February 2015 PERSATUAN PERUBATAN MALAYSIA ...February 2015 Berita MMA Vol. 45 No. 2 (For Members Only) PERSATUAN PERUBATAN MALAYSIA †MALAYSIAN MEDICAL ASSOCIATION Welcoming the

February 2015Berita MMA Vol. 45 No. 2

(For Members Only)

P E R S A T U A N P E R U B A T A N M A L A Y S I A • M A L A Y S I A N M E D I C A L A S S O C I A T I O N

Welcoming the Auspicious

Year of the Ram

beritaMMA Vol.45 • February 2015

ContentsMMA EXECUTIVE COMMITTEE2014 – 2015

President Dr Krishna Kumar H. [email protected]

Immediate Past President Dato’ Dr N.K.S. [email protected]

President–Elect Dr Ashok Zachariah [email protected]

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

Honorary General Treasurer Dr Gunasagaran [email protected]

Honorary Deputy Secretaries Dr Koh Kar [email protected]

Dr Rajan [email protected]

Members Dr Navin @ Datesh A/L [email protected]

Dr Ganabaskaran [email protected]

Editorial Board 2014 – 2015

Editor Dato’ Pahlawan Dr R. [email protected]

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

Editorial Board Members Dr Gayathri K. Kumarasuriar [email protected]

Datuk Dr Kuljit [email protected]

Assoc Prof Dr Jayakumar [email protected]

Dato’ Dr N.K.S. [email protected]

Publication AssistantMs Tamaraa [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 President’s Message

9 From the Desk of the Hon. General Secretary

55th MMA AGM15 Registration Form

SCHOMOS17 Holier-Than-Thou

PPSMMA19 General Practitioners & Specialists: Where Do We Stand?

SMMAMS20 My Journey in Psychiatry

General 22 A to G of Patient Safety

25 The National Human Rights Action Plan

26 Obesogenic: The Obesity Epidemic

28 Postgraduate TrainingSmart Partnership: Private Medical Schools & Ministry of Health

30 MMA Healthy Ageing Symposium 2014

Travelogue32 Trekking Holiday at the Himalaya Mountains

Personality35 Datuk Seri Dr TP Devaraj: Uncut

Branch News40 MMA Wilayah Meeting with State Health Director of Wilayah Persekutuan

41 MMA Kelantan MMA AGM 2015: Host City Under Yellow Water

Memoriam 43 Prof Dato’ Dr Manickavasagar Balasegaram

46 Mark Your Diary


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EditorialDato’ Pahlawan Dr R. Mohanadas

[email protected]

Dato’ Dr Tharmaseelan with Tan Sri Nasir, Chairman of the Malaysian Health

Promotion Board

~~~Let us do some

charity by attending the AGM in Kota Bharu and

help boost the local economy through hotel

stays, shopping and local tours

~~~ The Malaysian Health Promotion Board (MyS iha t ) recen t l y

conducted a Seminar on “Hala Tuju MySihat” at Gambang, Pahang. I had the opportunity to attend. The event was offi ciated by Tan Sri Dato’ Sri Dr Hj Mohd Nasir Bin Mohd Ashraf, the Chairman of MySihat. A paper on a renewed direction of the Board was presented by its newly appointed Chief Executive Offi cer, Dr K. Manimaran. MySihat will focus on 4 key areas this year: Tobacco Control, Physical Activity, Healthy Diet, and Research into Health Promotion.

Results of the 2011 Global Adult Tobacco Survey had revealed that in Malaysia, 4 out of 10 adults are exposed to second-hand smoke (SHS) in their homes, 4 out of 10 at their workplace and 7 out of 10 at restaurants. The World Health Organization estimates that 50% of women and children are exposed to SHS.

Melaka has taken the lead in the Smoke-Free City initiative, through its Melaka Bebas Asap Rokok programme, supported by MySihat. A total of fi ve zones, in Melaka City, Alor Gajah and Jasin have been declared smoke-free.

The subject of sin tax was discussed at length. Sin tax is derived by imposing taxes on certain goods and services that are harmful to health, thus increasing their prices so as to discourage consumers from overindulging in them. Tobacco, alcohol, gambling, and in some countries even candies and fast food are subject to heavy taxes. In the United Kingdom, sin tax on cigarettes

has been regularly increased that today, three quarters of the price one pays for a packet of cigarettes in the UK goes to the Government’s coffers. The benefi cial effect of such high taxes has been a reduction in smoking prevalence, from 45% in the 1970’s to currently, 22%. The MMA has been a strong advocate of regularly increasing the sin tax on alcohol and cigarettes, and for the taxes collected to be channelled towards Health Promotion activities. The Government, this year, has allotted RM10 million for activities conducted by MySihat. The forum also agreed to invite corporate organisations to donate and participate in MySihat activities as part as their corporate social responsibility.

MySihat is keen to work with NGOs, provide leadership training to NGOs on health promotion strategies, and support programmes and research in the 4 key areas stated. This is an opportunity for MMA Societies and Branches to work with MySihat and initiate programmes that could benefit the community where we work. MySihat is located at Menara Prisma, Presint 3, Putrajaya. Dr Manimaran can be contacted through: [email protected]. Dato’ Dr N.K.S. Tharmaseelan is a member of the Health Promotion Board and is available for advice.

It is once again the build-up to the MMA National Elections and the MMA National AGM. The call for nominations shall be published for the last time in this issue and the closing date is 13 March 2015. It is hoped that aspiring candidates would collect the nomination papers from the MMA Secretariat.

The manifestos of candidates will be published in the April issue of the Berita, so please prepare your manifestos early for approval by the Elections Committee.

The Grand Riverview Hotel at Kota Bharu will be the venue of the 55th AGM and Scientifi c Meeting. The AGM starts on a Friday, 29th May and goes on till Sunday, 31st May. The offi cial announcement of the AGM has been circulated. The registration form is published in this issue of the Berita. You may have to photostat or tear off the forms! Let us all support the Kelantan Branch, they are organising a National AGM after almost 35 years. We could also boost their local economy after the fi nancial losses caused by the fl oods – that could also be our act of charity to the state! The MMA had responded to the fl ood situation. Donations were given out to various affected states through MMA branches, and a lot of good work had been done by MMA Kelantan and the MMA VoC at Gua Musang and its neighbouring Orang Asli villages. The presence of a few hundred of us in Kota

Bharu in May (normally up to about 500 with family members included at the AGM) and the shopping or local tours taken by our families would defi nitely benefi t the local traders. Let us all look at another side of this charity, i.e. attending the AGM!

Wishing all MMA members, families and fr iends A Very Happy & Prosperous Chinese New Year!

Dr Krishna Kumar H. Krishnan [email protected]@yahoo.co.ukPresident

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Ironing Out the Wrinkles


There are a lot of things happening around us that we have to keep updated. We try to address everything that we can. Some we are successful in,

while in others we may have failed. We hope that at least all our efforts would bear some fruit for the benefi t of our members. Here are some of the highlights of the month.

Meeting with Medical Practice Division, Ministry of Health (MoH)The MMA ExCo met with Dr Ahmad Razid Salleh, Director of Medical Practice, MoH, and his team on 19 January 2015. The main agenda of the meeting was to discuss the rules of the Private Healthcare Facilities & Services Act (PHFSA).

We noted that there were two volumes on the Rules and Regulations for the PHFSA. The fi rst is on Primary Care while the second is on Hospital Care. Both these volumes have been published by the national press and are available in most major bookshops.

We discussed the amendments for the PHFSA and agreed to remove all the jail terms in the Act, with the exception of those without a medical practice license. These bogus doctors will be given jail terms.

Previously, the fi nes were all up to RM10,000 with no exemptions, resulting in many court cases. This wastes time for both the MoH staff and the doctors as even minor infringements would result in this process. During the discussion, we have agreed in principle to create a compound below RM300 which can be sorted out within a shorter period, benefi tting both parties. We have received the amendments recently and the PPS is going through the details to ensure that it fulfi ls our agreement.

Medical IndemnityMedical Indemnity Insurance will become compulsory in the New Medical Act. Based on our discussions with the Minister of Health last year, it is anticipated that the Rules and Regulations for the Act will be out in August this year.

MMA has taken preliminary action by seeking the Bar Council’s advice on how they implemented the compulsory indemnity process. Based on their advice, we have been courting and discussing the possibility of starting our own indemnity insurance with the help of local or foreign brokers. These discussions will ensure that our local doctors will not be held ransom by the limited choices of medical indemnity at present.

We have also noted that the fees for the Medical Protection Society (MPS) and Malaysian Medical Insurance (MMI) will rise this year. We would however like to state here that the fee for Obstetrics Services was reduced from RM70k+ to RM44,680. Unfortunately, there is also a catch. It is no longer limitless as before but limited to RM10 million per claim at the discretion of the MPS Council. This changes the way they cover the doctors.

Meeting with the Inland Revenue Board (LHDN)The MMA ExCo met up with the Inland Revenue Board or Lembaga Hasil Dalam Negeri (LHDN) last week. We met with Ms Julie Yeap who is in charge of the Act and Policy, and her colleague at the LHDN Headquarters in Cyberjaya.

MMA addressed its concern about tax-exemption for medical indemnity premiums. We have noted that it will be compulsory later in the year – when the regulations for the New Medical Act have fallen into place – that all doctors will have to pay premiums for medical indemnity. If the doctor claims deduction from tax for the premiums, he will be charged for tax when the payouts are made.

Professional Indemnity Insurance, Public Ruling No. 3/2009

7.0 Tax Treatment of Insurance Proceeds and Compensation7.1 Where a professional has been allowed deduction for a Pll premium paid, any proceeds on the policy received in connection with the Pll will be subjected to tax. Proceeds are taxed regardless whether the insurance company makes payment to the professional or pays compensation directly to the claimant.

7.2 Compensation to the claimant can be paid in the following manner: The insurance company pays the proceeds to the professional and the professional pays that amount to the claimant; or the insurance company pays directly to the claimant.

The compensation paid in both the above methods is not allowed under subsection 33(1) of the ITA since it is made to compensate the loss of the professional’s personal assets.


exco • president’s message8

We have advised them, that we are unable to pay tax in this manner and that the cost of running a medical practice will increase. We have therefore requested for tax-exemption in this matter. They have advised us to come back with a proposal paper on why we are different from other professionals and require this tax-exemption. It is interesting that nobody had taken note of this ruling prior to the involvement of MMA. We would also like to mention that NOBODY had approached the LHDN to rectify the issue.

Meeting with the Pharmacy Division, MoHA meeting was held between MMA ExCo and the Pharmacy Division of MoH on 13 January 2015 to discuss issues involving the Trans-Pacifi c Partnership Act (TPPA). It was clarifi ed in the meeting that there will not be an increase in the patency. There will not be an evergreening of patency for extension of indication except three years for the second indication. There will be no extension for change of the compound or adding other compounds or drugs.

They will not change current practises. Our current legislation will be followed. There will be no further protection of data or any other compromise made. This was presented by Puan Siti Aida who is part of the negotiation team.

In that meeting, we also clarifi ed that the separation of dispensing and prescribing WILL NOT happen this year. There are still a lot of other issues to be resolved before this issue can be addressed. However, the Pharmacy Division is considering merging fi ve current laws into one single law governing all aspects of Pharmacy Service and also updating it to current needs. It was also made known here that the current laws require the doctors, and not the unqualifi ed staff, to dispense medication. Something for the General Practitioners to refl ect upon.

The Pharmacy Division also informed us that they, along with other stakeholders, have sent a memorandum to the Prime Minister for exemption of all drugs from Goods & Services Tax, but have yet to receive a response.

Perlis State DinnerThis dinner was held on the 20 January 2015. It was the fi rst time I had visited the state in 15 years. I have previously worked at a hospital there more than 20 years ago and the place still looked the same though with some additions. I would defi nitely not get lost there as I have met several old friends and classmates who showed me around. The dinner itself was an informal event with the attendance of the State Health Department Director. This is one of the dinners where the members did not have to pay to attend.

SCHOMOS National Working Committee (NWC)The SCHOMOS NWC has been running several projects.

Some of the projects will benefi t all members. These include special prices for buying Peugeot cars as well as when fl ying with Air Asia. The details will soon be out.

Goods & Services Tax (GST)We had a meeting with the Treasury over the impact of GST on healthcare. They are basically not going to provide any form of discounts as they are very short of money and hence will not look into any requests which would reduce the Government’s revenue. We have put forward our case and they have asked us to concern ourselves with doctors only and not the general public. We have been told to provide various scenarios for them to address but GST is here to stay.

Another note to make here is that the request by pharmacies for tax-exemption of all medication has also been rejected, again for the reason stated above.

DengueThe Minister of Health has voiced out very strongly against private primary care practitioners on missing dengue cases. However, we have replied with the possible reasons for this, which include:

• Not a standard practise to identify if it is dengue on the fi rst day of fever

• Economic cost • Doctor-hopping• Patient’s awareness and compliance to instructions

I have done some research and would like to share that you could get full kits at RM400 for 25 kits from a company called All Eights. That brings the cost to RM16 per rapid kit. Results are immediate when compared to the current mode of sending blood for serology testing at labs. It costs between RM110 to RM180, depending on the lab and its packages. The result takes three hours and you would need to call the patient back.

In the previous Budget Speech by the Prime Minister, it was stated that private doctors will be given the testing kit for free. However, on routine calls, most doctors have not seen or heard of this, hence the absence. Even those who managed to get a few kits ran out of supply very quickly and had to wait several weeks for replacements. With the changing weather, we are again anticipating a spike in the number of dengue cases. So beware and take the necessary precautions to protect yourselves and your patients.

I hope this continuous update of information to all members would help shed light on MMA’s efforts. We strive to provide the best for the Association and sincerely hope that the benefi ts would reach each and every member. Thank you again for all the support and help.

Happy Chinese New Year, May the Year of the Ram be Prosperous!


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

From the Desk of theHon. General Secretary

20 December 2014Gathering of The Great Minds (GOTGM) was organised by the Society of MMA Medical Students (SMMAMS) and the Medical Society of University of Malaya (MedSoc UM), Faculty of Medicine, UM. The theme of the event was “Know Potential, No Obstacles”. GOTGM was a motivational and inspirational session by guest speakers from the health profession as well as those who have excelled in different fi elds. The speakers were none other than the Director General of Health, YBhg Datuk Dr Noor Hisham Bin Abdullah, YBhg Tan Sri Dato’ Dr M. Jegathesan and the Dean, Faculty of Medicine UM, Professor Dr Adeeba Binti Kamarulzaman. The session was very interesting with an excellent turnout of students from several medical universities in Malaysia. It was held in the T.J. Danaraj Auditorium, University of Malaya.

6 January 2015

Annual General Meeting (AGM) Organising Committee Meeting was held at the Kelantan Golf & Country Club. This was the second AGM Organising Committee meeting that Dr Ashok and I have attended. We had the privilege of meeting the State Executive Council Member, YB Dr Ramli Mamat, who is part of the Organising Committee and a Member of MMA. This was just after the fl oods in Kelantan. The whole town was dusty with heaps of rubbish all over. The people of Kelantan have been devastated by the recent fl oods. Despite all the setbacks, the AGM Organising Committee is trying very hard to host a good AGM. I believe all the members should support MMA Kelantan and register for the 55th AGM & Scientifi c Meeting.

