Posts tagged ‘medicine’
By creating a new and innovative way to look at massive amounts of patient data worldwide, one man hopes he can change the way public health crises are managed, as Cynthia Graber reports.
Imagine you are a foreign aid worker trying to persuade a senior politician in a developing world country to introduce a pneumococcus vaccination programme. It’s not just a case of stressing how the bacterium causes diseases including pneumonia, meningitis, and sinusitis, and kills over a million children under the age of five every year worldwide. The politician has to decide how to allocate scant resources. How does the death toll compare with malaria and AIDS? Aren’t road traffic accidents a bigger problem? Has vaccination been a success in neighbouring countries?
These statistics exist, but you don’t have the relevant reports and academic papers to hand. And even when you do have the information, a list of numbers may not the best way to express the strength of your case.
By creating new and innovative visual displays out of oceans of data, Christopher Murray hopes his tool can change this situation for the better. Called GBD Compare, users can rapidly determine which diseases are most harmful to children in Africa, or view how the developing and developed worlds compare in terms of heart disease, all with a few clicks of a computer mouse.
The data viz tool processes data from the Global Burden of Disease (GBD) report, which compiles statistics, charts and graphs on causes of death and disease. “The thing that’s really neat about the visualisations is they allow people to see the problem in context – in the context of all the other problems, how it’s changing over time, how it compares to other countries,” says Murray, director of the Institute for Health Metrics Evaluation (IMHE), based in Seattle.
When Murray shows this tool to people outside the academic world of public health, Murray says, they immediately get it. “That just totally changes who you can engage in a thoughtful discussion about what are the key health problems and where they’re going,” he says.
The new tool has the enthusiastic backing of no less an advocate than Bill Gates, and, just three months after its launch, it’s already leading to changes in health policies.
Murray’s interest in international public health was sparked at age 10, in 1973, when his father, then a cardiologist at the University of Minnesota, decided to take a sabbatical year and volunteer in Africa. The family raised donations, flew to the UK, bought a couple of Land Rovers, and, recalls Murray, drove out across the Sahara to eastern Niger to take over a hospital that had been built but never opened.
“We all had jobs,” says Murray. “Mine was – being at the bottom of the totem pole there – in charge of the pharmacy.” While his father met with patients and wrote prescriptions, the young Murray organised and stored the pills and dished the appropriate ones out. That year overseas was “extraordinarily influential on everyone in the family,” says Murray. His parents repeatedly returned to volunteer in Africa, and both his siblings now work in health. Murray went on to study medicine and health economics, eventually working for the World Health Organization (WHO) and heading Harvard University’s Initiative for Global Health.
In 1991, the World Bank sought his help in creating a comprehensive policy document on international health problems. The result of Murray’s partnership with Alan Lopez at the WHO was the first GBD. The GBD released official health statistics on the burden of disease, beginning with 1990 data on 50 causes of death across seven international regions. A decade later, the team once again compiled health data for the WHO, along with legions of maps, charts, and graphs, based primarily on what the authors thought would be useful.
The latest version of the GBD is both bigger and better. For one thing it includes more than a billion pieces of information covering 291 causes of injury, disease, and death, for 187 countries, measured in 1990, 2000 and 2010 (published in a traditional form in a series of studies in the Lancet in December).
More radically, the team (now overseen by the IHME, which Murray founded in 2007 and still heads) has now made the information accessible to a wider audience by presenting it in visually engaging ways on an interactive website. Launched in March, their visualisation tool shows causes of disease, injury and death within a rectangular pie chart made up of blocks whose sizes are proportional to the numbers they represent.
Categories are highlighted in different coloured blocks, which are sub-divided into specific causes in different shades, according to whether they are on the increase or decrease. Red signifies communicable diseases, such as malaria or diarrhoea, as well as maternal, neo-natal and nutritional disorders. Blue is for non-communicable diseases, including cancer, heart disease, and diabetes, while injuries are represented in green.
