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The demand for healthcare is rising and continues unabated, with opportunities for improvement and innovation in diagnoses and treatment. However, economic uncertainties and budgetary constraints continue to put significant financial pressures on the provision of healthcare services.
The net impact of these contradictory pressures is uncertain. What will Malaysian healthcare be like in 2018?

Impact on Patients
The Federal Court reaffirmed in Kok Choong Seng & Sunway Medical Centre v Soo Cheng Lin in 2017 that the legal standard for the provision of information to patients is the Rogers v Whitaker principle, i.e. doctors have a duty of care to disclose material risks.
A risk is material, if “in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it, or if the medical practitioner is, or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it”.

Although this patient-centred standard has been around since 2006, many healthcare providers still do not understand their legal duties, with some of them having been held liable by the courts for their failure to inform.
Patients’ voices will become louder in 2018 as they are increasingly more informed, particularly from the electronic media – although the quality of health information on the Internet is variable.

The Malaysian Health Data Warehouse (MyHDW) was launched in April 2017 with the objective of using Big Data for analysis and decision-making, with the potential for reducing cost, reducing waste and optimising the use of limited resources.
The collection of personally-identifiable data is unavoidable. Questions about data security, its de-identification when released to users, and oversight of MyHDW have not been clarified.

With the reported leaks of the personal data of mobile phone subscribers, organ donors and members of medical organisations, patients need assurance that their health information is always kept confidential. Interestingly, the Personal Data Protection Act does not apply to the public sector.
Public trust in allopathic healthcare delivery systems continue to wane. Many people willingly entrust their healthcare to the non-health sectors with technology providing them the tools to do so, e.g. refusal to vaccinate, home deliveries by unregistered personnel, and purchase of unlicensed medicines unavailable locally through the Internet.

The public will increasingly demand to be treated as human beings with better patient experiences enhanced by providers, and not as entries in medical records. The demand for patient safety and quality of care will continue to pressure regulators and payers to ensure that the healthcare services provided are safe and of high quality.

Increasing Healthcare Expenditure
Healthcare expenditure will continue to rise because of the ageing population, the double whammy of non-communicable and infectious diseases, new technologies and increasing patient demands.

The need for long-term care and non-communicable disease management will increase for the senior population and an increasing number of young adults. This is inevitable as large segments of the population are unhealthy with diabetes, hypertension, overweight and obese.

Concomitantly, infectious diseases, especially dengue, will continue to plague the public. Despite vector control measures, dengue and malaria prevail with no cure for the former and increasing drug resistance in the latter. Some previously-eradicated diseases like rabies are also making a comeback.

There will be increasing out-of-pocket expenditure in the private sector, and even in the public sector, particularly with increasingly expensive medications and procedures. An increasing number of people will face financial ruin if they or their relatives get catastrophic diseases like cancer and heart attack.

Medical inflation will continue to exceed the increase in GDP (gross domestic product). Cost containment in private hospitals has not succeeded.
The Private Healthcare Facilities and Services Act regulates doctors’ professional fees, which comprise not more than 20%-30% of the private hospital bill, but hospital charges continue unregulated. A RM100,000 private hospital bill, which was uncommon at the beginning of this decade, is now common.

Concomitantly, charges in private clinics, and even in private hospitals, are increasingly being capped by managed care companies and third-party administrators. More general practitioner clinics will close, primarily because of financial unsustainability, and rarely because of retirement.

When middlemen take a share of the healthcare ringgit, compromises are inevitable, with consequent impacts on safety and quality of care. Studies about a national health financing scheme have been on-going since the 1980s. Although voluntary health insurance was announced in October 2017, details are yet to be disclosed.
Private practice for public sector specialists may or may not stem the outflow to the private sector, as the outflow is often due to service conditions and not just financial compensations. Would the care of public sector patients be affected by such private practice? Only time will tell.

Medical Workforce
There are too many medical schools, too many graduates, and too few house and medical officer posts. Over-production of the medical workforce continues although the public is wiser, with decreasing applications to private medical schools, which will lead to mergers, acquisitions and closures of some.
The crunch will come in 2021 when the four-year contracts of the initial cohort of junior doctors in the Health Ministry will end. Some will continue to be employed, but the rest will have to find their way in the saturated private sector or seek alternative employment.

Delays in the appointment of housemen after graduation from medical schools has led to some of our best and brightest doing their housemanship training in regional countries that provide certainty of appointments. Training doctors at taxpayers’ expense for other countries is, to say the least, illogical.

Medical Technologies
Healthcare has lagged behind others like telecommunications, transportation, retail etc, in utilising new technologies like artificial intelligence and virtual reality.
The smartphone, portable or at-home diagnostics, smart drug delivery mechanisms, digital therapeutics, genome sequencing, machine learning, blockchains (decentralised databases) and the connected community will begin to impact on multiple aspects of healthcare delivery, e.g. operations, workforce management, business models, patients’ confidentiality and security.