Meeting with AGM Organising Committe, Kota Bharu

~~~A gentle reminder to all General Practitioners registered with the Private Healthcare

Facilities & Services Act are GST EXEMPT even if the turnover

exceeds RM500,000.00. All Specialists who have their own practices and are registered under the

PHFSA (which means they are not attached to any Private Hospitals) are

also GST EXEMPT.

~~~

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exco • hgs10

14 January 2015Meeting with the Tax Policy Department, Inland Revenue Board (LHDN) of Malaysia. We met with the department’s representatives, Ms Julie Yeap Siew Kuan, Head Assistant Director, and Ms Khoo to highlight the issue of tax-exemption for premiums on Medical Indemnity. We were told that we could seek exemptions for premiums paid. However, if there is a claim and a payout is made to anyone, then the doctor concerned will have to pay tax for the amount that has been paid out. We expressed that this was ridiculous, because the payout is made directly to the claimant and not to the doctor. Therefore, it is not logical or fair to ask the doctor to pay taxes for the amount paid out. With the increasing premiums and the New Medical Act (where Medical Indemnity is compulsory for APC renewal) that is going to be implemented soon, doctors will defi nitely be facing fi nancial constraints. MMA has always encouraged all doctors to purchase Medical Indemnity insurance, and will therefore strive to do whatever possible to help with this issue. We have been asked to submit a proposal on the reasons for tax-exemption of Indemnity premiums and payouts.

15 January 2015Meeting with the Board of Estate Hospital Assistants (EHA). This meeting was chaired by YBhg Datuk Dr S. Jeyaindran, Deputy Director General of Health (Medical). The discussions held were on the shortage of EHAs throughout the country and the results of those who have appeared for the examinations. Datuk Dr Jeyaindran requested that MMA propose and prepare to conduct a course to train male nurses as EHAs. He has given his assurance if the course is of a required standard, then it will be endorsed by the MoH. I have conveyed this information to the Chairman of the Plantation Health Committee of MMA so we may devise a programme. If anyone wants to be involved in this please contact me.

Meeting with the Board of EHA

13 January 2015Meeting with the Pharmacy Division of Ministry of Health (MoH) on Trans-Pacifi c Partnership Agreement (TPPA). This meeting was chaired by YBhg Dato’ Eisah Binti A. Rahman, Senior Director Pharmaceutical Services and Dr Salmah Binti Bahri, Director Pharmaceutical Services. The meeting was held as a result of our concerns with the TPPA, rising cost of generic drugs and also the extension of patency which will indirectly increase the cost of medicine and therefore increase healthcare cost in general. We were given an assurance that all these issues have been carefully assessed and a proposal had already been made to the Government. MMA is only concerned that there should not be a trade-off for other matters with these issues. The MMA is very positive that if these matters are not addressed, the cost of healthcare in this country will rise and affect the public. Meeting with Pharmacy Division on TPPA


exco • hgs12

19 January 2015

Meeting with Medical Practice Division, MoH. This meeting was chaired by the division’s Director, Dr Ahmad Razid Bin Salleh, and was held to discuss the amendments to the regulations of the Private Healthcare Facilities & Services Act (PHFSA) 2006. We have heard about amendments being made to the Act, but apparently none were carried out. We went through the proposed amendments and the most striking were prison sentences for minor offences. We have requested that all prison sentences be removed and all fi nes be compoundable. They have agreed to this and we have also requested for other amendments as well. The amended version will be circulated to us for comments before it is implemented. Dr Ahmad Razid is very approachable and reasonable. We hope that all the amendments requested by MMA will be approved by the MoH.

20 January 2015MMA Perlis Annual Dinner and Installation Night. The President, President-Elect and Hon. General Secretary were invited for the installation of Dr Hari Ram Ramayya as the Chairman of Perlis Branch. It was held at Putra Palace Hotel in Kangar, Perlis. The event received an encouraging response from members and was also attended by Chief Guest Dr Mohd Zaini, Director

of Perlis Health Department. It was interesting to note that MMA Perlis does not charge its members and guests for dinner, as this would encourage non-members to also attend the function, therefore opening another opportunity for the branch to recruit more members.

16 January 2015The MMA Volunteer Corps (VoC) left for Gua Musang, Kelantan, on a fl ood relief mission with 7 doctors and 60 students from the Medical Faculty of Universiti Putra Malaysia (UPM), 2 students from Melaka Manipal Medical College, and 1 student from Monash University. I had the privilege of being one of the volunteers. We left in three buses and visited Gua Musang, Kampung Star, Kampung Limau Kasturi, and Manurai. The whole place had been destroyed, as if a tsunami had hit these areas. Many people were left homeless. The MMA VoC and students went house to house counselling the locals, donating cash, clothing, and food. I must say a BIG THANK YOU to all the doctors and students who volunteered, and not forgetting another Big Thank You to the donors. The MMA conveys its deepest appreciation to all those involved in this venture.

MMA Perlis Annual Dinner & Installation Night

Meeting with MoH

MMA VoC fl ood relief effort

Wishing MMA Members, GONG XI FA CHAI!


REPLY FORM

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55th mma agm 15

55th MMA NATIONAL AGM & SCIENTIFIC MEETING

The Grand Riverview Hotel, Kota Bharu – 29 to 31 May 2015.

AGM REGISTRATION FORM


55th MMA NATIONAL AGM & SCIENTIFIC MEETING

The Grand Riverview Hotel, Kota Bharu – 29 to 31 May 2015.

AGM PAYMENT FORM

55th mma agm16

beritaMMA Vol.45 • February 2015beritaMMA Vol.45 • February 2015

Dr Datesh [email protected] National SCHOMOS

Holier-Than-Thou

Welcome to the new year and hopefully we will be blessed with a more

profound understanding that we are not all we are made up to be. Neither are we too dumb nor too smart to impose ourselves as such. We are all just right and it takes a fair bit to get where we are in our lives currently. Medical school is no walk in the park and mostly it is the ‘best’ that manage to get in.

Doctors are high achievers. The grades needed to secure an interview for a spot in medical school, in most places other than Malaysia, would mean successful applicants are likely to have been top of the class throughout their school years. For many doctors, the initial weeks and months of training are the fi rst time they would be solely surrounded by colleagues of similar, if not superior, academic prowess.

So that is where all problems actually stem from. From the moment the not-so-deserving, in the eyes of the more qualifi ed, waltz into medical school on various trump cards from donation fees to certain social beliefs. It is here that the ‘holier-than-thou’ attitude starts and it carries forward right into public service. The stigma may not even stop at the completion of training as there will be bias and mistrust amongst the peer group itself. We all know this and

we see it daily. Yet we can do nothing.

There will always be different apples in the basket. The quality control mechanism ensures they are not too far off from each other. But when the system itself is fl awed then it is likely the basket will smell even with just one rotten specimen.

Our profession is seeing its decline in the reputable club. We were once considered the crème de la crème of society but now we carry a tagline borrowed by a popular, low cost, budget, airline.

“Now Everyone Can MBBS!”

But let it be known, becoming a competent doctor is no piece of cake. The course, exams and tuitions are grueling. The working hours, the gybes, the feeling of

incompetence are astounding. We all suffer through this phase almost equally. The only thing that really matters fi nally is companionship, friendship, mentorship, and a lot of patience. What we need is this understanding and belief. We need to throw the veil of supremacy away to ensure this journey is as atraumatic as it can be. Bullying your juniors or subordinates will only expose your own weaknesses, insecurities, jealousy, and maybe even racism.

I recently did some reading on bullying amongst medical professionals in the western world and came across an interesting research paper done in New Zealand. A signifi cant proportion of doctors reported being bullied at work. Their questionnaire contained the following points:

Undermine your workUnjustifi ed criticism

Innuendo and sarcasmVerbal threats

Making jokes about youTeasing

Physical violenceViolence to property

Withholding necessary informationIgnoring you

Undue pressureSetting impossible deadlines

Undervaluing your effortsDiscrimination

Discrimination exists in a large scale in Malaysia. Gender, race, alma mater, political beliefs etc. This also exists in many parts of

“If you cannot get rid of the family skeleton you may as well make it dance”

George Bernard Shaw

schomos 17

dical sschool on cardss from to ceertain t is here er-thaan-

staarts forwaard publlic tigmaa stop tion

here and gst up ll d


the world and we are no different. Seniors need to be more aware and take necessary steps at their department level to curtail this.

The transition from student to doctor brings with it a whole new set of workplace relationships, and the high-pressure environment in many clinical departments can create a breeding ground for bullying. In many cases, the bullying experienced by junior medics is usually perpetrated by other doctors in a pecking order of seniority, although nurses and midwives are also sources of negative behavior. The relatively transient, short term nature of doctors’ training placements can also perpetuate bullying because permanent staff feel, in some way, superior to the junior doctors they work with.

Bullying is also dependent on what an individual perceives. It is important to recognise that the generation has changed. The thinking, understanding and whole philosophy of life has taken a new dimension. Reprimanding a new intern – just two days into his job – with words suggesting how he is a ‘scum’ or ‘stingy bloke’ because he had not made his own name tag and is awaiting the hospital to make one for him, is rubbish! Yes, he must be made to understand that it is not acceptable to walk into the ward without a proper identifi cation tag, but there are other ways of speech to stress the importance of having a tag made quickly. We are supposed to be smart, remember? So do improve your communication skills, please.

It seems it has become easier to extend house offi cers (HOs), as since there are so many, the steps required to justify an extension is fast-tracked! Let me give you a deplorable example. In a ward of maybe 20 HOs who work the shift system and thus do a fair bit of work, you may not be seeing the same patient every day as you may be circulating between

wards. So on Patient A’s eighth day of admission, HO A does the ward rounds with the attending specialist seeing Patient A for the fi rst time. Prior to that, HO A had done his own rounds and as usual, this being a cancer patient, the staging is copied from the previous day’s clerking. That is the normal practise as far as I can remember. Yes, the fi rst clerking is the most important where all reference is

made to the Clinic Card and scans reviewed etc. This patient was in for chemo obviously, and HO A who was on his follow-up rounds copied the staging from the previous day’s documentation. The rest of course was in order and current. Now Superior A comes along, quizzes HO A regarding the staging, looks at the notes and tells HO A he has written the wrong thing! The staging is wrong and because he had copied the previous day’s heading, he is extended two weeks point blank! HO A is fl abbergasted, scrambles through the notes and sees that the staging had been wrongly documented from Day 1. Why did this boy get caught? Why did all the HOs, medical offi cers and specialists who were also seeing that patient daily not get reprimanded? You would not expect a HO to stage a cancer patient independently without a senior’s input would you? I think the HO was being bullied. Scapegoated!

The current generation does not accept humiliating behavior. Why should they? With the constant nagging about ‘my time’ and ‘your time’, little is actually achieved. Let me just ask, why should medicine be painful? Why should training be both emotionally and physically strenuous? Is that the only way for us to succeed and become hardened physicians?

No, it is the only way to become hardened bullies! I have worked overseas and did not witness any ‘suffering’ by my interns as we do here. Why are they not given any respect? Why is it a sin to refer to their seniors by their fi rst name? What gave you the right to consider yourself the gold standard?

The answers are in the paragraphs above. I do not blame you for feeling holier-than-thou, my dear seniors. But enough of this now. The young doctors are but members of our own family. They are mostly innocent. Do not use them as political and cultural punching bags. Do not use them to justify your own turbulent journey. Let the junior doctor phase be the most pleasant and rewarding. They too suffered 5 to 6 years of medical school in some of the most diffi cult, challenging places on the planet. Some did spend their time on a beach too, but then again that was their good fortune. They have worked hard and have come back to what should have been the start of a beautiful career. Not the start of a life of suffering, humiliation and poor self-esteem.

We may envision our human resource as skin and bones for the meat has vanished. But let us not crumple, let us dance together.

Be strict, not vindictive. Teach, not persecute. Penalise, not destroy. Guide, not disillusion. Punish if needed, do not create a scapegoat!

~~~The transition from

student to doctor brings with it a whole new set of workplace relationships, and the high-pressure environment in many

clinical departments can create a breeding ground

for bullying

~~~

schomos18


ppsmma 19

Since time immemorial there has been a close relationship, fellowship and comradeship between the General Practitioners (GPs) and Specialists in

this country. We have worked well as colleagues and as a team to provide good health to our patients. We are still working well together but do we have the same working relationship as before, I wonder?

In the early part of the 80’s when private hospitals came into existence, the GPs played a major part in referring their patients to their known and friendly specialist colleagues who were just starting their practices in these specialist hospitals and centres. We still do. I remember when the fi rst specialist hospital in Johor Bahru, the Johor Specialist Hospital came into being, I used to receive so many friendly calls from my specialist colleagues who had just started their practices. It was a norm in those days for most specialists and consultants to see their patients through referrals by GPs. Over the years though, this practise has dwindled tremendously due to many factors. Now, most patients go directly to these private hospitals for consultations without visiting their regular GPs or Family Physicians fi rst. How did that trend fall into place?! The most glaring reason is the economic and fi nancial strength of Malaysians which are now being bolstered with the introduction and growth of Medical Insurance Cards. Another factor that could attribute to this trend, would be ‘time’. Why visit a GP when you could go straight to a specialist even for trivial health conditions like the common cold and fl u. After all, they could also get their other investigations done in these private hospitals which also act as one-stop centres.

While all the above and other reasons could be valid, is this fair to the GPs who are struggling in their practices now? Everyone knows the GP practice in this country is dwindling due to many factors, mainly stringent rules and regulations, with new acts like the Private Data Protection Act (PDPA), rising cost of drugs, and the reduction in referrals to their specialist colleagues. With more than 7,000 GP clinics in this country, it is not going to be easy anymore to earn a decent living as a GP. Gone are the days when we were considered the top professional earners in this country. More than 500 GP clinics have closed during the last fi ve years for many reasons; the most important being a major drop in patient load and the inability to earn a decent living for the long hours they have put in. Is it worth starting a GP practice these days? The answer is a defi nite “No”! The proof is in the pudding. During

the last two years, only about 100 new GP clinics have opened. Gone are the days when hundreds of GP clinics were opened yearly.

Is it not time for a reversal of roles to take place? The GPs had wholeheartedly supported their specialist colleagues when they started their practices in the early 80’s, therefore it is time for our specialist colleagues to reciprocate the same to the GPs now in their time of need.

One of the ways if I may suggest, is to request for all private specialists to encourage their patients to consult their GPs or family physicians fi rst before they come back for specialised treatment with referral letters.

This may sound impractical and many may even suggest that it would result in double expenses for patients, but I am sure with the kind of charges GPs are incurring now, cost may not be the real issue. Furthermore, most managed care organisations (MCOs) and third party administrators (TPAs) still prefer their clients (who are mostly corporate employees) to be seen by GPs before they are referred to their specialists for further treatment. Private patients with medical insurance cards who wish to visit their specialists directly without fi rst seeing their GPs may do so out of convenience and also to save time. Again, I would like reiterate my point above by suggesting for all consultants and specialists to encourage their ‘cash patients’ to fi rst consult their GPs or family physicians before visiting them for further treatment.

This is only one of my humble suggestions and I hope to receive some positive response from our specialist colleagues!

General Practitioners & Specialists:

Where Do We Stand?

~~~The GPs had wholeheartedly supported

their specialist colleagues when they started their practices in the early 80’s,

therefore it is time for our specialist colleagues to reciprocate

~~~

Dr N. Ganabaskaran [email protected]

ChairmanNational PPS

D N G b k


smmams20

My Journey in Psychiatry

‘Mental people’, ‘Problem to the society’, ‘Mad’, and ‘Lunatics’ are the few

terms used by many to identify and describe patients with psychiatric disorders. Patients with psychiatric illnesses experience a painful stigma where they are not given any form of respect by society.