Users can select the entire developing world, for example, and pull the lever from 1990 to 2010 to see that communicable diseases overall have decreased as a percentage of mortality. They can view metrics across the whole world, regions or individual countries, focus in on specific time frames and ages, or look at outcomes for men or women only. Other visualisations allow comparisons and rankings of causes of death, disease and injury in different countries.
Projects on this scale have only recently become possible thanks to the enormous increase in data, greater computing power, and new ways of doing statistical analyses, according to Peter Speyer, data director at IMHE. “The technology was not advanced enough even five years ago to have an easy way to visualise all this data,” he says.
The initial spark of inspiration came in the autumn of 2010 when Kyle Foreman, then working as a research fellow at the IMHE as part of his Masters degree in public health at the University of Washington, got fed up with boring charts. Foreman taught himself D3, the program the team still uses to create the visualisation, and made a prototype for internal use.
“It didn’t take long before we realised just how powerful these tools are,” says Murray. “That’s when we realised that we needed to invest in doing this in a way that everyone could use.”
The effort to collect and interpret the data was immense. Speyer says that in addition to the nearly 500 official authors from 50 countries, the IMHE worked with thousands of organisations around the world to access the data.
Despite that, it’s not perfect. The results are only as good as the data collected on the ground, and Murray has heard occasional criticisms. “There are always people saying, ‘No, you haven’t done a fair job for blindness, or you haven’t got cholesterol right in Indonesia because you missed my favorite study’,” he says.
That’s an easy fix, he says. If and when new data becomes available, his team can integrate it. There are also plans for more general updates at least once a year. Some problems, however, can’t be solved by larger data sets. For instance, some scientists claim that malaria is over-diagnosed in hospital deaths in Africa. “That’s a tough one to deal with,” adds Murray. “You have all the data on one side and expert opinions on the other. The bottom line is, we won’t really know until more studies are done.”
The tool is already leading to policy changes. Researchers in the UK teamed up with Murray to produce a report on how it compared with 19 other wealthy countries, in both 1990 and 2010. Published in March in The Lancet, the study demonstrates the UK has successfully reduced cancer deaths, but lags behind in addressing cardiovascular disease and tackling the increasing rates of alcohol- and drug-related illnesses.
“From a policy perspective, that’s extremely important,” says Sir Michael Richards, director for reducing premature mortality at National Health Service England. “Instead of saying how fantastic it is that we’ve improved, this says that we’ve still got a lot to do if we want to be among the best in the world.”
Chinese scientists have also worked with the IMHE to compare health statistics in their country today with those from 20 years ago, and to other major economies in the G20. In a study published in the Lancet earlier this month, the team found that while China has made rapid improvements in reducing infant mortality and improving life expectancy, it is facing a growth in diseases related to poor diets, high blood pressure, tobacco use, and environmental and household air pollution.
The tool has proven so useful that other countries are now working with the IMHE to collect and analyse their own health outcomes on the regional level within each country. Murray says Indonesia’s minister of health and office of the President are “very excited about the visualisations” and want to drill down into local results with a larger team of Indonesian researchers. China, Australia, Brazil and the UK are also interested in more detailed, within-country versions, and the government of Saudi Arabia has begun a new collaboration with the IMHE to track the health of its citizens and inform future policy decisions.
For now, the website is designed with policy makers in mind – government officials and scientists. Some curious non-experts may feel a little overwhelmed by the volume of information available. For these people, the team is considering adding a simpler layer that will be even more accessible for the general public, “taking away all the complicated controls, the great degree of detail, and just hammering home key points,” says Speyer. The goal, he continues, is to “make it more intuitive and more fun,” to encourage even more people to engage with the data.
Bill Gates, whose foundation funds both the IMHE and the GBD, raved about the site during a speech to mark its launch at his foundation’s headquarters in Seattle, calling it “one of the best efforts that has been done” in data visualisation.
He went on to stress how important it is in the work of the Bill & Melinda Gates Foundation, which seeks to improve healthcare and reduce extreme poverty internationally, by, for example trying to convince the governments of countries including India to adopt the pneumococcus vaccine.
