopy Unit
68100 Batu Caves, Selangor
|Tel||+603 6120 3233 ext 2177|
|Fax||+603 6120 7753|
25 – 28 August 2004 (Wednesday – Saturday)
5th MOH-AMM SCIENTIFIC MEETING (Incorporating the 7th NIH Scientific Meeting)
“QUALITY AND MEDICAL PROFESSIONALISM”
|Organiser||Academy of Medicine of Malaysia &Ministry of Health Malaysia|
|Venue||Sunway Lagoon Resort Hotel, Petaling Jaya, Selangor, Malaysia|
|Secretariat||19 Jalan Folly Barat, 50480 Kuala Lumpur|
|Tel||+603 2093 0100, 2093 0200|
|Fax||+603 2093 0900|
26 – 29 August 2004 (Thursday – Sunday)
29th ANNUAL DERMATOLOGY CONGRESS AND ANNUAL GENERAL MEETING
“CLINICAL DERMATOLOGY – RECENT ADVANCES”
|Organiser||Dermatological Society of Malaysia|
|Venue||CyberLodge, CyberJaya, Selangor, Malaysia|
|Secretariat||c/o Mr Andrew Tan
Summit Co (M) Sdn Bhd
Lot 6 Jalan 19/1
46300 Petaling Jaya, Selangor
|Tel||+603 7958 2740|
|Fax||+603 7957 2200|
28 – 30 August (Saturday – Monday)
WORLD FORUM ON THE CHILD 2004
“CHILD DEVELOPMENT, HEALTH AND EDUCATION : THE CHALLENGES OF THE
|Organiser||Kulliyah of Medicine, International Islamic University Malaysia|
|Venue||Kulliyah of Medicine, International Islamic University Malaysia,
Kuantan, Pahang, Malaysia
World Forum on the Child
Dean’s Office, Kulliyah of Medicine
International Islamic University Malaysia
25150 Kuantan, Pahang
|Tel||+609 571 6402|
|Fax||+609 571 6770|
02 – 04 September 2004 (Thursday – Saturday)
AGM/ANNUAL SCIENTIFIC MEETING OF MALAYSIAN PAEDIATRIC ASSOCIATION
|Organiser||Malaysian Paediatric Association|
|Secretariat||3rd Floor (Annexe Block)
National Cancer Society Building
66 Jalan Raja Muda Abdul Aziz
50300 Kuala Lumpur
|Tel||+603 2691 5379|
|Fax||+603 2691 3446|
05 – 09 September 2004 (Sunday – Thursday)
14th TRIENNIAL CONGRESS OF ASIA PACIFIC ORTHOPAEDIC ASSOCIATION
|Organiser||Asia Pacific Orthopaedic Association|
|Venue||Shangri-La Hotel &Mutiara Hotel, Kuala Lumpur
Wilayah Persekutuan, Malaysia
|Secretariat||19 Jalan Folly Barat, 50480 Kuala Lumpur|
|Tel||+603 2093 0100, 2093 0200|
|Fax||+603 2093 0900|
MEDICAL DEGREE PROGRAMME (PRE–CLINICAL & CLINICAL)
Applicants must possess the following :
Chief Executive Officer
Only short-listed candidates will be notified
The Depts. of Anaesthesia and Ophthalmology & Visual Sciences, Alexandra Hospital, National Healthcare Group, Singapore, will organise the Ophthalmic Anaesthesia Course and Workshop in Alexandra Hospital, Singapore .
For details of any events, click on the "Calendar of Events"...