Despite being medical students, my batch mates and I did not think much of them either until we did our psychiatric rotation. I still remember how scared we were before we started this posting.

Lunatic screams, uncontrollable aggressive behaviours, chilling moans, and people lost in their own world are the fi rst few things that enter our imagination when we picture a psychiatric ward.

Let me assure you that this was my own initial assumption about the patients in the ward based on the biased views of society and the media. I still remember I was having tachycardia on the fi rst day of posting. I was so scared to enter the ward. However, this perception changed the moment I stepped in.

I learnt that Psychiatry is a branch of medicine that specialises in the treatment of brain disorders which primarily causes disturbance of thoughts, behaviours and emotions. Here I also learned the importance of communicating with the patient and treating them as a whole person.

My batch mates and I realised that people with psychiatric illnesses are just like any other person we interact with in our daily lives. They also have feelings, are susceptible to other physical illnesses, and have hopes and dreams like anyone else. This is how my journey in this ward began.

My batch mates and I had an orientation on the fi rst day where we met the staff in charge of the ward. We were introduced to the specialists, medical offi cers, and house offi cers in the department.

We were then brought around the ward by the staff to get acquainted with the running of the ward. She briefed us about the various divisions in the Psychiatric Department that we would need to be attached to: the ward, outpatient specialist clinic, Community Psychiatry Unit,

Rehabilitation Unit, and grand ward rounds. She also informed us that we would be required to witness Electroconvulsive Therapy being carried out on patients. She briefed us on how all these subdivisions worked together as part of the department. We were briefly exposed to the patients on the fi rst day.

Our apprehens ion g radua l l y disappeared when we realised that many of them were forthcoming and friendly. We were cautioned not to approach the patients who were hostile and those who were less stable.

There is only one psychiatric ward in Hospital Sultan Abdul Halim, Sungai Petani. This ward consists of 28 beds, 20 beds for the male patients and 8 for the females. The male beds are on the left while female beds are on the right, separated by a lounge for the patients to relax. Here they carry out their indoor activities, read and watch television.

Opposite the lounge is the working area where the specialists and medical offi cers, conduct their daily rounds.

Ms Kiranjit Kaur a/p Gas Mel [email protected]

AIMST Univeristy, KedahStudent Member MMA

hmhA

My group and some of the department specialists in the CPU room


~~~We also attended grand

community rounds where the doctors would

discuss each individual patient’s progress and treatment plan which

includes the Bio-Psycho-Social aspect, a holistic

approach

~~~

Every morning, we would follow ward rounds. We observed how the doctors conducted the interviews with the patient and how they arrived at a diagnosis. It was an eye-opening experience as it was different from other disciplines.

Here I saw how important it was to have effective communication skills, not to mention the patience one must have to sit through the interview! It was not easy to get information from these patients who sometimes kept changing their answers! The doctors would discuss with us about the patients’ presenting complaints and symptoms, and explained how they went about making the diagnosis and treatment based on standard criteria and guidelines.

After observing the doctors, we got to interview the patients. This was what we would do on non-clinic days. We would briefl y ask them their history and how they got admitted into the hospital. They would tell us about their illnesses, experiences and sufferings. They confi ded how sometimes their families and society would treat and label them unfairly. Sometimes we would get more information from the patients and inform the treating doctors who would be very appreciative of our input. It felt good to know that we had in some way contributed to the patients well-being.

While some doctors were doing the ward rounds, the others would start the general psychiatric follow-up clinic, held twice a week at 8.00am sharp every Monday and Tuesday.

After attending the ward rounds, we would go down to the clinic. On the days with outpatient clinic sessions, we would distribute ourselves, three to a room, and sit in with the allocated doctors. In the clinic, we observed how the specialists interviewed the patients who came for their follow-up. The specialists would evaluate the progress of the patients, revise the effectiveness of their medication, address their concerns, and provide both the patient and their family members with psychoeducation about their illnesses.

We were also given the chance to interview the patients. We were guided on how to enhance our communication skills so that we would be able to extract relevant information from them. Sometimes,

there were patients who had defaulted their medication for a while. These patients required a longer consultation time than the regular follow-up patients.

Another experience we had was following the Community Psychiatry Unit (CPU) for their visits. Community Psychiatry is a branch of Psychiatry where the doctors and the staff in the unit will have to follow-up with certain patients in the community. These patients would be referred to the CPU by their treating doctors for several reasons ranging from giving acute treatment to ensuring their compliance to medication as well as giving support, both emotional and moral, to the patients and their families. Depending on the severity of their condition, the patients will be placed under acute, subacute or assertive care. The team also does home visits for these patients when necessary.

The CPU team also enlists the help of neighbours, v i l lagers, local village heads as well as the Welfare Department and other NGOs as part of their management of the patient in the community. A lot of dedication, perseverance and networking is required to ensure that each patient receives optimum treatment and support. We were lucky to have been able to follow the team for home visits. It was a different experience altogether, seeing the patients at home in their environment. We were lucky as the families were welcoming. We were informed that sometimes, certain families would refuse to open their doors despite being informed that the team would be coming for a visit. We also attended

grand community rounds where the doctors would discuss each individual patient’s progress and treatment plan which includes the Bio-Psycho-Social aspect, a holistic approach.

The Rehabilitation Unit in the Psychiatric Department is run by an occupational therapist and the department staff. This unit assesses the activities of daily living (ADL), and guides and encourages patients to carry out normal living activities such as self-care, cooking and being independent. The stable patients are also brought to do grocery shopping sometimes to teach them how to use money. Apart from that they are also taken for activities like car washing and gardening, where they will be paid according to the work they do. This unit is also involved in supported employment where patients are interviewed and placed in suitable jobs. Support is given, whilst they are working, by using the ‘place and train model’.

Another interesting aspect of my psych ia t r i c ro ta t ion was witnessing patients going through Electroconvulsive Therapy (ECT). There are numerous indications as to why a patient is referred for ECT. Basically it is done to achieve a quicker recovery and to stabilise a patient in a shorter duration of time. I used to have the wrong impression about this procedure before I witnessed it fi rst-hand. It is not as inhumane as painted by the stories we often hear. It is carried out in the operation theatre where patients are sedated, with the help of the Anaesthetic team, while a mild dose of electric current is sent through two electrodes placed on the scalp to achieve a seizure, which is recorded on a graph. The results were amazing, for I saw how quickly these patients started recovering.

That was my journey in Psychiatry. Being in the psychiatric ward was an eye-opening experience and patients with psychiatric illnesses are defi nitely not scary. It is all in the manner of how one approaches them and the respect one shows them.

By the end of the posting, my batch mates and I realised how Psychiatry was not what we thought it would be. While it has its similarities to other postings, it also has its unique differences. In fact, I learnt a lot during my posting and had a really good time.


Professor Dato’ Dr Ravindran [email protected]

MAHSA UniversityLife Member MMA, Negeri Sembilan

A to Gof

Patient Safety

Medical errors can possibly occur from the beginning of life till the end. A woman who gave birth to someone else’s child after a mix-up in the sperm samples in an IVF procedure sued the fertility centre

and the embryologists responsible in a neighbouring country two years ago.

In our own country, an adolescent started questioning whether her parents actually gave birth to her as she started looking very different in appearance to her family members but similar to another family that lived nearby. A mix-up which resulted in an exchange of babies between two couples that happened almost twenty years previously then became apparent and was confi rmed after genetic testing.

Both sets of parents in the two incidents described utter devastation and being torn between their love for the person living with them on one hand, and the vast social, legal and economic implications of the mix-up on the other.

Even at death, wrong bodies have been returned to grieving families only to be discovered at the very last moment at the time of the funeral rites. Imagine the agony that families go through at their moment of grief at losing a loved one. This is why stringent identifi cation processes are in place from the ward or ICU where death occurs right through till the body is handed over to the rightful person for funeral rites.

A doctor or healthcare worker may be complacent with the view that it will not happen to them. However conscientious they may be, if they happen to work in a hospital with weaknesses in the system, mistakes may still occur.

In one instance, a patient responded to what sounded like his name and quietly subjected himself to a testicular biopsy whereas he had actually been scheduled for an ultrasound of the prostate. The mistake only came to be known when the patient who was actually scheduled for the biopsy, kicked up a fuss as to why he was waiting for a long time to be called! Blame it on the Asian culture of not asking questions and being inquisitive. The root cause was actually the failure to follow the standard procedure for

general22


ascertaining the identity of the patient by using another identifi er besides the name as often, you would have two persons with similar names in any ward or clinic session.

Letchumanan, Sararaks et al. performed a study on medical errors under the auspices of the Institute of Health Systems Research in Malaysia on randomly selected specialist and non-specialist hospitals. It showed that 6.3% of admissions into Ministry of Health (MoH) non-specialist hospitals had an adverse event and 69.7% had a near miss. The majority of errors were related to clinical management and cognitive-related factors plus behaviour of personnel.

In specialist hospitals, 15.2% of all admissions experienced one or more adverse events while 49.8% had one or more near misses. The majority of errors were related to clinical management.

As long as one is admitted to any hospital, there is a risk of an adverse event or near miss. The risk would be less in a hospital or clinic that is accredited as the system would have been strengthened to inculcate a quality management system that emphasises risk reduction and clinical audit. Training and systems that improve privileging processes would also have been incorporated into the clinical governance processes of such hospitals.

When one studies incident reports in any department, one recurring theme would be that most incidents would involve junior level doctors and nurses. One obvious remedy then would be to improve the training regarding patient safety in the medical schools.

It is thus important to include patient safety education in the curriculum of a medical school so that they learn to deliver safe care. There is already in existence a World Health Organization (WHO) curriculum guide that identifi es areas of importance i.e. understanding that healthcare is delivered in complex systems where the risk of patient harm is high, that medical errors can be committed by anyone and not just the incompetent person, that a more open attitude is needed where such events are reported so that we learn from them to reduce such incidences in the future. It is important that students understand these concepts.

A study was done to assess the level of knowledge about patient safety among fi nal year students in one medical school in Malaysia. In this particular school, the concept of patient safety was introduced in the community medicine module. Human factors engineering was also included in this module. Other aspects of patient safety were covered in the respective clinical disciplines and delivered in an integrated way during the clinical years. There were no formal lectures, tutorials or self-directed learning modules in the clinical years dedicated to patient safety. The clinical teaching was in a major public hospital where patient safety was in the quality framework of the MoH.

Students in the fi nal semester were given a self-administered (anonymous) questionnaire. The questions included true or false answers to level of patient safety decisions, the repercussions to reporting patient safety

incidences, the type of doctor who commits such errors and whether asking for help is indicative of incompetence. Open-ended questions included providing examples of patient safety errors and their causes or contributory factors. Students were also asked to identify some safety measures in blood transfusion, baby safety, safe surgery, and hospital infections.

The class totalled 139 students. Fifteen (15) students did not respond, making the response rate 89.2%. Sixty-seven (67) students (54%) had heard of patient safety while 39 (31.4%) had not and 9 (7.2%) were unsure. When asked to explain what patient safety was, none could provide an accurate defi nition. Some 10 (8%) students could not provide a reasonable explanation, while 61 (49.2%) were incorrect and 56 (45.1%) did not attempt to answer. Students were asked to provide fi ve examples of patient safety errors each. They were given a point for each correct answer. Only 1 student scored 4 points, 2 scored 3, 7 scored 2, 18 scored 1, while 87 (70.1%) did not score any points.

The students were asked to list fi ve causes or contributory factors to such errors and 28 students had responded incompetence and poor training while 28 had listed a lack of knowledge. However, 31 (25%) had listed workload and staff shortage, 14 (11.2%) had listed long hours, fatigue and lack of sleep, 8 (6.5%) communication issues while only 2 had listed organisation and defective systems.

The students were asked to list patient safety measures in blood transfusion, newborn safety, surgical procedures and the prevention of hospital infections. The total score was 12. The highest score was 7 (one student), while 91 students scored less than 3 marks.

Thus the study showed that there were weaknesses in the delivery of the planned curriculum. Medical education tends to focus on diagnosis and management of illnesses and thus the basic concepts of patient safety may be lost in that process. Patient safety needs to be delivered in a formalised fashion where the concepts are fi rst introduced before being covered in an integrated manner across disciplines.

It is thus no surprise that mistakes and patient safety events still continue to hog the limelight currently. There has been a move to use checklists as a method of reducing errors in complex medical care. The WHO Patient Safety programme has put together a framework for identifying a range of clinical care processes where checklists would save patient lives and reduce serious harm. The surgical safety checklist is well known and many Malaysian hospitals have adopted the time out before surgery as part of this process. Initially, there was a lot of resistance from senior clinicians that this was a waste of time but eventually even the reluctant fell into line as clear benefi ts could be seen in patient care and outcomes. Wrong site surgery is now becoming almost unheard of.

Atul Gawande’s book entitled The Checklist Manifesto fi rst made the powerful case for checklists. No matter how expert you are, well-designed checklists can


general24

improve outcomes. He made the case that there are two types of errors: errors due to ignorance and errors due to ineptitude. Failures in modern medical practice is mainly due to the second of these i.e. mistakes that we make due to the failure to make proper use of what we know. Therefore, well-designed checklists will help overcome this. This Safe Surgery Checklist has now been shown to be evidence-based in reducing errors in surgical practice.

Currently, the Safe Childbirth Checklist is being pilot- tested in over 100 hospitals in the world. Hospitals from Iran, Pakistan, India, Bangladesh, Sri Lanka, China, and the Philippines in Asia are participating in the trial to test whether adoption of the checklist improves health outcomes for mothers and neonates. The trial is being conducted by the Harvard School of Public Health and is expected to be completed in 2015. Almost certainly the results would show the benefi t of using checklists for improving safety in this area.

Another checklist that is available is the WHO Pandemic H1N1 2009 Clinical Checklist. A promising checklist currently being developed is the Trauma Care Checklist. This includes components of injury assessment and initial management steps for the care of the trauma patients.

The medical fraternity has learnt from the airline industry about the benefi t of checklists. It is a well-known fact that even the commanding pilot cannot overrule staff and take off without the pre-embarkation checklist being completed. However, doctors tend to not follow checklists sometimes to their own detriment. This must not happen again.

I foresee one day medical schools teaching and emphasising the use of checklists in medical care across various disciplines. The other is the increasing use of inter-professional education with the collaboration of nursing and other allied health schools. Even the study of the humanities will contribute to the making of a better doctor. A humanistic doctor who emphasises teamwork and professionalism would defi nitely be a safe and good doctor.

What do we learn from all this? Doctors are not perfect. Haidet and Stein in the Journal of Gen. Intern Medicine in 2006 talked of the hidden curriculum in Medicine. A number of assumptions are made by caregivers based on the following premises:

Assumptions Premises

Doctors do not make mistakes

Doctors must be perfect

Only one right answer Uncertainty to be avoided

OK to be rude in performing a task

Outcome is more important than the process

Doctors are married to work

Medicine is priority number one

Must not question senior doctors

Hierarchy is necessary

We now know that all of this is not correct. Doctors do make mistakes. There is no one right answer in Medicine. It is not OK to be rude. We need to cultivate humanity and be a humanitarian. We must look outside our work to become better and we need to question whether we are doing the right thing even if one is a senior doctor.