“When you have a tool like this, you can even drill down and see the various studies that have been built up to support this information,” said Gates. “This is going to help us tell that story and get better health policies more rapidly than we’ve been able to do in the past.”
SINGAPORE: Two doctors were on Thursday fined for practising without valid certificates.
Ng Hor Liang, 45, admitted to one count of practising medicine at Bukit Batok West Clinic in January 2012 without a valid certificate.
He also pleaded guilty to fraudulently declaring in January last year to the Singapore Medical Council (SMC) that he was not diagnosing and treating patients when he did.
A third similar charge was taken into consideration.
For these, Ng was fined a total of S$12,000.
Separately, Gladys Wong Mei Ling, 48, admitted to fraudulent declaration in January last year (2012) that she was not involved in any clinical practice when in fact she was.
The mother-of-seven had done so at Healthpoint Family Clinic and Surgery at Tanglin Halt without a valid practising certificate.
For this, Wong was fined S$4,000.
The prosecution said it is the first time such a case has happened and asked for a fine.
To renew their practising certificates, each doctor needed 50 continuing medical education points, which can be accumulated over two consecutive years.
In both cases, the two doctors did not accumulate the required number of points and when they realised this, they tried to make up for the shortfall.
But in submitting their letters of undertaking to the SMC, Ng and Wong declared that they had not been practising, which was false.
Both doctors have since renewed their practising certificates and are treating patients.
SEREMBAN: A minimum RM500,000 fine and mandatory jail sentence of at least one year awaits any individual caught selling counterfeit or adulterated drugs under the proposed Pharmacy Bill to be tabled in Parliament soon.
A company involved in a similar undertaking will be slapped with a minimum RM1mil fine and its owner jailed for a minimum of one year under the proposed legislation set to replace a clutch of archaic pre-Independence laws.
The comprehensive Bill, which has been deliberated for close to a decade now, will replace the Registration of Pharmacist Act 1951, Poisons Act 1952, Sale of Drugs Act 1952 and the Medicines Act 1956 (Sale and Advertisement).
The Health Ministry is seeking feedback from the public, drugs and cosmetics industries, pharmaceutical companies, associations and academic institutions on the new legislation before tabling the Bill.
The public online engagement ends on Nov 29.
The ministry said the absence of specific provisions in the existing laws made it difficult to check the flooding of fake and unregistered drugs, including traditional medicines, in the market.
“We hope the new legislation will be a deterrent to those who hope to benefit from the loopholes in the existing laws,” the ministry said.
Under the Sale of Drugs Act, people arrested for selling fake drugs are only liable to a RM50,000 fine or a jail term not exceeding three years. Companies may only be fined up to RM100,000 for a similar offence.
Under the new Bill, individuals caught selling unregistered medicines may be fined up to RM100,000 as against RM25,000 at present.
Also, those found to have sold psychotropic pills are now only liable to a fine of up to RM10,000.
The ministry said the new Bill also proposes the setting up of a National Pharmacy Council to formulate new regulations on drug classification, prohibited and controlled items and fees for the various licences.
Minister Datuk Seri Liow Tiong Lai cited statistics which showed that 22,970 SSFFC (substandard/spurious/false label/falsified/counterfeit) drugs worth RM27,461,997 were seized last year.
In 2010, the ministry seized 16,862 SSFFC drugs worth RM22,000,047 and 12,825 SSFFC drugs worth RM13,596,290 in 2009, he said.
“The trade of such drugs has been a growing problem because of the limitations of old legislation … heavier penalties will give the ministry more teeth in tackling the problem,” he added.
It was reported that some counterfeit drugs like sex stimulants, painkillers, eye drops and cough mixtures are dangerous and can kill.
The ministry’s Pharmaceutical Services Division director Mohd Hatta Ahmad said most of these drugs were brought in illegally and sold in traditional medicine and sundry shops and roadside stalls.
The public can check whether a medicine is counterfeit via several methods like using a Meditag decoder found in licensed pharmacies to check the autenticity of the hologram label on the product.
Another way is to verify the registration number printed on the outer packaging by going to www.bpfk.gov.my and searching the “registered product” bar.