Stay Healthy
Staying healthy is critical to avoid receiving healthcare. A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding smoking, moderate alcohol consumption and keeping vaccinations current are some of the measures to stay healthy. This requires some work, smart lifestyle choices and the occasional medical check-up.
Wishing all readers good health in the Year of the Dog!

Taking stock of new evidence in the field and building on previous ESMO statements and dedicated Clinical Practice Guidelines, ESMO is calling attention to the evolving and growing gap between the needs of cancer patients and the actual provision of patient-centered care from the time of diagnosis, including supportive, palliative, end-of-life and survivorship care.

“New studies in the field of supportive and palliative care show that there may be a gap between what doctors think is important or disturbing for patients, and what patients really need.

“With this new position paper, we wanted to call attention to the fact that, as well as anti-tumor treatment, cancer patients need physical, psychological, social and spiritual support, at every stage of the disease from diagnosis. We refer to this as patient-centered care,” said Dr Karin Jordan from the Department of Medicine V, Haematology, Oncology and Rheumatology, University of Heidelberg, Germany, and ESMO Faculty Coordinator for Supportive and Palliative Care, ESMO Clinical Practice Guidelines supportive care section subject editor, and main author of the paper.

She continued: “Patients must ‘set the tone’ in supportive and palliative care. We need to make it easy for them to tell us how they feel, what they need, and of course, allow them to be fully involved in decision-making if we are to provide optimal patient-centred care.

“The concept of patient-centred cancer care is described in this paper (encompassing both supportive and palliative care), along with key requisites and areas for further work.

“We chose this term because we believe in a continuum of care focused on alleviating patients’ physical symptoms and psychological concerns.”
Dr Matti Aapro from the Cancer Centre, Clinique de Genolier, Switzerland, and co-author of the position paper, ESMO faculty member and past president of the Multinational Association of Supportive Care in Cancer (MASCC), said: “Recent studies show that palliative and supportive care not only improves treatment, it also contributes to better use of existing resources, avoids waste, and may ultimately also reduce the cost of treatment.”

The ESMO Position Paper states that individual cancer patients will express different physical, psychological, social, existential and spiritual needs at different stages of the disease, that will often evolve over time.

Therefore, patient-centred care cannot be standardised, even though it is provided through a standard framework.
Patient-reported outcomes (PROs) should be highly encouraged as requesting them has been shown to be associated with better quality of life, fewer hospitalisations, and even increased survival, compared with usual care.

“A cancer diagnosis, the disease itself and the effects of anticancer treatment are major stress factors for patients. Around 14 million people are diagnosed with cancer around the world every year,” explained Dr Jordan.

“Over the last decade, clinicians have accepted that, while survival and disease-free survival are both fundamental factors, overall quality of life is also crucial for patients.

“Patient-centred interventions should be routinely discussed and evaluated by the multidisciplinary team (supervised by the oncologist) together with tumour directed treatment,” she said. “Of course, patient preferences and cultural specificities should be respected.”

“We hope that this paper will contribute to develop a generalised culture and acceptance of supportive and palliative care, worldwide,” said Dr Aapro.
“Basic patient needs such as pain relief are still not being widely met. Education is vital to make sure that essential supportive care is accessible to all cancer patients, everywhere.

“Quoting Dorothy Keefe, past MASCC president, I would say: ‘Supportive care makes excellent cancer care possible’.”
“ESMO is committed to increasing awareness and education to bring patient-centred care closer to all professionals; to improving collaboration between healthcare providers for the good of patients; and to promoting research, so that patient-centred interventions are not only integrated, but also based on the best evidence,” said Andrés Cervantes, chair of the ESMO Educational Committee.

“Despite growing awareness of the need to develop patient-centred care and recent progress in the field, more and better scientific evidence is required so that effective interventions can be proposed to cancer patients at each stage of their illness,” said Dr Jordan.

“This paper is important because it takes ESMO’s long-standing interest in supportive and palliative care – shown, for example, in its Designated Centres of Integrated Oncology and Palliative Care accreditation programme – a step further.

“Developments since the last ESMO position statement in supportive and palliative care in 2003 show that, not only do these interventions improve patient’s quality of life, but also, overall outcomes.

“ESMO appeals to health authorities in Europe and beyond to ensure that cancer patients have equal access to the best possible patient-centred cancer care that resources allow,” she concludes. “This is a medical and ethical imperative.” – ESMO

According to Malaysia’s National Health and Morbidity Survey 2015, mental illness is expected to be the second biggest health problem affecting Malaysians by 2020. It’s estimated that one in three people will suffer some form of mental health issue such as anxiety, stress or depression in their lifetime.

While the projection seems bleak, there are many organisations and initiatives geared towards alleviating the problem.
What’s difficult to manage, however, is that people often find it hard to open up and talk about their mental health issues, particularly within a culture that puts a premium on saving face. Traditionally, showing emotions has been viewed as a weakness that demonstrates a lack of resilience.

As a teenager, I had a fascinating conversation with my granddad that has stuck with me ever since. He was a burly man even in his 60s and 70s, and certainly no weakling. I asked him about the idea that “boys shouldn’t cry” and received an unexpected response from the ex-army man.
He told me, “People say crying is a weakness and only girls should be allowed to cry. But crying isn’t a weakness, it’s a strength. It takes a lot for a person to show how they feel.”