We are now told we have too many doctors. Housemen are falling over themselves in the hospitals. We now need to train them to think as humanistic doctors in the medical schools and clinicians need to inculcate the necessity of using checklists to avoid medical errors. With the numbers that we have, we should not be complaining that there is no time. The quality of the doctor–patient encounter now needs to improve.

I have kept emphasising to junior doctors that most things can be crystallised down to ABC. It is from the alphabet that the English language fl ourished to produce the literature that exists today. So to learn to avoid mistakes, doctors need to learn the following A to G:

AAvoid shortcuts. Audit your practice.

BBenchmark against good practises.

CCompetence. Do not do anything till you are

competent. Even if your seniors say so!

DDocument. Write down your logical thoughts

in managing the patient.

EEvidence-based medicine. You cannot justify

anything else.

FFrankness. Develop a good doctor-patient

relationship by being open.

GGuidelines. Good departments and hospitals need

guidelines to make medical practice safe.

If we work at it and use the best practises that are available, we will improve. We should and we must. We owe it to our patients.

References on request.


The National Human Rights Action Plan

Dr Ashok Zachariah [email protected]

President-Elect

~~~Trying to limit individual

rights by referring to cultural or religious

norms is imposing your views on others

~~~

On 13 November 2014, I attended the launch of the process of formulating a

National Human Rights Action Plan (NHRAP). This was held at the Hotel Bangi Putrajaya, which is a little off the beaten path, but conveniently located for me, coming as I did from Melaka.

In true Malaysian style, there was a coffee break even before the start of the proceedings, and during this I met quite a few people from various Non-Governmental Organisations (NGOs) and civil society groups who had been invited to the seminar. Many of them were young, idealistic and enthusiastic. I hope they continue to remain engaged in the public life of our country.

The meeting kicked-off with a speech by the Minister in the Prime Minister’s Department, YB Hajah Nancy binti Shukri. She explained that the United Nations has recommended the adoption of such an Action Plan so as to strengthen the protection of and respect for human rights. In order to be inclusive, the Government took the laudable step of setting up a Committee to oversee the process and invited NGOs and civil society organisations to participate.

The meeting was then addressed by representatives from the Bar Council, the Human Rights Commission of Malaysia (SUHAKAM) and the Centre for Human Rights Research and Advocacy (CENTHRA). Datuk Dr Khaw Lake Tee, SUHAKAM Vice-Chairperson, told the attendees that as SUHAKAM was supposed to monitor human rights in the country, it should not be involved in the formulation of the NHRAP. The representatives from the Bar Council and CENTHRA were both passionate and articulate, but to me they seemed to be at cross purposes. The Bar representative favoured a more

universal approach to human rights, while the CENTHRA representative asserted that Malaysian human rights should be based on what the majority of Malaysians think appropriate.

I must admit the latter approach disturbs me, because it runs counter to my perception of human rights. I believe human rights exist to bestow freedom upon individuals. If the majority is to decide what rights the minority can have, what is to prevent them from oppressing the minority? What recourse will the minority have if they feel their rights have been unreasonably circumscribed because the majority does not feel these constitute “Malaysian Human Rights”?

Individual Rights is the essence of human rights. The concept of individuals having rights that they can assert against the state and other organisations, as well as against other individuals, has taken a long time to take root. Early Greek ideas about democracy were quite restrictive, encompassing only male landowners, and slavery was rife. The Romans were little better, and of course most kingdoms and empires everywhere tended to be autocratic. The American and French revolutions did plant a seed that it took the horrors of World War II to bring to fruition. It has taken a long time to reach the stage where most people

accept the idea that it is important to the well-being of society that the individuals who comprise it should have inalienable rights.

The problem is that many in power view human rights as a nuisance or menace, making governing more diffi cult because more consultation and circumspection is needed to avoid violating them. Thus they try to limit them, decrying the most expansive forms as foreign or imperialist imports, unsuitable for the unique, unspoiled culture and heritage of the state concerned. It would be laughable if it were not so sad.

This is what we must not allow to happen here. To try to limit individual rights by referring to cultural or religious norms is imposing your views on others. In the fi eld of human rights, this is unwise as well as unacceptable. We do not hold these rights on sufferance. They are not given to us piecemeal and selectively. Rather, they are to be restricted only to the extent that the functioning of society requires. Thus, human rights do not include the right to harm or kill people, but they do include the right to offend people, because I have the right to free speech, and it is certain that sincere free speech will offend someone, somewhere. The remedy for this is not to curtail free speech, but to educate people to argue rationally, using words rather than fi sts, and using reason rather than imperfectly veiled threats.

As I mentioned, many NGOs were represented at the launch, and I believe the MMA should work with them to ensure that the NHRAP brings into being a human rights framework which we can be proud of, that allows for maximal human fl ourishing, which will enrich us all in many ways.

general 25


Obesogenic:The Obesity Epidemic Dr Norhaya Mohd Razali

[email protected] Respiratory PhysicianLife Member MMA, Terengganu

This is a follow-up on my earlier write-up on Obstructive Sleep Apnoea (OSA). This paper shall concentrate on the Obesity Hypoventilation

Syndrome (OHS). Most physicians would mention Charles Dickens’ Mr Pickwick1 if OHS is discussed.

Narrated Tirmidhi & Ibn Majah2, the Prophet Mohammed S.A.W. (peace be upon him) said, “It is important to eat only when you are hungry. When you do eat, you should not eat in excess. One should divide his or her stomach into three parts – a third each for food, fl uid, and respiration. Remember the hungry when you eat. One could avoid going to hell by feeding a hungry dying person or animal.”

Thus, alarm bells were ringing when we read the following article that appeared in the Star Newspaper (16 June 2014)3 entitled, “Malaysia’s Obesity Rate Highest in Asia”.

The report quoted, Science Advisor to the Prime Minister, Tan Sri Zakri Abdul Hamid, fi ndings from British Medical Journal, The Lancet4, showed that 49% of women and 44% of men in this country were found to be obese.

According to the study4, Malaysia was rated heavyweight at 45.3% of its population, followed by South Korea (33.2%), Pakistan (30.7%) and China (28.3%).

The problem is big as it is not just linked to breathing diffi culties, but also to diabetes, heart problems and an array of many other medical disorders.

Defi nition

OHS is defi ned by a triad of obesity, daytime hypoventilation, and sleep-disordered breathing. Daytime hypoventilation is defi ned by an awake arterial partial pressure of carbon dioxide (PaCO2) >45mm Hg and arterial partial pressure of oxygen (PaO2) of <70mm Hg. Sleep-disordered breathing occurs in the form of OSA in 70% to 90% of cases and as nocturnal hypoventilation in 10% to 30%.5 Alternative causes for hypoventilation such as neuromuscular disease, obstructive lung disease, and metabolic or central processes must be ruled out.

The prevalence of OHS in Asian patients with OSA is similar to that reported in white populations,

suggesting OHS occurs at lower BMIs compared to whites.6

OHS is associated with significant medical comorbidities, compared to obese controls, OHS patients are at greater risk for congestive heart failure (CHF) [odds ratio (OR), 9], angina (OR, 9), and cor pulmonale (OR, 9). Rates of hospitalisation, healthcare resource utilisation, intensive care unit (ICU) admission (40% vs. 6%), and mechanical ventilation (6% vs. 0.04%) are also signifi cantly greater with OHS. Furthermore, after two years of treatment, the rate of hospitalisation in OHS patients decreases and becomes equivalent to that of the obese control group. Compared with OSA controls, OHS patients have greater rates of pulmonary hypertension (50% vs. 15%) and greater mean pulmonary arterial pressures.7

OHS is being increasingly recognised in the ICU, when patients often present symptoms of acute chronic hypercapnic respiratory failure. Marik and Desai recently described a cohort of patients with “malignant obesity hypoventilation syndrome.”8 These patients had been admitted to the hospital an average of six times over two years, and the majority had been incorrectly diagnosed most commonly with chronic obstructive pulmonary disease (COPD) and 86% of them had been treated for CHF. These patients were severely obese with an average BMI of approximately 49 kg/m2, and suffered from signifi cant comorbid diseases including type 2 diabetes mellitus, liver abnormalities, diastolic dysfunction, and pulmonary hypertension. Mortality rate was 18% during their index hospitalisation. Long-term mortality was 3%, 8%, and 30% for 1, 2, and 5 years, respectively, after hospital discharge.

~~~Thus, healthy eating habits, correct type of food in adequate amount, regular exercise, and a smoking-

free lifestyle are the key to a host of numerous medical problems

including OHS

~~~

general26


FIGURE 18. Patients with OHS are more susceptible to acute respiratory decompensation when presented with common respiratory and metabolic challenges. OHS indicates obesity hypoventilation syndrome; PaCO2, partial pressure of arterial carbon dioxide; PAP, pulmonary arterial pressure; RHF, right heart failure; VCO2, carbon dioxide elimination.

We would like to stress that, obesity prevention is the key to management of OHS. Thus, healthy eating habits, correct type of food in adequate amount, regular exercise, and a smoking-free lifestyle are the key to a host of numerous medical problems including OHS or the Obesity Epidemic (Obesogenic).

The Sleep Disorder Society Malaysia (SDSM) shall be organising roadshows on Sleep Medicine next year. The target audience shall be the ‘fi rst-liners’ (General

Practitioners, Family Medicine specialists and junior doctors). Our objective is to improve awareness on Sleep Medicine. At the end of each roadshow, we hope doctors would know when and where to refer patients suspected to have sleep problems for further evaluation.

References

1. The Posthumous Papers of the Pickwick Club is Charles Dickens’ fi rst novel. 1836.

2. English: Vol. 4, Book 29, Hadith 3349. Arabic: Book 29, Hadith, 3474 Tarmidhi ibn Majah. Narrated by Miqdam bin Madikarib.

3. The Star Newspaper (Published: Monday 16 June 2014).4. Marie Ng, Tom Fleming, Margaret Robinson, Blake Thomson, Nicholas

Graetz, Christopher Margono et al. Global, regional and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, Vol. 384, No. 9945; 766-781 (Published online: May 28 2014).

5. Kessler R, Chaouat A, Schinkewitch P, et al. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest. 2001;120:369–376.

6. Akashiba T, Akahoshi T, Kawahara S, et al. Clinical characteristics of obesity-hypoventilation syndrome in Japan: a multi- center study. Intern Med. 2006;45:1121–1125.

7. Fletcher EC, Schaaf JW, Miller J, et al. Long-term cardiopulmonary sequelae in patients with sleep apnea and chronic lung disease. Am Rev Respir Dis. 1987;135:525–533.

8. Marik PE, Desai H. Characteristics of patients with the “malignant obesity hypoventilation syndrome” admitted to an ICU. J Intensive Care Med. 2012.

NoReserve

Acute Respiratory Failure in OHS

Acute respiratoryinsult

Atelectasis

Sedation

Acutehypercapnicrespiratory

failure

Pulmonaryedema

Metabolicalkalosis

Hypermetablicstate ( PaCO2)

PAP, RHF( VCO2)


Dr Tharmalingam [email protected]

MMA Medical Education Committee

Head of Department of Medicine,

Hospital Sultan Abdul Halim, Sungai Petani

In 2013, Medical Specialists from all over the country gathered in Melaka for a meeting held by the Ministry of Health (MoH).

We discussed various aspects of medical doctors’ training, including postgraduate training in medical disciplines.

The end result of it was to develop or initiate full time postgraduate specialist training in Private Hospitals as well. Currently more than 98% of specialists are being trained in Government Hospitals.

Most specialists (70%) in Internal Medicine and Paediatrics are trained under the membership qualifi cation of MRCP and MRCPCH respectively. The remaining 30% come from the MoH Masters programme.

The reality is, even though currently private institutions are not involved in the postgraduate area of clinical specialities, the private institutions can form a Smart Partnership with MoH Hospitals to train specialists.

As a follow-up to the meeting in Melaka which was chaired by Deputy Director General of Health (Medical), YBhg Datuk Dr S. Jeyaindran, and offi ciated by Director General of Health, YBhg Datuk Dr Noor Hisham Bin Abdullah, I had a discussion with Datuk Dr Jeyaindran and subsequently initiated the smart partnership between AIMST University and Hospital Sultan Abdul Halim (HSAH) in postgraduate medical training.

MRCP Mock Exams and training programmes were planned for 2 & 3 April 2014 at two venues – AIMST’s campus and in the Department of Medicine, HSAH.

On 2nd April, Datuk Dr Jeyaindran visited the AIMST campus and its Clinical Skills Laboratory. Then we had a meeting with Vice Chancellor Prof Dr Premkumar Rajagopal, Dean Prof Dr P.K. Rajesh, and Registrar Prof Dr Aruljoethy, to discuss the long term Smart Partnership.

Postgraduate TrainingSmart Partnership:

Private Medical Schools & Ministry of Health

Left to Right: Prof Dr Aruljoethy (Registrar AIMST), Prof Dr P.K. Rajesh (Dean, AIMST), Datuk Dr Jeyaindran (Deputy DG MoH), Dr Premkumar Rajagopal (Vice-Chancellor AIMST), and other faculty members of AIMST University, Semeling Campus, Sungai Petani.

general28


Datuk Dr Jeyaindran suggested that the Smart Partnership between AIMST and HSAH should address the following areas of interest:

• Development of Avuryedic, alternative medicine postgraduate training in AIMST University.

• Postgraduate training membership programmes, namely MRCP (UK) and also MRCP (Ireland) by using the clinical skills lab by MoH Doctors especially in Part 1 and Part 2 MRCP training. This includes, MRCP Master Class – scheme in systematic membership training.

• Development of Endoscopic or Laparoscopic Skills Lab for MoH doctors in AIMST University campus under the supervision of Laparoscopic Gynaecology Surgeon and Head of Department of Obstetrics and Gynaecology, HSAH, Dr Kunasegaran Kanniah. The skills lab will be fully funded by AIMST University for training of MoH doctors. The Vice Chancellor of AIMST agreed to this project on principal.

The following day, on 3rd April, the MRCP preparatory course – Mock Examinations was conducted for the MRCP 2014 candidates.

This training was partially funded by AIMST University and was conducted in the Department of Medicine, HSAH. We were indeed honoured as the Deputy DG, Datuk Dr Jeyaindran himself, agreed to be the Chief Examiner!

We were assisted by other senior and eminent Consultant Physicians including Datuk Dr Chandran (Hospital Raja Perempuan Bainun), Dr Lechumanan (Hospital Taiping), Datuk Paduka Wira Prof L.R. Chandran (AIMST), Dr Chen Cheng Hua (Hospital Sultanah Bahiyah), Dr Sunita Devi (HSAH), Dr Paras Doshi (Hospital Kuala Lumpur), Dr Suresh (University Malaya Medical Centre), and Dr Khor Boon Tat (HSAH).

The course was attended by 20 MRCP candidates from Penang, Kedah and Perak. We received many positive feedback from candidates who wished such courses would be organised on a regular basis. It was indeed a successful training session.

Organising such a course was very laborious and intensive, but it was for the good of the profession and MoH.

I was fortunate to have a very dedicated and hardworking team comprising of Dr Zainura Che Isa, Dr Tan Ying Jie, and Dr Sumithra Appava who worked relentlessly to ensure that the training went on smoothly. Kudos to them!

My heartfelt thanks to AIMST University and HSAH Director for their kind cooperation.

We organised another MRCP Preparatory Course/Master Class on 17 & 18 January 2015, as a continuation for the Smart Partnership in Postgraduate Medical Training in MoH programme.