Ensuring everyone gets good doctors.
ONE of the basic principles taught to all medical students and doctors is Primum non cere – first, do no harm. It is a reminder that an intervention can lead to harm to the patient, however well-intentioned it may be.
This principle is even more relevant today than in yesteryears.
Healthcare today is complex and more effective than before. However, according to the World Health Organization, the likelihood of harm is high, with a one in 300 chance of being harmed by healthcare compared to one in 1,000,000 chance of being harmed while in an aircraft.
Data from developed countries reveal that one in 10 hospitalised patients are harmed because of adverse events or errors. Similar data has been found in local studies.
The future of patients and their families depend on what doctors say and do. Imagine the good and harm that can result from doctors’ actions and inactions.
The media focus on housemen in recent years raises questions about the quality of medical education and training, as well as the challenges in ensuring that everyone gets good doctors, and by extension, the quality of healthcare patients will be receiving in the future.
There are more applications for entry to medical schools worldwide. Many young people want to become doctors, whether of their own volition, at the behest of their parents, or for other reasons.
Until 2011, high academic qualifications were the sole criteria for admission to all public medical schools except University Science Malaysia (USM), which required an interview as well.
Since 2011, the Malaysian Medical Council’s (MMC) guidelines require all applicants to local medical schools to pass an interview to assess the applicant’s aptitude.
Although the minimum academic qualifications for entry into medical schools are prescribed by the MMC and the Malaysian Qualification Agency (MQA), there are still reports of non-compliance by some private medical schools. There are also reports that some private medical schools take in more students than permitted.
The situation in foreign medical schools is varied. Medical schools in advanced economies require high academic qualifications and aptitude assessments. However, some medical schools in some developing economies admit students whose academic results would not even qualify them to enter a Malaysian university for other courses which require lesser academic qualifications.
Many such students gain entry through the good offices of the agencies of these medical schools.
It is necessary to emphasise that selection for entry into medical school implies selection for the medical profession. Findings from studies worldwide confirm that although some students have achieved the academic qualifications required for entry into medical school, they are not suitable for a career in medicine.
It is in the interest of the public and such students that they should not gain admission, rather than to have to leave the course or the profession subsequently.
Feedback from some public local medical schools indicate that more than 50% of students do medicine because of parental or peer pressure, glamour, hope of financial rewards later, etc.
Can such students end up as good doctors?
Should the quality of students doing medicine be of concern to the public?
What should be done to those admitted to local or foreign medical schools without minimum academic qualifications?
The message to parents that good examination results do not make a career in medicine suitable for their progeny has to be repeatedly emphasised. There is nothing worse than getting into a profession that is unsuitable for one’s personality.
There are currently 34 medical schools for Malaysia’s population of 28 million, compared to nine and 12 medical schools in 2002 and 2007 respectively. Sixteen new medical programmes commenced in 2009 and 2010.
Data from the Avicenna Directory maintained by the University of Copenhagen, in collaboration with the World Health Organization and the World Federation for Medical Education (WFME), show that countries with similar populations like Australia (23 million), Saudi Arabia (28 million) and Canada (35 million) currently have 26, 16 and 16 medical schools respectively.
Our ASEAN neighbours, Indonesia, Singapore, Thailand and Philippines, with populations of 238 million, five million, 65 million and 92 million respectively have 35, two, 19 and 54 medical schools respectively.
Germany and the United Kingdom have 41 and 38 medical schools respectively for populations of 82 million and 62 million.
The issue is compounded by the fact that the government recognises more than 370 medical qualifications worldwide. This list was inherited from our colonial masters and has been added to over the years.
In addition, graduates from unrecognised medical schools can sit for the Medical Qualifying Examination (MQE) and, upon passing, will be registered by the MMC. The examination, which used to be the final year examination of the University of Malaya, National University of Malaysia and University Sains Malaysia, is now also conducted by 13 other universities.
The recent announcement that there is no limit to the number of attempts at the MQE raises fundamental questions about the quality of some of these doctors. Where in the world can someone be permitted unlimited attempts at any examination, let alone in medicine?