I pressed him and asked, “But if crying is a strength, why do people say we shouldn’t do it?” He replied: “Because people don’t know how to deal with feelings – and that’s a weakness.”

At the time I nodded along sagely, but it would be years before I had a real understanding of what he meant and how it affects mental health.
In life, we have order and chaos. Rational thought, rules, etiquette and composure exist within an order that we easily understand and happily work with. Whenever order is broken, it’s difficult to make sense of chaos. Rather than make sense of it, it’s easier to dismiss it as quickly as possible.

The understanding of how minds work is in its infancy. What we don’t understand, we fear. If we break an arm, people know how to fix it. If we get anxious or stressed, they feel less equipped to support us in dealing with our mental health.

Nevertheless, most people experience anxiety, stress, depression and trauma at some point. Some suffer more than others. Recently, I corresponded with a young woman about her anxiety. She lost her father unexpectedly a few years ago. In her struggle to cope with her grief, she found her self-assurance and confidence had left her.

Though she can “put on a brave face” to help her get through the day, she finds herself in a constant state of struggle. Like many, she tries hard to suppress the difficult emotions. Sadly, this serves to compound the suffering that always finds some way to manifest itself as a mental health issue. It’s sad to hear people say that they don’t wish to be a burden on their families, but it’s an understandable reaction given that so many are uncomfortable with conversations about grief, stress and trauma. Nonetheless, it’s something we should address. We can start by asking “How are you?” of those around us, and showing that we are genuinely willing to stop and listen to what they have to say. Burying our heads in the sand is a dangerous strategy that has long-term implications for the mental health of our family and friends. We also miss out on one of the most precious aspects of life – forming an authentic, deep connection with the people we love.

When we courageously open up to each other, we create an opportunity to share our troubles and give each other permission to reveal our true selves, ultimately strengthening our bond considerably.

In his 2013 book The Trauma Of Everyday Life, psychotherapist Mark Epstein notes, “When we stop distancing ourselves from the pain in the world, our own or others’, we create the possibility of a new experience, one that often surprises because of how much joy, connection, or relief it yields. Destruction may continue, but humanity shines through.”

Buddhist teacher Thich Nhat Hanh suggests that the greatest gift we can give is our presence. Feelings of loneliness, isolation, and being misunderstood often stem from our struggles. Being present for our family and friends can significantly reduce these struggles. We should never underestimate the difference that being there for someone can make.

Finding the courage to have genuine conversations might initially feel uncomfortable, but so much can come from going beyond the small talk to find out if someone is really OK. Having just one conversation can reaffirm a deep level of love and support. It could be enough to ease the heaviness of a person’s burden and save their life.

Most of us want to look well-proportioned, but the mirror is often disappointing: saddlebags on the hips, love handles around the waist, spare tyre on the belly. If you’ve had trouble shedding flab the natural way, you might have thought of liposuction to get rid of the excess fat.

But such an intervention is not always the best idea. “Many of those who are interested have misconceptions about liposuction,” says Riccardo Giunta, head of the Hand, Plastic and Aesthetic Surgery Department at the Ludwig Maximilian University of Munich, Germany.

Liposuction is not for people who are overweight and simply want to lose a few kilos just like that. On the other hand, if someone changes their diet and gets lots of exercise and stubborn problem areas remain, liposuction may help.

However, it is anything but risk-free. “A few things can go wrong, when it is done by an insufficiently qualified or inexperienced doctor,” warns Torsten Kantelhardt, a plastic and cosmetic surgery specialist.

Ugly dents may appear if the expert removes too much fat, while liposuction can also lead to swelling and bruising, for example.
Before undergoing such a procedure, patients should seek out as much information as possible about the potential risks and complications associated with liposuction, says Christoph Kranich, of the consumer advice centre in Hamburg.

Patients should also bear in mind one rule of thumb. “The longer the operation lasts and the more fatty tissue is suctioned out, the higher the risk of complications,” Kantelhardt explains.

“The most gentle procedure is water-assisted technology,” Giunta says.
With this method, tissue is removed using a water jet, which also has some local anaesthesia and adrenaline. First, this fluid soaks and loosens fat cells. Then, through a cannula, that tissue is suctioned out along with the fluid, using a vacuum method.

Ultrasound technology is another alternative for liposuction. The problem area is connected to a device that sends off ultrasonic waves to liquefy fat deep down, while keeping the top layers of the skin untouched. In the best-case scenario, the body disposes of this fat on its own, so that it does not need to be suctioned out.
Fat cell suction creates a wound that will heal over time, as the skin tightens up. However, it may happen that the patient’s skin will not adapt well enough and will instead remain baggy. “In such cases, the skin can be tightened through surgery,” Kantelhardt notes.

The cost of liposuction will depend on the size of the problem area in question and on the length of the operation. Potential patients should choose their surgeon with great care, making sure they are properly trained to perform this procedure. – Sabine Meuter/dpa