I encourage Consultants in other Government Hospitals to organise similar training sessions at least once a year to ensure continuous supply of specialists in our Government Hospitals.

MRCP Mock Exam Training in progress: Datuk Dr S. Jeyaindran, Dr Tharmalingam Palanivelu (Head of Department of Medicine, HSAH) and Dr Zainura Che Isa addressing postgraduate MoH Candidates and Medical Offi cers in Department of Medicine, HSAH.

~~~Though currently private institutions are not involved in the postgraduate

area of clinical specialities, the private institutions can form a Smart Partnership with MoH Hospitals to

train specialists

~~~


The MMA Committee for Health of the Older Person (HOP) held an echo symposium in Kuala Lumpur on 24 October 2014 following the International Conference on Healthy Ageing which was

held on 20 & 21 October 2014 at the International Medical University (IMU). The symposium aimed to raise awareness on the impact of an ageing population and the need to ensure that people can grow old with dignity. This symposium was also held in conjunction with the UN International Day of Older Persons which is celebrated yearly on the 1st of October. The 2014 theme for the 24th commemoration of the International Day of Older Persons is “Leaving No One Behind: Promoting a Society for All.” This symposium was timely in view of the major challenges that the country will face in the near future with an increase in the ageing population as there is now, more than ever, better availability and accessibility to healthcare as well as continuous improvements in the medical fi eld nationwide. The symposium was open to all healthcare personnel and about 50 participants attended.

As the Chairperson of the HOP Committee, Dr Sumitra Sithamparam delivered the welcome address. She commented on key areas of concern to contend with, such as: income and income security; health, access to healthcare and healthcare fi nancing; legal issues that challenge older people; coping with growing old and intergenerational relationships; and, participation and involvement in community activities. The eminent speakers who were invited to present their talks were Prof Dr Abdul Rashid Khan (Head, Department of Public Health Medicine, Penang Medical College), Assoc. Prof Dr Sajaratulnisah

MMA Healthy Ageing

Symposium 2014

Dr Rosanna [email protected]

ChairpersonMMA Healthy Ageing Symposium 2014

Member MMA, Wilayah

~~~The other area of concern

by the audience was the lack of support in terms of caring

for our elderly population at a national level. It was

proposed that MMA should lead the steps by highlighting

this problem to the Ministry of Health

~~~

f f

general30


Othman (Consultant, Primary Care Medicine Department, University Malaya Medical Centre), Prof Dr Tan Maw Pin (Consultant, Geriatric Medicine, Univers i ty Malaya Medical Centre), Assoc. Prof Dr Ritabelle Fernandes (Community Geriatrician, Hawaii, USA), and Dr Susy Matthews (Psycho-Geriatrician, Brisbane, Queensland, Australia).

Prof Dr Abdul Rashid Khan shared relevant statistics and demographics on the ageing population in Malaysia. Some of the salient points were: the national ageing population of 60 years and above has been rising steadily from 5.7% in 1990 to 6.3% in 2000 and is expected to be 9.8% in 2020. Prof Rashid offered explanations for this increase, which included falling mortality rates, improved health and nutrition which lead to a longer life expectancy, and declining fertility rates. Prof Rashid also addressed the social problems that the elderly were facing, such as loneliness and isolation as the country faces more urbanisation and societal lifestyle changes from living in an extended family household to living in nuclear family households.

Assoc. Prof Dr Sajaratulnisah, the second speaker, enlightened us

on the problem of abuse in the elderly that is becoming increasingly common in our society. The types of elder abuse addressed in this talk were physical, emotional, sexual, fi nancial, and neglect. Dr Sajaratulnisah also commented on the consequences of abuse in the elderly and the role of doctors in identifying these patients, managing them and referring them for other appropriate services as deemed necessary.

Assoc. Prof Dr Ritabelle Fernandes delivered a very thought-provoking presentation on caring for low income seniors in the community w i th l im i ted resources . She described the community work that she was involved in Kokua Kalihi Valley, Hawaii and the programmes for seniors that help them to live independently in the community. She provided examples of how senior adults in this community may age healthily and positively by being active in exercise programmes and volunteer work, in addition to earning a stipend by caring for other ageing people. Examples of healthcare models in several other low-income communities in various islands of Hawaii and Polynesia were also given.

Prof Dr Tan Maw Pin shared her knowledge and experience on the problem of confusion in the elderly. She addressed the main t h r e e c o n d i t i o n s that often lead to confusion, which were, del i r ium, dementia and depression. Dr Tan described a case-scenario of a confused patient and the ideal method of assessment and management of the patient.

Dr Susy Matthews talked on the various mental health problems faced by the elderly and how diffi cult it can be to make an accurate diagnosis. She emphasised the importance of obtaining an adequate and comprehensive history from the patient as well as their carers to aid in making the correct diagnosis, which would in turn ensure appropriate management of the patient and help him or her to functionally recover soon.

The symposium came to a close with an invigorating interactive forum in the afternoon, chaired by Dr Sumitra Sithamparam. The panel in this forum included the fi ve speakers, Dr Sumitra, Dr Vigneswary Nataraj and Mr Peter Terence D’Cruz as the commentators. Rapporteurs, selected from across the healthcare spectrum, recorded the discussions. One of the main issues that was discussed in this forum was the lack of focus on the abilities of older people, as the medical fraternity often puts too much emphasis on problems and disabilities in the elderly rather than looking into what they are capable of doing; we should also look for mechanisms to help them reach their best potential in these areas. The other area of concern by the audience was the lack of support in terms of caring for our elderly population at a national level. It was proposed that MMA should lead the steps by highlighting this problem to the Ministry of Health and relevant Non-Governmental Organisations in order to encourage more funding and care-improving programmes for the older people in Malaysia.

Organising Team with Speakers


Trekking Holidayat the Himalaya Mountains

Doctors are generally very busy people, and when they take a holiday, it is likely to be for leisure, besides ‘balik kampung’ for family obligations. Taking a break to the mountains where you have to trek or climb for hours is not the usual kind

of holiday that fi ts their schedules. Moreover, it is not a matter of just packing and taking off, with your spouse or secretary making all the preparatory arrangements. Training is needed in preparation for the trip and this may take weeks to months of hard work.

I recently took a two-week trekking trip to the Himalayas with three others, and found it very exciting. However, I regretted this late discovery. I would have enjoyed it more had I been younger and stronger. I am now 62 years old and there may not be many years left for me to embark on such holidays. During the trip, we trekked to the Everest Base Camp or EBC, to a height of 5,364 metres (17,585 feet). As a comparison, Mount Kinabalu, the highest peak in Southeast Asia, is 4,095 metres (13,435 feet).

This was in fact my second trip to the Everest Base Camp. My fi rst trip was fi ve years earlier with my son and his friends (all in their twenties), but I had to turn back after reaching Dingboche (4,300m) due to altitude sickness. It had always been my dream to go back and complete the journey before my knees become an issue.

Everest Base Camp is one of the most popular trails in the Himalaya mountains. There are dozens of trails you can take, some longer and tougher, and some shorter and more leisurely. The Annapurna trail, which was recently hit by an avalanche and blizzard, is another popular route (Note: The blizzard and avalanche actually happened much higher up, far from the usual Annapurna Base Camp trail). We met four doctors from various hospitals in Malaysia and who are from the alumni of Malacca Manipal Medical College. They were trekking to Tengboche (3,867m), along the route to EBC, which commands a panoramic view of the Himalayan mountains and the fi rst clear view of Mount Everest.

By,Datin Dr Ang Kim [email protected] Life Member MMA, Selangor


B

travelogue32


To get to EBC, you have to fl y to Lukla (2,840m) from Kathmandu. This takes about 30 minutes by small 15-seater twin otter planes. Flights in and out of Lukla can be unpredictable. The small planes cannot take off or land if there are low clouds or strong winds. Often, fl ights are delayed or cancelled and this could be for days at a stretch. Therefore, do schedule a few additional days in Nepal for your return fl ight to Malaysia in case this happens. Make use of the additional days to do some sightseeing in and around Kathmandu if your fl ights in or out of Lukla proceed as scheduled.

Most trekkers leave for Pakding immediately upon arrival at Lukla (2 to 3 hours away), where they pass the night so that trekking to the next station at Namche Bazaar can start after breakfast the next morning. Namche is another

7 hours away but we took 10 hours at our speed. It is one of the largest mountain townships and the Sherpa capital. Visit the Sagarmatha (Everest) National Park (a UNESCO Natural World Heritage site) and the Museum to learn about Sherpa history and culture, as well the Khumjung Mountain and Wildlife Conservation Programme.

The scenery along the trekking route is breathtaking – with majestic mountains, waterfalls and roaring waters from mountain streams that you hear before you see them. There are many suspended steel bridges that take you across deep mountain gorges. The trails are mostly natural terrain following mountain contours with some parts consisting of just rocks and stones. Along the way, you will meet many donkeys and yaks carrying goods for tea houses and lodges up the mountains. You have to step aside (towards the mountain side) less you fancy getting nudged off the slope as the trails in some stretches are very narrow.

Facilities at the mountain lodges are very basic with only beds and blankets in the rooms. Toilets are usually shared but the one we stayed at in Namche Bazaar had attached toilets but this is very rare. Meal choices are limited with eggs as the main protein source. Breakfast is usually toast, pancake, or oat porridge with eggs and coffee. For main meals, there is rice or noodles cooked in different ways, pasta, pizza and hot soups, although some offered meat options. Momo, a kind of Nepalese dumpling (steamed or fried) with meat or vegetable fi lling is always available. I brought along a bottle of Tabasco chili sauce and a few cans of chilli tuna to spice up our meals. You may also want to bring your favorite 3-in-1 coffee or tea bags in case you are not accustomed to the taste of their coffee or tea.

~~~Everest Base Camp is one of the most

popular trails in the Himalaya mountains. There are dozens of trails you can take,

some longer and tougher, and some shorter and more leisurely

~~~


This is certainly not a holiday for leisure, but an adventure of sorts for those who like nature, outdoors, and physical challenges. It is refreshing to the soul, walking in solitude and immersed in the vastness and remoteness of the mountains. For me personally, it enhances the dexterity of my limbs and sharpens my senses. Every step taken is measured – where to land your foot less you slip or trip and fall. Stepping on a loose rock or stone, or pebbles on a downward slope can be disastrous. Hence, you have to keep your eyes focused and choose the spot to land your foot. The use of a trekking pole is of great help. It provided support and saved me from many falls. Some trekkers prefer using double poles but you need to get used to them.

Mountain trekking is a very healthy form of exercise that will keep you physically fi t and mentally strong. I believe the mental stimulation will help to keep dementia at bay. What is the difference compared to hiking up Mount Kinabalu, you may ask? Mount Kinabalu is a mountain-climbing activity, more of a fi tness and physical endurance exercise. It is over in two days, from Timpohon Gate (1,866m) to Low’s Peak (4,095m) and back to the base. Nevertheless, it is challenging and an adventure for those who cannot afford to take too many days off from work.

Trekking to EBC takes at least 12 days from Lukla and back, with two acclimatisation stops (staying two nights) at Dingboche (4,300m) and Louboche (4,910m). Trekking takes between 8 to 10 hours for most days, or longer depending on your speed and how frequent you stop to catch your breath.

The fi nal stretch to the Base Camp was the most challenging. It was all the way from Louboche after breakfast, to the last station at Gorakshep (5,160m) for lunch and to unload our baggage, before proceeding to the Base Camp and back to Gorakshep for the night. We took more than 13 hours, and only reached EBC when the sun was setting. It was close to 9.00pm when we fi nally returned to Gorakshep for our dinner and rest. It was nevertheless a feat, for all of us made it to EBC. You can understand why we were so slow – we were all senior citizens!

Was it worth the challenge to undertake this journey at our age? I have no regrets making the trip. I am glad I took the second chance while I still could. It was hard, but it was now or never! It was a lifetime experience, an unforgettable journey we could tell our friends and grandchildren in many years to come.

Finally, my advice to senior citizens who wish to venture as we did. Arrange for a less compact itinerary, especially for the last part to EBC so that you can take your time and not have to trek until nightfall like we did. Train hard before the trip – not just on fl at land, but on mountain trails or simulation exercises in the gym to build up your leg muscles. You may want to go for lighter or shorter trails like up to Namche or Tengboche only. There are many packages being offered, including to other parts of the Himalayas. The best, however, is to go whilst you are still young.

~~~Mountain trekking is a very healthy form of exercise that will keep you physically fit and mentally strong.

I believe the mental stimulation will help to keep dementia at bay

~~~

At the EBC: I did it!

travelogue34


personality 35

“You give but little when you give of your possessions.

It is when you give of yourself that you truly give.”

– Kahlil Gibran, The Prophet

I was pleasantly surprised hearing the youthful voice of Dato’ Seri Dr TP Devaraj greet me when I had called to make an appointment to interview him. Warm, friendly with a tad

of hoarseness as he was at the tail end of his bout of fl u, melted away all my apprehension of meeting this dynamic fi gure whom I had admired and respected from afar. Weaving my way through the hostile Penang roads after work, on a blistering hot evening, I was hoping fervently that Moses will make a miraculous appearance and part the traffi c for me, like he did the Red Sea. Oh, the ‘joys’ of driving in Penang! I was going to be late! As I alighted from my car, Dato’ Seri (DS) greeted me with a heart-warming smile that reached his kind eyes which was winged by a pair of silvery grey brows. He brushed aside my apology with another heart-stopping smile, as I had successfully lost the battle on being on time.

“Interesting, I have never been interviewed by a Shrink before.”

Uh oh! Was he going to clamp up? He had this youthful grin which broke into laughter when he saw my blank expression. He led me to his dining room which was adjoined

to the living room, where this amazing man of 90 took me through an euphony of anecdotes whilst imparting valuables lessons in life.

Family & ChildhoodDS Devaraj is amongst the fi rst generation of Malaysian Indians. His parents came from a village in South India a few miles from Trichy. His dad came to Malaysia in 1902 and worked in the Malayan Railways, fi rst in Butterworth then Ipoh. He describes his father as a learned man who strived to help the community. His mother was a housewife who had passed away three years after DS was born, so he never really knew her. He was brought up by his only sister, who had to forsake her studies to take care of household duties and the two younger brothers. There were six of them of which DS Devaraj is the youngest. Three have passed on. His only sister, now 98, his fi fth brother now 92 and DS Devaraj himself, 90, are the only ones left from the siblings. Seeing the amazement on my face, he grinned as he told me that his paternal grandparents lived beyond 90 years of age. He attributed this to his family probably having a longevity gene. “It’ s not just genetics, one also has to have a moderate lifestyle, no smoking and an active life outside oneself,” he added.

DS Devaraj had a very interesting childhood, one that many who lived during the war had. His was unique in that it had some extra twists.

Everything was quite normal until 1940 when he was in Standard 8 at the Anglo Chinese School, Ipoh. His father was going to India to visit his father and the family decided that he should be accompanied as his health was not that good. Little did DS Devaraj know that it was to be his last trip with his father. Three weeks into the visit, his father had a stroke and passed away. All attempts to go home failed. After being stuck in that village for three months, he decided to take matters into his own hands. He went into Nagapattinam where the shipping offi ce was, and asked to see the manager. He was not leaving without a ticket home. The manager was a white man, ‘Dorai’ as they are so often called by the locals. Now we are taking about an era where no Indian dared make any demands, let alone grab a chair and sit in front of them. DS Devaraj did both. He just uttered one fi rm sentence “I want to go back to Malaya, I need a ticket”. Perhaps more out of shock than anything, he was given a ticket! Thus he was able to resume school. Being absolutely ignorant about the ways to conduct himself in front of the Dorai, he showed that even during those times “Malaysia Boleh”!