In spite of the marked shortage of medical educators in Malaysia, the expansion of medical schools continued unabated in the past five years, thereby exacerbating the shortage. The majority of teaching staff in many medical schools are foreigners, some of whom do not speak any of the local languages, and some with no previous teaching experience.
It is not only the number, but also the quality of medical educators that is crucial in producing doctors that will make a positive impact on the public’s health. Medical educators are role models for students. It is well known that a deficient doctor is reflective of a deficient teacher; just as a child’s conduct is reflective of the parent’s.
Do the local medical schools take responsibility for the quality of their graduates? Are they responsive to societal needs and act proactively to meet those needs by addressing various issues that include selection criteria and admission policies; curricular improvements with emphasis on the concept of social accountability, medical ethics and human rights; and the quality and quality of medical educators?
Does the quality of medical education focus on the core educational needs of a doctor, providing him with the knowledge, attitude and skills necessary to address public health and clinical challenges?
Is this achievable when medical education is so much driven by the profit imperative?
What is the quality of medical education in recognised local and foreign medical schools, and how robust is its monitoring?
What is the role of agencies of foreign medical schools and how robust is their monitoring?
During the course of the newly graduated doctors’ future practice, there will be continuing advances in medical science and clinical practice, healthcare delivery and financing, increasing expectations of patients and the public, and changes in societal attitudes.
By itself, the basic knowledge and skills taught in medical schools is insufficient. The housemenship period is the time to start developing of the ingredients of the MMC’s “Good Medical Practice” (http://mmc.gov.my/v1/docs/Good Medical Practice_200412.pdf).
The young doctors have to learn to always put the interests of their patients first, and that the doctors’ professional practices affect the experiences of patients and their families. The skills of continuing professional development have to be developed so that their practices can advance in accordance to changes in medical knowledge and practices.
Prof TJ Danaraj, Foundation Dean of Medicine at the University of Malaya, wrote: “There is a worldwide acceptance of the views that the education of a physician extends over a lifetime, each stage resting upon the preceding one, and each preparing him for that which follows.”
Learning during housemenship is significantly experiential. There has to be sufficient quality teachers for this aspect of the young doctors’ training. The teachers, who are usually specialists, have a crucial role to play as they are role models for young doctors.
There has to be exposure to sufficient numbers of patients for young doctors to gain the experience required for independent practice. For example, they have to be exposed to the different ways in which the common conditions, appendicitis and urinary tract infections, present.
Failure to make an accurate diagnosis will lead to threats to life in the former, and long term consequences in the latter.
When there are few patients relative to the many housemen, it will, inevitably, have a negative impact on the latter’s training.
My classmates and I always remember our housemenship year. Some of our specialists were good teachers; some were less so. Some were excellent at expressing themselves verbally; others expressed their skills with their hands. Some did ward rounds before going home, and some even came back at night to do ward rounds.
We learnt from every specialist and from ourselves; what to do and what not to do in differing situations. Time was not a consideration. We finished our work before going home, whatever the time was.
There were instances when we would go to other wards or attend other specialists’ ward rounds, even after work, to learn from cases with interesting features. Those were not easy times. It was hard work, but our enthusiasm made the difference.
There were discussions and analyses which made us better doctors because we learnt from our specialists and ourselves. And, most importantly, we learnt how to learn.
The recent media report that “50% of housemen in Sabah can’t cope, need retraining” (http://www.theborneopost.com/2012/05/17/50-of-housemen-in-sabah-cant-cope-need retraining) is worrying.
Equally disturbing are media reports of claims by housemen that they are overworked, training is minimal or absent and there is “bullying” by specialists.
There are also statements by specialists that some housemen work by the clock and that they do not even know the names of some housemen assigned to their wards and clinics “because there are so many of them”!
What is the quality of housemenship training and how robust is its monitoring? What is the quality of healthcare that patients can expect from the large numbers of housemen who need retraining?
What happens when they become Medical Officers after completing their housemenship? The possible long term effects on the quality of healthcare delivery in the country are indeed mind boggling!