On 8 February 1941, the Japanese attacked Kota Bharu when he was sitting for the last paper of his Senior Cambridge exam. Soon after, they destroyed the British fl eet off Kuantan as it sailed to Kota Bharu, thus allowing for a rapid advance south. About 10 days later, the Japanese reached Ipoh by road. They were also using the railway lines by ingeniously removing the tires from their military trucks. Our railways lines were medium gauge tracks in which the

Interviewed & written by,Dr Gayathri K. Kumarasuriar [email protected] Board Member

Dato’ Seri Dr TP Devaraj:Uncut


personality36

rims of these vehicles fi tted perfectly. Everything was at a standstill. People of all races lived in fear. Friends protected each other, regardless of race, even with the imminent threat of being beheaded if they were discovered to be anti-Japanese.

DS Devaraj was 18 when the Japanese attacked our country. Cycling for miles to get food, at the risk of being caught and beheaded on suspicion of harbouring and feeding the anti-Japanese forces in the jungles, he went through a lot of hardship like others during those times.

He spoke of his fondness for the two people who infl uenced him most as a teenager, his uncle Samuel and his late second brother, Tan Sri Dr TJ Danaraj.

Uncle Samuel, his father’s cousin was someone DS Devaraj could open his heart out to. Before the war, he would cycle 36 miles to Tapah from Ipoh, a journey that took three hours each way, after school on Friday to spend the weekend with him. He was a very learned man. He retired as the Secretary in the Ipoh Town Council. He was a constant source of motivation even during the war.

The second was his late brother, Dr Danaraj, who had inspired him to do medicine. DS Devaraj’s father, due to fi nancial constraints, had advised him to become a Health Inspector. Tan Sri and his wife, the late Dr Winifred Danaraj, were working in Penang when the war broke out and retreated to Singapore. Both became professors at the medical school while Tan Sri was the Dean before returning to Malaya in 1960 to establish the Medical Faculty, University of Malaya and the University Hospital. The University Library has been named in honour of him.

Hot-blooded as any teenager, with a quest for freedom, he joined the Indian National Army (INA) at 20. He was sent for training in Singapore but to his disappointment was never deployed to the war zones. Instead he was sent as a Second Lieutenant to train soldiers while many of his fellow offi cers were sent to fi ght in Burma. He soon fell foul with the INA in 1945 and was amongst the few who were arrested and sent to a concentration camp in Singapore on the suspicion of plotting with the Japanese. Within a few days into captivity, Hiroshima and Nagasaki were bombed and they were all released. On his release, he made the decision that Malaya was his home.

DS Devaraj was discharged from the army with about 40,000 ‘Banana’ money, which he had spent on a kati of sugar for his sister!

Medical CareerDS Devaraj applied to the Singapore Medical School using his Senior Cambridge results and was admitted. He said he did not do ‘terribly well’ sporting a result of only 3A’s. All that was needed for medicine then was a minimum of 6C’s (and one wonders what could be so stressful about life nowadays!). We are talking about admissions into the créme de la créme i.e. Yale, Harvard and the likes.

After DS Devaraj graduated in 1952, he did his internship in Singapore. He completed six months in Surgery at Singapore General Hospital and six months in Obstetrics and Gynaecology (O&G) at Kandang Kerbau Hospital. He then continued his training in O&G as a Medical Offi cer (MO). His application for a permanent job in Singapore was

turned down along with others, three of whom were from Singapore. They found out later, that 12 British doctors were already given the jobs and the interview was just an eyewash.

JohorIn 1953, DS Devaraj applied to the Federal Ministry of Health for a job. He was appointed as a Federal Offi cer seconded to the state of Johor effective 1 February 1954.The Chief Medical Health Offi cer, akin to the position of a State Pengarah, was Dr Ungku Salleh. He gave him a choice to work in one of the three hospitals with no doctors. DS Devaraj chose Mersing. It was a one-doctor hospital with about 90 beds. He recalled with amusement (and to my horror!), that he had to also be a makeshift Dentist. So he did a short stint at the dental school in Singapore where he was advised, “Take the forceps to the tooth, then just Pull, Twist, Rock, then Pull again”! Being lily-livered when it comes to any dental procedures, I felt the fi rst few waves of panic fl ow through me.

His Hospital Assistant was also trained to do the ‘twist’! With a chuckle he recounted an incident where his HA had come frantically looking for him, stating that while he was extracting the tooth, the patient got up and fl ed for his life because he had pulled out the wrong tooth! Thank God I was sitting down!

He recalled his experience of running a hospital with no prior training in administration, no supervisors, having to be on-call every day, ordering medications, equipment, and writing annual reports. As a Division 1 Offi cer, he was making a whopping RM700 every month and doing the jobs of many (sound familiar?). He caught the eye of a Dr Barnes, the State O&G Specialist who was impressed with his management of the obstetric patients. After a year, he was sent to work at Kluang Hospital. Including him, there were three doctors; a medical superintendent and two MOs.

PostgraduationTwenty months later, DS Devaraj was sent to Johor Bharu Hospital where he was attached to the Medical Unit. He worked as the Registrar for one and a half years and was then given a study leave to take the Membership exam. In September 1958, DS Devaraj fl ew to Scotland with his wife and eldest son. It was to be an 18-month stint. He fi nished it in six months. His wife and son returned home three months later, while DS Devaraj went to the Radcliffe Infi rmary, Oxford. It was not all work. He also found the time to enjoy some of Shakespeare’s plays in Stratford-upon-Avon.

PahangUpon his arrival home, he was informed that he was to start work at KL General Hospital. He requested for a post in the East Coast instead, where doctors were scarce along with no “specialists” and was sent to Kuantan in 1959. There were only three doctors in Kuantan Hospital; one MO, one Surgeon and DS Devaraj, who was the State Physician and in charge of the hospital. Both he and the MO did alternate day calls. He noticed that there was a lot of redundant paperwork for the staff then (Newsfl ash: Nothing much has changed now either!). He told the State Pengarah that he would rather use the time to visit other hospitals in Pahang which had no in-house physicians. He had also shot down several ideas from the Ministry and was advised by well-meaning friends not to be a stiff-necked recalcitrant!


One of the proposals that he spoke out against involved an approved plan to annex the mortuary to the new operation theatre. He was advised not to contradict the authorities. However his opinion is that politicians are always open to these suggestions and feedbacks from medical professionals for they want to know what would benefi t the people. It is the little Napoleons in any system that came up with annoying rules most of the time.

As a doctor in the line of duty, there were many times when he had thrown caution to the wind with regards to his own safety, only to ruminate on his reckless acts much later.One late evening, in the midst of the monsoon season, he had to make it across the deep and fast fl owing waters of the Pahang River to answer an emergency call in Pekan, about 30 miles away. Together with the police who had escorted him, they had to travel in the throes of darkness. The river was swollen to the brim, the monsoon storm causing her waters to swirl furiously. Strong howling winds were sending forth heavy logs which knocked mercilessly unto the steel boat he was in, rocking the boat precariously. The police offi cials who had escorted him, pleaded with him, “Tuan, tolong jangan balik malam ini”. They were all hanging onto their dear lives. He did not think twice about disagreeing with them in this instance.

KedahIn 1961-1964, he was posted to Kedah as the State Physician. Professionally it was eye-opening – seeing yaws for the fi rst time as well as viper bites, the only patient with rabies and a cholera outbreak. He was also fascinated by the presentation of the local Malay postpartum mothers who were admitted to his ward with peripheral neuritis due to nutritional defi ciencies arising from a postpartum diet of just rice and ikan bilis. He was impressed that these mothers had stronger abdominal walls in comparison to the mothers of the other races due to the ‘urut’ techniques used by the traditional midwives. Together with (Tun) Dr Siti Hasmah, they organised regular meetings with the O&G and public health doctors to promote health education for potential mothers. He continued what he had started in Pahang i.e. visiting district hospitals as well as Kangar Hosptal, Perlis.

PenangThe Ministry of Health (MoH) offered a position of State

Physician, Penang if one was prepared to also to be in charge of the Snake and Venom Research Institute (SVRI) set up by Dr A Reid, the retiring physician. So in April 1964 he moved to Penang till retirement in 1979. There were two medical units, one headed by Dato’ Dr V Thuraisingham and one by DS Devaraj. They had weekly ward rounds with General Practitioners as well as combined ward rounds amongst the two units. They were active in running the training for the Membership exams. DS Devaraj was well-known for being strict, a reputation that followed him from Pahang. With a glint in his eye, he informed me, “Every case fi le on discharge came to me for inspection before being fi led away.” This was to ensure that nothing was left out in the patients’ care and the referring doctors would be given a proper and detailed feedback. The SVRI sent sea snake venom to Melbourne to prepare vaccine, while viper and cobra vaccines were available from Thailand and India respectively.

He also recounted with sadness the experiences he had had as a doctor and the problems faced by citizens during the Hartal in 1967 and the May 1969 riots. He and his team were right smack in the middle of these incidences, treating and responding to the emergency situations. The Accident & Emergency Unit became their treating centre, triaging the patients according to priority. He recalled how he and his staff had not gone home for several days, attending to the needs of the patients.

Marriage & ChildrenQuick-witted and blessed with a sense of humour as well as charming, this gentleman must have broken many hearts in his younger days. He denied it vehemently, though. DS Devaraj married Elizabeth Sarojini Oorjitham after he had graduated. How did he meet his soul mate, best friend and wife of so many years? As his thoughts drifted to the past, a small smile played around his lips. Oh good! I was going to get a true love story! The romantic in me all ears, “Any sparks, Dato’?”. One fi rm word, “No”. He grinned when he saw my crestfallen expression.

He had met his future wife for the fi rst time when he went to send his sister off for a holiday to India at the shipping wharf. It was three years later when he was a medical student that their romance bloomed. He stared at me squarely as I sat there expecting more details. Okay, I was not going to get any more than that from him! So, I did not get my romantic love story but I have to tell you here, I witnessed something that really touched me very deeply. I realised that

Family Time at the Kew Gardens in London:DS Devaraj, wife and son

DS Devaraj and Datin Elizabeth


personality38

it is not the spark of the fi rst meeting that ensures a lifelong commitment of love, loyalty and companionship. It is the process after that. I was almost in tears witnessing fi rst-hand the way he cared for her, at his age of 90. He cherished her! Taking her out for her favourite meals, ensuring she is alright, eating enough, taking her for her follow-up, caring for her, showing her that he is there for her, despite his extremely busy schedule. She is one lucky lady. Together, they created a family where all the members have dedicated themselves to social work, each of them, in their own way focused on helping to improve the quality of the lives of others. Datin Sri Elizabeth, was with him every step of the way – in family planning services in Alor Setar or as a lay volunteer in hospice in Penang. Still so beautiful at 85 with the most dazzling smile, she greeted me warmly when I was introduced to her. She still keeps herself occupied with activities which interest her.

As the past echoed through his mind, refl ected in his wistful expressions, my gaze darted around the room. The walls and tables were dotted with photos of his fi ve grandchildren, one great grandson, family, images from the past, treasured moments all frozen in time.

He spoke with pride about his four children. His eldest, Dr Jeyakumar, a Physician until he resigned from MoH, currently a member of Parliament and also a Life Member of MMA, needs no introduction. His fi rst born, he said, has always been socially active. When Dr Jeyakumar was the Rotaract Chairman at school, instead of having an annual dinner and inviting top speakers like his predecessors had done, he organised a public service activity to dig ‘Pour Flush Latrines’. Dr Jeyakumar and the Rotaract members adopted a village where they dug ‘earth closets’ for the villagers to perform their daily morning ‘evacuation’ and ablution, then cover their ‘produce’ with a layer of earth. This was to be repeated until the pit was full. They were then advised to dig up fresh pits. Immediately the image of a chocolate layered cake fl oated into my mind. It will be a while before I eat one!

“This sure beats doing their morning jobs at the river banks where other activities are done as well, like fi shing for instance,” he elaborated. He burst out laughing at my horrifi ed expression! “What do you think fi sh eat?”. I really did not want to know but DS Devaraj took it upon himself to educate me on the fi sh’s various sources of nutrition.

His second daughter, Sheila, was a teacher, now helping her husband, Dr Xavier Jeyakumar, a Dental Surgeon by profession and current state assemblyman for Andalas, Klang. His third son, Rajan, is the CEO for the Bar Council with a soft spot for cats, he said with much amusement. Fourth, his daughter, Prema, well-known in Penang for her commitment to issues of gender and the Women’s Centre for Change (WCC).

All his children went to local universities. He did not let them apply for scholarships as he could afford to educate them and did not want to deprive the less fortunate. My respect for him went up a few notches listening to this bit of information.

Post-Retirement, Hospice & Other CommitmentsFollowing his retirement, DS Devaraj applied for re-employment only to be offered a Medical Offi cer’s post with

a condition that he could be posted anywhere. He said no thanks (not the phrase he used!) and took on a post as Honorary Consultant Physician in Adventist Hospital, Penang, while also working as a Consultant to a large private practitioners group.Later, in 2011, he was appointed Chancellor of the International Medical University. Amongst his relations to other well recognised bodies, DS Devaraj was also an elected member of the MMC from 1979 to 1998.

His involvement in voluntary services, however, started when he was a medical student. The country was just coming out of the grip of a war. The country and its citizens, ravaged, destroyed and stripped to the core. He knew he had to do his part in helping out. His voluntary activities continued throughout his career but accelerated after his retirement. He was very keen on expanding and educating the public about family planning. This became a success in Kedah thanks to Tun Dr Siti Hasmah’s involvement. Later DS Devaraj became the Chairman of the Federation of the Family Planning Associations in the 70’s.

The National Cancer Society was formed in 1966 and the Penang Branch which was set up in 1968 offered PAP smear service, the fi rst in Penang. Smears were received from doctors in private practice as well as hospitals and the Family Planning Association. The screening mammography service was started in 1989. Again, a fi rst for Penang. The mammogram reports were read by private Radiologists without a fee. The society was also instrumental in getting an internationally-recognised course of training for Cytotechnicians in Malaysia, which was sited in the Pathology Department of the University of Malaya. DS Devaraj also took pride in the organisation of the 13th Asia Pacifi c Cancer Conference in 1996 in Penang which had about 1,600 delegates.

Then in 1984, with the MoH and Medical Department, Penang also initiated the fi rst population-based Cancer Registry. A staff was sent for training in Melbourne. The Registry has already produced three 5-year reports.

Hospice in Penang was started in 1992, beginning as a home care programme for patients with advanced cancer. From the beginning, no charges were levied for the visits of doctors and nurses. A similar programme was started in Kuala Lumpur at the same time by Hospis Malaysia. As pioneers of this innovation in healthcare delivery, DS Devaraj was actively involved in the initiation of such a service in many other towns in the country. Many MMA Branches

DS Devaraj visiting a boy with cancer at home


helped him in this endeavour. The fi rst and second National Palliative Care Conferences were held in Penang in 1993 and 1999, respectively. In 2011 DS Devaraj organised the 9th Asia Pacifi c Hospice Conference in Penang.