It may interest the reader to know that several government agencies are involved in medical education. The Ministry of Higher Education (MOHE) controls all medical schools. It grants approval to establish a new medical school and through the Malaysian Qualification Agency (MQA), it requires all medical schools to comply with accreditation standards.
The hospitals of the Ministry of Health (MOH) and MOHE provide housemenship training and employment for Medical Officers upon its completion.
There are reports from some specialists that they find it increasingly difficult to cope with the dual tasks of providing care to patients and training housemen, with the former always having to take priority over the latter. Even the Ministry of International Trade and Industry (MITI) impact upon the health sector. There is linkage between goods and services in MITI’s trade negotiations with the World Trade Organization (WTO), ASEAN and other trading partners. The concessions permitting the presence of foreign ownership of private healthcare facilities and practising rights for foreign doctors in Malaysia will inevitably have an impact upon the quality of healthcare provided.
It is regrettable that there is no published national medical manpower planning policy. How many doctors does the country need, and by extension, how many medical schools?
Do the MOH and MOHE provide feedback to medical schools, regarding the skills, knowledge, attitudes and competency of their graduates? What is the quality of the feedback? Do the medical schools act on the feedback?
How many top notch foreign doctors will come to Malaysia to practise on a long term basis? What mechanisms are there in place to assess the quality of foreign doctors intending to practise here? Are there robust and valid assessment mechanisms in place?
Malaysian Medical Council
The MMC’s function is that of recognition of medical schools and professional regulation, based on its Code of Professional Conduct and its guidelines.
The local medical schools are given time-limited accreditation after assessments by teams comprising representatives from the MMC and MQA. However, it is impossible to accredit all the foreign medical schools recognised by the government because of manpower, logistic and financial reasons.
Most governments in developed economies acknowledge their limitations in assessing the quality of medical education. They require all those who want to practise medicine, particularly graduates from foreign universities, to pass a licensing examination.
Many Malaysian doctors who have practised abroad, particularly those above 40 years, have passed these licensing examinations without difficulty simply because of the quality of medical education they received.
Why is there no licensing examination when about half of the doctors commencing housemenship are graduates of foreign universities?
The number of disciplinary cases per 1,000 doctors dealt with by the MMC has increased in recent years. Although it is less than that of Singapore, the question as to whether the increase is due to the public’s increasing awareness of their rights, quality of care or both is not easy to determine.
Like all medical regulatory authorities worldwide, the MMC is addressing the issues of professionalism and performance measurement. This is of relevance as it is crucial to the enhancement of the trust of the public in individual doctors, in particular, and the medical profession, in general.
What this means
Many in the medical profession have stated publicly their concern that there is more emphasis on the quantity instead of the quality of medical graduates. The consequences in other areas of studies may not be significant, but in healthcare, it can be a matter of life and death for a patient or potential patient, which means all the population.
Healthcare delivery is so complex today that it is crucial to have doctors who put a premium on patient safety. If one has to make a choice, the public interest is better served by fewer good quality doctors than larger numbers who are deficient in their knowledge, skills or attitudes.
Society deserves nothing less.
Everyone, whether students, parents, medical schools, governmental agencies and the MMC, has a role to play in ensuring that everyone gets good doctors. However, the onus on medical schools, policymakers and regulators is paramount.
In concluding, everyone, particularly medical schools, policymakers and regulators, should be cognizant of the instructive statements of Hippocrates (460-377 BC), Avicenna (980 – 1037) and Sir William Osler (1849-1919). Hippocrates wrote, “Whenever a doctor cannot do good, he must be kept from doing harm”, and Avicenna “An ignorant doctor is the aide-de-camp of death.” Sir William Osler’s statement, “The best preparation for tomorrow is to do today’s work superbly well” is very apt for medical education and training.
Pahang Menteri Besar Datuk Seri Adnan Yaakob (2nd from right) Health Minister Datuk Seri Liow Tiong Lai (2nd from left) give a go at calligraphy at the CNY Open House organised by the Kuantan Tionghua societies in Kuantan. NST/ LUQMAN HAKIM ZUBIR