Malaysian Medical Association (MMA)DS Devaraj was one of the founding members of MMA. Though he was asked to run for President many times in the earlier years, he declined. His reason was simple, “There may be times when I would as the President, have to criticise the ideas proposed by the Ministry. There could be a confl ict of interest there as I was still beholden to the Ministry and could not represent MMA fairly. A Government Doctor is perpetually busy with the workload. The private doctors need to be in their clinic to ensure their patient load does not diminish. With all this, where is the time and the commitment for MMA?”.

So he only stood for the President’s post after he retired. For three years he was in the Council, then in 1983 he stood for President and won. He had proposed the idea of getting a CEO to help run the Association and represent MMA at meetings, like how the Secretary General represents the Minister in numerous occasions. Though the MMA did have a CEO, a couple of times in the nineties or so it had never taken off, one reason allegedly being that the CEO was not given the space to function effectively. He urged potential candidates of any posts in the MMA to ensure they had the time to dedicate and commit themselves should they win, for the betterment of the Association and doctors. In the early years, the MMA AGM was held at the regional and not national level. There was a Southern, Central and Northern Region. Therefore, when it was the turn of a particular region to house the AGM, the President, a candidate from that region, would be elected by the members from that region to represent MMA at the national level. At one such meeting in Ipoh, there were only 17 members present! DS Devaraj proposed to the Council that the President should be elected by all the members of MMA.

This was agreed and since then, till recent changes, the AGM was held at the national level. DS Devaraj was also the Chairman of the Ethics Committee for more than a decade and a trustee in the MMA Foundation. Poor membership had always been an issue in MMA. “We are an association, not a statutory body such as the Bar Council”; “People must join on their own free will,” he said. “So it is up to those holding offi ce to bring in more members,” he reiterated further. Offi ce bearers do try but over the years “service” appears to have become less attractive.

A Caring Physician & TeacherHe applauded the doctors who were in the forefront treating those with Ebola, SARS and any highly contagious diseases. So many have l ost their lives in the line of duty. We salute them and their dedication. This is a man who stands by his principle, “I am a doctor, this is my calling. I must help”. He downplayed his dedication by saying that doctors do that all the time. In turn, we as doctors owe so much to those we give care to, for in the fi nal analysis it’s relationships that matter. His efforts and dedication did not go unnoticed though. In 2005, the World Medical Association acknowledged his services and awarded DS Devaraj “The Caring Physician of the World” award. For his contribution to our national Continuing Medical Education and Continuing Professional Development programmes as a Pioneer and active contributor, he was awarded the “National CME/CPD Service Award” on the FPMPAM Doctor’s Day Awards in 2014.

How is it possible for one person to exude so much warmth? There was such a peaceful aura about him, a face so tranquil. Kindness, compassion and energy radiated from this gentle soul. In this same person I also saw what kept him young, full of ideas and mischief sparkling in his eyes numerous times, his sense of humour and wit catching me off guard and sending me into fi ts of laughter while he was spewing out one anecdote after another. It was certainly a painstaking task to fi t nine decades of life into a few pages.

One of Mahatma Gandhi’s quotes sprang to my mind as I drove home after my third and last interview session with DS Devaraj: “Strength does not come from physical capacity. It comes from an indomitable will.” That, Dato’ Seri Dr TP Devaraj has in bountiful!

DS Devaraj delivering his speech as MMA President in 1983

Left to Right: The Late Dato’ Dr K. Sarvananthan, Late Dato’ Dr Lim Say Wan, DS Devaraj, and Late Tun Dr Lim Chong Eu

at the AGM

~~~People must join on their own free will ... So it is up to those holding office to bring in more members

~~~

branch news • wilayah40

The Chairman and Committee Members of MMA Wilayah paid a courtesy call and had a round table meeting with the State Health Director of Wilayah

Persekutuan (WP) at the WP Health Offi ce on 25 November 2014.

The MMA Wilayah team consisted of:

1. Assoc. Prof Dr Andrew Tan Khian Khoon, Chairman2. Dr Thana Sehgaran Shanmugam, Vice Chairman3. Dr Krishnan Menon, Treasurer4. Dr Ravi Venkatachalam, PPS Representative 5. Dr Koh Kar Chai, Committee Member (Primary Care)6. Dr Balachandran, Committee Member

The meeting started promptly at 2.30pm at the WP Health Department’s meeting room.

Datuk Dr Narimah welcomed the MMA Wilayah team and thanked us for taking the initiative to have this meeting. The contingent from both parties then introduced themselves. The WP Health Offi ce’s offi cials present were Dr Ummi Kalthom Binti Shamsudin (Deputy Director of Health, Public Health), Dr Zainal Abidin Bin Abu Bakar (Head Assistant Director, Vector Unit) and Dr Mohd Nasir Bin Abd Aziz (Head Assistant Director HIV/STI Unit), among others.

Assoc. Prof Dr Andrew Tan then brought forward issues from the Wilayah Branch which were of much concern to the state’s medical practitioners and members. Matters discussed included:

1. Circulars from Wilayah Health Offi ceIt was noted by MMA members in Wilayah that some circulars from the Health Offi ce were not sent to all medical practitioners in Wilayah. Datuk Dr Narimah and her team noted that because of logistics issues as well as practicality [e.g. Notices on dengue test kits were sent to General Practitioners (GPs) in hot spots and those who were regularly notifi ed of dengue cases], which explained why some notices sent through Health Clinics were only sent to selected GPs.

Datuk Dr Narimah however agreed that in the future, her offi ce will send out all circulars and notices to MMA Wilayah to be circulated to its members via its website and Facebook page.

2. Feedback on Notifi cation of Infectious Disease CasesIt was brought to the attention of the Health Offi ce that the GPs who regularly notify cases of infectious diseases usually do not get any response on the outcome of the cases.

Datuk Narimah and Dr Ummi informed the MMA team that it is diffi cult for the Health Offi ce to respond individually to all notifi cations, as they do not have the manpower and technology to do so at present. However, she reassured us that all notifi ed cases were promptly reported to the Ministry of Health (MoH) at Putrajaya, which ensured the mandatory follow-up of those cases.

3. Dengue Cases and Pregnant MothersDatuk Dr Narimah was very concerned that some patients treated by GPs were not properly examined and monitored, especially in dengue cases with pregnant mothers involved. This had resulted in some mortality.

Dr Zainal wanted the MMA to notify its members that the attendance of doctors, with patients who died of dengue, at the Dengue Mortality Meeting is mandatory. He also urged all GPs to make use of the Dengue Clerking Sheet supplied by the Health Department. He cautioned doctors to be careful when using nonsteroidal anti-infl ammatory drugs (NSAIDs) such as Voltaren in treating fever. All information and circulars issued by the Health Department can be accessed online via the website www.infosihat.gov.my

Doctors are also urged to dial the emergency number 999 when calling for an ambulance, instead of calling individual hospitals, as the Emergency Department can deploy an ambulance from the nearest point more effi ciently.

The meeting ended cordially with the promise to hold such meetings at least once annually.

Meeting in progress: Raising important issues brought up by branch members and doctors

MMA Wilayah delegates with State Health Director of Wilayah Persekutuan, Datuk Dr Narimah, and her team

Assoc. Prof Dr Andrew Tan Khian [email protected] Wilayah

Meeting with State Health Director of Wilayah PersekutuanDatuk Dr Narimah Nor Binti Yahaya


MMA AGM 2015: Host City Under Yellow Water

Since the middle of November 2014, Kota Bharu and other East Coast states were heavily affected by the Northeast Monsoon. The series of downpours,

which lasted for a few weeks each, had caused small fl oods in multiple areas. Kelantan was no stranger to such weather conditions, so we handled the situation with much normalcy while following the usual protocol. A few fl ood centres were open for few days, but then they closed abruptly when the evacuees left. It was as though the rain had been meddling with us last year. It came and then subsided.

It was the last week of December when I noticed how deprived I was of sunlight as the rain continuously poured in Kota Bharu. My Facebook newsfeed and WhatsApp inbox were suddenly fi lled with updates from ‘wannabe-reporters’ who urged everyone to prepare for another ‘one of the worst fl oods’ to ever take place.

Such ‘clairvoyant’ messages, like the ones predicting the Haiyan Hurricane or the Jangmi Typhoon, would usually be circulated during the fi rst wave of the natural disaster. Since we have been fooled by these rumours for a number of times, many of us had dismissed the alert and took things rather lightly. Things were rather peaceful until we received news that most rivers in the East Coast and Perak were reaching dangerous levels, causing all the roads to be closed to small vehicles. On Christmas Eve, news broke that a few districts in Kelantan were submerged in water, forcing 30,000 Kelantanese to evacuate their homes and seek relief. During this time, my WhatsApp notifi cation system acted like an alarm clock because the bad news and fl ood updates just kept fl owing in. The condition in certain areas appeared to be life-threatening, and I began to worry as my hometown was listed as one of the districts where many relief efforts were carried out.

I was fortunate to reside on higher grounds in Kubang Kerian, a fair distance from the Kelantan River, as I had to be on-call for two weeks straight. This is the ‘advantage’ of being a single man in a family-oriented department. However, I was worried about my parents and kept calling to check on their safety. My parents, like thousands of Kelantanese, preferred to stay in their own home although the water continued to rise. This was probably

Dr Long Tuan Mastazamin Bin Long Tuan [email protected]

ChairmanMMA Kelantan

D L T M

Indicating how high the fl ood was based on the mud mark left at the Istana Balai Besar gate

~~~My nightmare had suddenly become

a reality. Would this flood be the worst in Kelantan’s history... or rather, in

Malaysia’s history?

~~~

Hospital Raja Perempuan Zainab II submerged in water

branch news • kelantan 41


steered by the thought that, “If the home is still in one piece and we can get clean food and water, there is no need to seek for help.” Few of my friends and colleagues also rushed to the aid of their families and moved them to areas round Kota Bharu; this resulted in massive road jams and fully-booked hotels. The shopping complexes, retail outlets and regular stores had suddenly ran out of necessary supplies like eggs, bread and candles. Town locals began to panic as waves of people from Kuala Krai and Tanah Merah poured into Kota Bharu for food, shelter and clean water.

My place in Universiti Sains Malaysia (USM) Kubang Kerian was lucky to be selected as the donation collection centre. We gathered contributions like food, blankets, and mineral water from many Non-Governmental Organisations (NGOs). As the days passed, the severity of the fl ood intensifi ed and reached the Hospital Raja Perempuan Zainab II area, causing the hospital and many surrounding business operations to close. The Sultan Muhamad IV Stadium also turned into a pool! My nightmare had suddenly become a reality. Would this fl ood be the worst in Kelantan’s history … or rather, in Malaysia’s history?

Over time, even the East Malaysia state of Sabah and South Peninsular states like Johor and Negeri Sembilan became affected. By 28th December, the news reported that 200,000 people or more, have been forced out of their homes and into fl ood relief centres all around Malaysia. Although so, there were still million others who had chosen to stay put in their unsafe, electricity-devoid houses just like my parents! Our Prime Minister visited the affected areas and fi nally labelled it as the worst fl ood we have had in decades; he hoped it would subside soon so that no more precious lives would continue to perish. Our beloved football fi eld at USM Kubang Kerian fi nally played an important role as a treatment ground for many patients who were unable to seek medical attention from the closed hospitals in their districts or towns.

There was an accident involving a Royal Malaysia Police helicopter that crashed and injured four crew members onboard during a patrol at Tanah Merah. This incident happened near the MMA and Malaysian Red Crescent Society medical camp. Dr Seri Buana Zainuddin (Vice Chairman of MMA Kelantan) and his medical personnel were the fi rst to respond to the scene. Thank Allah there were no fatalities, credit to fast and effi cient effort of the team.

During the disaster, I got many calls from the MMA ExCo and Branch Chairmen who expressed their sympathies. They hoped that the fl ood would be managed well in Kelantan. Some branches voluntarily collected donations to help us; MMA Kedah even donated their own branch savings and became the fi rst state to provide us with fi nancial aid before Christmas! MMA Central also contributed RM20,000 and led a team under the Volunteer Corps (VoC) fl agship to Kelantan. A nationwide mass gathering for prayers was held and many offi cial New Year’s Eve celebrations were cancelled in light of the severe fl oods which affected fi ve states. Although a sceptic myself (a Scully, not a Mulder), I have always believed in the power of the Almighty. So by 2 January 2015, the fl oodwater began to recede and the number of evacuees also reduced.

The Government and NGOs formatted a post-disaster plan to help fl ood victims get back on their feet – it may be progressing slowly but at least it is proceeding well. I can already see shopping malls, tourist spots, hospitals, and schools which are now clean from mud and fl ood residues. To date, I still do not know how many people have lost their precious lives and belongings to the fl ood, but I know as a Malaysian, we can stay united in the face of adversity like before (with reference to the MH370 and MH17 tragedies) and will keep on striving to improve our nation’s future. In fi ve months’ time, MMA Kelantan promises to look its best when welcoming you to the 55th MMA National Annual General Meeting.

Donation collection and distribution center at USM Kubang Kerian

Dr Seri Buana providing medical consultation at one of MMA’s medical camps, Gua Musang

Dr Selasawati and her team at one of the badly affected areas

branch news • kelantan42


In Memoriam:Prof Dato’ Dr Manickavasagar

Balasegaram (1929 – 2014)

One of Malaysia’s most renowned veteran surgeons, from a surgical era bereft of technological tools, was remembered recently in the country’s premier

state-of-the-art surgical centres.

The Balasegaram Memorial Lecture honoured the immense contributions made by Prof Dato’ Dr M. Balasegaram toward the development of surgery. It was held at the Advanced Surgical Skills Centre (ASSC), UKM Medical Centre, on 23 November 2014.

Prof Dato’ Balasegaram, a Life Member of MMA, who passed away on 5 May 2014 at the age of 85, was described as “one of Malaysia’s most distinguished doctors”. Considered one of the fathers of modern liver surgery, he won numerous international awards for researching the anatomy of the liver and designing a surgical clamp – the “Balasegaram clamp” – to control bleeding, thus simplifying liver surgery.

He was also remembered for grooming many of the country’s top surgeons of today. As the former Head Surgeon of General Hospital Kuala Lumpur (HKL), he was a tough taskmaster who set rigorous standards for the

hundreds of doctors he trained. He did not just impart surgical skill – duty, discipline and dedication to the art of surgery were also held paramount.

The lecture was attended by some former trainees of Prof Dato’ Balasegaram, popularly called “Prof” or

General Surgeon & Liver Specialist MBBS (1955), FRCS (1960), FRCS (Ed) (1960), FRACS (1968), FICS (1968), FACS (1969), FPCS (Hons) (1975),

FIAP (1977), FCICD (1978)

Key Achievements & Awards:• Hunterian Professorship (1969) – Royal College of Surgeons of

England (fi rst Asian to win it)• Jacksonian Prize (1971) – Royal College of Surgeons of England

(fi rst Asian to win it for his original research summarised in his book “Modern Concepts in Surgery of Liver Trauma”)

• Chienne Memorial Lecture (1970) – Royal College of Surgeons of Edinburgh

• Abraham Colles Lecture (1974) – Royal College of Surgeons in Ireland

• Designed “Balasegaram clamp” and other instruments to help liver surgery.

• Temporary advisor, surgical manpower and problems – World Health Organization (WHO), Geneva

• Gold Medal for Outstanding Research (1987) – Rotary Club• Co-founder various local and regional associations – Asia-

Pacifi c Association for the Study of the Liver (APASL), Asian Surgeons Association, Liver Foundation Malaysia, among others.

• Author of almost 200 peer-reviewed articles in journals.• Served on the editorial board of 15 international journals.• Guest Lecturer invited to over 40 countries and Trainer of

hundreds of surgeons at home.

Memorial lecture plaque at ASSC

memoriam 43


“Bala”, members of his family, and surgeons in training. Giving the lecture was one of his “troops” trained and mentored by him, Prof Dato’ Dr P. Kandasami, Master of the Academy of Medicine and Past President of the College of Surgeons, Malaysia.

The lecture was organised by the ASSC Director, Assoc. Prof Dr Hanafi ah Harunarashid, with the endorsement of the College of Surgeons.

From Bare Facilities to High-Tech SurgeryThis was the second memorial lecture held for Prof Dato’ Balasegaram. In October, an inaugural memorial lecture highlighting his work was held during “Research Day” in Seremban Hospital, where he began his pioneering research. The event followed celebrations to mark 100 years of research at Seremban Hospital.

Prof Dato’ Kandasami’s citation listed his former mentor’s contributions and discussed how surgery evolved alongside technological advances. He described two markedly different situations – from the threadbare theatres of the 1960s to the high-tech facilities of today.

His slides illustrated his point. One of Seremban Hospital’s operating theatres in the 1960s showed a small building with several steps in front. When Prof Dato’ Balasegaram began work here, patients had to be carried on a stretcher up the stairs. Inside, the theatre was very bare (diagnostic tools such as CAT-scans and MRIs arrived much later). Prof Dato’ Balasegaram instead relied on good clinical acumen.

Thus, it was all the more surprising that Prof Dato’ Balasegaram achieved what he did. “It was very remarkable,” Prof Dato’ Kandasami noted. “He made do with whatever he had. And we did the same.”

By contrast, today’s surgeons employ numerous diagnostic tools and support. The ASSC has cutting-edge technology for training and minimally invasive (“keyhole”) surgery. The fi ve-storey high centre is one of the region’s most comprehensive, offering training in many specialities.

Prof Dr Hannafi ah said in future, surgeons could be trained with simulators, in the same way pilots are trained. “We can no longer afford to practise operating on patients,” he said. This would be a world away from the surgery and training of Prof Dato’ Balasegaram’s era.

Using Rubber for ResearchToday, surgical specialities exist for all areas of the body. Yet when Prof Dato’ Balasegaram began his career, surgery was still in development. Liver surgery was simply not explored. Rich with blood vessels, the liver was a “vascular sponge” prone to uncontrollable bleeding and infection. Surgeons avoided it.

Prof Dato’ Balasegaram boldly confronted the many challenges of liver surgery in Seremban Hospital, which received many road accident cases, due to its proximity to busy highways. Seatbelts were not mandatory then, and drivers often suffered liver trauma when they hit steering wheels.

Frustrated to see patients die, Prof Dato’ Balasegaram decided to study the anatomy of the liver. “He used what was available locally,” Prof Dato’ Kandasami noted, adding that good research did not require great resources.

Prof Dato’ Balasegaram returned to a material he knew well from childhood – rubber. Coloured latex was injected into cadaveric livers. Red latex revealed the intricate arterial system, blue the venous system and green the bilial network. Once organ tissue was removed, the liver’s blood and bilial network was revealed. This research opened up the fi eld for liver surgery.

Putting Seremban on the MapBut the bleeding was still a problem. To counter this, Prof Dato’ Balasegaram designed a clamp, manufactured in London by Down Brothers, a fi rm making surgical instruments. He never sought royalties for the instruments he designed as he wanted them to be affordable to all.

Then he ran into another problem – aftercare. “Support services were very limited then,” Prof Dato’ Kandasami explained. So Prof Dato’ Balasegaram built one of the earliest modern intensive care units in the region. The Rotary Club, which raised funds for it, declared it “the fi rst of its kind” in Southeast Asia.

His work put Seremban on the international surgical map. He travelled widely, giving lectures on his research at top institutions and medical schools in the United States, Japan, Germany and dozens of other nations.

In the United States, many surgeons knew his name due to his research and his clamp, but few had heard of Malaysia. They were surprised to discover the level of surgical progress and research in a small hospital, in a small town, in an unfamiliar country.

The Night of May 13, 1969One of the key moments in Prof Dato’ Balasegaram’s career was on 13 May 1969. That evening, Prof Dato’ Balasegaram, who had recently been transferred to GHKL, was just sewing up a patient when a man rushed into the theatre, holding his bloody intestines. He was the fi rst of many victims. Dozens of injured patients, many with liver injuries, soon followed. Remembering

Balasegaram clamp

memoriam44


what he saw in a military hospital in Vietnam, Prof Dato’ Balasegaram began triage. His team worked feverishly all night.

When he ran out of gloves and gowns, he operated with his bare hands (yet despite this, no patients got infected afterwards). His unique experience and learning, and the need for emergency preparedness, were documented in lectures and journals, such as the American Journal of Trauma. Overnight, his surgical prowess and knowledge had grown.

Early DeterminationThroughout his career, Prof Dato’ Balasegaram confronted numerous surgical challenges. He was noted not just for his skill in surgery, but his courage to take on complex and diffi cult operations that very few attempted (besides perhaps G.B. Ong in Hong Kong). With his troops, his was the “salvage” team, taking on cases everyone avoided.

Confronting challenges was second nature. All his life, he had been fi ghting battles. Born from humble beginnings (his father, a Ceylonese migrant, was a supervisor in a plantation), he fought a tough battle for school. He left home at a young age. At that time, education was a privilege, not a right for all. When he fi nally got a place as a boarder in a good school, St Johns Institution, the war arrived. After his father was arrested by the Japanese army, he became responsible for his large family.

Yet he never gave up on his childhood dream to become a doctor – a grand ambition then, given that Asian doctors were a rarity. Eventually he won a state scholarship to study medicine in Singapore’s King Edward VII Medical School. He was the fi rst non-Malay to become a Selangor

state scholar. When he graduated in 1955, the news that Malaya had 17 more doctors was made into print.

His hunger to operate was inspired by Dr Thomas Thornton at General Hospital Kuala Lumpur. A skilled surgeon and good teacher, Dr Thornton was a powerful infl uence. His “creed” to always put the patient fi rst was a teaching that never left Prof Dato’ Balasegaram.

Making Records as a PatientAfter Prof Dato’ Balasegaram retired from Government service in 1983, he went into private practice, operating in several hospitals. As one of the few liver surgeons, he was in high demand. The toll on his health proved too much. He took strong painkillers for raging headaches. This led to kidney failure. By 1989, he was on regular haemodialysis. Many dialysis patients do not live long. But for him, this became another battle to fi ght. He became probably the longest-surviving dialysis patient of the country. His disciplined nature enabled him to exercise great self-control.

Prof Dato’ Dr M. Balasegaram lived his life achieving goals. His last goal was to live to 85. In the early days of dialysis, that seemed impossible. But he never gave up. He achieved his goal on April 15 last year, celebrating with his family. On May 5, he died peacefully at home, with loved ones nearby.

Written by,Ms Mangai Balasegaram

The Royal College of Surgeons of England also has an obituary at: http://livesonline.rcseng.ac.uk/biogs/E005466b.htm

International Psychology Centre®

Your Partner in Comprehensive Psychological Services Centre for Psychotherapy

Penang : 04-684 6527Kota Kinabalu : 088-834 7627Johor Baharu : 07-296 6327Melaka : 06-274 6127

E-mail : [email protected] : www.MalaysiaPsychology.com; Psychology.com.myFacebook : http://www.facebook.com/ipc.kualalumpurTwitter : http://twitter.com/msiapsychologyBlog : http://malaysianpsychology.wordpress.com

Kuala Lumpur : No.11, Wisma Laxton, Jalan Desa, Taman Desa 58100, Kuala Lumpur. Tel: 03-2727 7434 Fax: 03-2727 7520

“One-quarter of

what you eat keeps

you alive. The other

three-quarter keeps

your doctor alive”– Egyption Proverb

mark your diary46


YEAR 2015FEBRUARYMEDICAL REVIEW OFFICER (MRO) COURSE & CERTIFICATION ORGANISED BY AOEMDate : 7 – 8 February 2015Venue : Kuala LumpurCantact : Ms HemaTel / Fax : +603-4051 8211

CPD ON UPDATES IN OCCUPATIONAL MEDICINEDate : 7 February 2015 Venue : Equatorial Hotel Penang Contact : Ms Jennifer Edward JennerTel : +603-4041 1375 (Ext 102) Fax : +603-4041 8187/4041 9929Email : [email protected]

MALAYSIA SOCIETY OF GASTROENTEROLOGY & HEPATOLOGY (MSGH) UPDATE Date : 7 February 2015Venue : Zenith Hotel, KuantanContact : Secretariat Tel : +603-4023 4700/4025 4700/4025 3700Fax : +603-4023 8100Website : www.msgh.org.my

MARCH9TH INTERNATIONAL ACADEMIC CONFERENCE IN OTOLOGY, RHINOLOGY & LARYNGOLOGYDate : 5 – 7 March 2015Venue : Royale Chulan Hotel, Kuala LumpurContact : Secretariat Tel : +603-4023 4700/4025 4700/4025 3700Fax : +603-4023 8100Website : www.orliac2015.com

PREPARATORY COURSE FOR CLINICAL EXAMINATION MASTER OF PAEDIATRICS AND 7TH NATIONAL PAEDIATRIC RESEARCH CONFERENCE Date : 12 – 14 March 2015Venue : Preparatory Course ~ Department of Paediatrics,

Level 11, University Malaya Medical Centre Research Conference ~ Audiotrium Menara Selatan, Level 13,

University Malaya Medical CentreContact : Preparatory Course ~ Dr Premala;

Email: [email protected] Dr Tan Khian Aun; Email: [email protected] Research Course ~ Dr Karmila;

Email: [email protected] Tel : +603-7949 2065/6440/4704

NUTRITION MONTH MALAYSIA FAMILY CARNIVAL 2015Date : 26 – 29 March 2015Venue : Upper Atrium, Level UG, Paradigm Mall, Kelana JayaContact : Nutrition Month Malaysia SecretariatTel : +603-5632 3301/5637 3526Fax : +603-5638 9909Website : www.nutritionmonthmalaysia.org.my

MMA 3RD SEMINAR ON POSTGRADUATE MEDICAL EDUCATION

Date : 28 March 2015Venue : Grand Seasons Hotel, Kuala LumpurContact : Ms SyamTel : +603-4041 1375 (Ext 220)Fax : +603-4041 8187/4041 9929Email : [email protected]

April11TH NATIONAL SYMPOSIUM ON ADOLESCENT HEALTHDate : 10 – 12 April 2015Venue : Hotel Concorde, Shah AlamContact : Ms Laila/Ms RiaTel : +6013-266 5911 (Ms Laila), +6013-353 2561 (Ms Ria)Fax : +603- 4050 2422Email : [email protected] : www.maah.org.my

ENDOSCOPY 2015Date : 17 – 19 April 2015Venue : University Malaya Medical Centre, Kuala LumpurContact : SecretariatTel : +603-4023 4700/4025 4700/4025 3700Fax : +603-4023 8100Email : [email protected] : www.msgh.org.my

MAY12TH MALAYSIAN CONFERENCE AND EXHIBITION ON ANTI-AGING, AESTHETIC AND REGENERATIVE MEDICINE & 5TH INTERNATIONAL CONGRESS ON ANTI-AGING, AESTHETIC AND REGENERATIVE MEDICINEDate : 1 – 3 May 2015Venue : Nusantara Ballroom, Sheraton Imperial Kuala LumpurContact : SAAARMM SecretariatTel : +603-4041 0092/4041 6336Fax : +603-4042 6970/4041 4990Email : [email protected] : www.saaarmm.org

MMA THIRD EVIDENCE-BASED SEMINAR ON TRADITIONAL AND COMPLEMENTARY MEDICINEDate : 16 May 2015Venue : Grand Seasons Hotel, Kuala LumpurContact : Ms MuthuTel : +603-4041 1375 (Ext 223)Fax : +603-4041 8187/4041 9929Email : [email protected] : www.mma.org.my

55TH MMA ANNUAL GENERAL MEETING (AGM)Date : 29 – 31 May 2015Venue : The Grand Riverview Hotel, Kota Bharu, KelantanContact : Dr Long Tuan MastazaminEmail : [email protected]

JUNEAPHM INTERNATIONAL HEALTHCARE CONFERENCE AND EXHIBITION 2015Date : 15 – 17 June 2015Venue : Kuala Lumpur Convention CentreContact : Ms Majmin YaacobTel : +603-4251 7032/ +6017-882 1680Fax : +603-4251 7031Email : [email protected] : www.aphmconferences.org

SEPTEMBER4TH ASIA PACIFIC CONFERENCE ON PUBLIC HEALTH

Date : 7 – 9 September 2015Venue : Kuala LumpurOrganiser : College of Public Health Medicine, Academy of Medicine of

Malaysia

MMA PENANG 18TH PENANG TEACHING CONFERENCE FOR GENERAL PRACTITIONERS

Venue : Bayview Hotel Georgetown, Lebuh Farquhar, PenangDates : Pre-conference workshops ~ 10th September 2015 Conference ~ 11 – 13 September 2015Secretariat : Mr SP Palaniappan, Email: [email protected] : +604 -2229 188, Fax: +604-2229 188/2262 994Enquiries : Dr Hooi Lai Ngoh, Email: [email protected] : +604-2266 699, Fax: +604-2292 379Webpage : www.mma.org.my/MediaandEvents/Events_Sep2012/

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9TH INTERNATIONAL CONGRESS OF THE INTERNATIONAL SOCIETY FOR HEMODIALYSIS 2015 (ISHD 2015)

Date : 13 – 16 September 2015Venue : Kuala Lumpur Convention Centre (KLCC)Contact : ISHD Congress SecretariatTel : +603-2162 0566Fax : +603-2161 6560Email : [email protected]

Please send CV, certifi cates, testimonials and photo (n.r.) to:Human Resources DepartmentPutra Medical Centre 888, Jalan Sekerat, Off Jalan Putra, 05100 Alor Setar, Kedah Darul AmanWebsite: www.putramedicentre.com.my Email: [email protected]

SPECIALISTS

HOSPITAL POSITIONS

PUTRA MEDICAL CENTRE is a 150 bedded hospital strategically located in the centre of Alor Setar. We are expanding and growing with an 8th Level New Wing. In line of our expansion, we would like to invite applications for the following Resident positions:

• Pharmacist

• Nursing Manager (With Post Basic Qualifi cation Dialysis and Accident & Emergency)

• Staff Nurse (With Post Basic Midwifery, Dialysis, Icu And Etc)

• Ophthalmologist

• Dentist

• Nephrologist

• Neurosurgeon

• Geriatrician

• Neurologist

• Intervention Radiologist

• Orthodontics

• Oncologist

• Obstetrician And Gynaecologist

• Rheumatologist

• Physician

• Endocrinologist

For enquiries contact:

Mdm Gan (012-582 0528)Dr Lim (016-440 9666)

Tel: 04-734 2888 Fax: 04-734 8882

Documents

February 2015 PERSATUAN PERUBATAN MALAYSIA ...February 2015 Berita MMA Vol. 45 No. 2 (For Members Only) PERSATUAN PERUBATAN MALAYSIA †MALAYSIAN MEDICAL ASSOCIATION Welcoming the