The withered “Medical Referral Ethics” in Myanmar and Malaysia?

Of the patients waiting at the Out-Patient Dep...

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I realized that in Burma and Malaysia, only a few specialists are replying to our referral letters given to them. I have noticed this as an awkward but not quite wrong Medical Referral Ethics due to special situation here.

But it may be quite strange for a doctor in UK, if I told them that in my 35 years of GP experience, I have never received any reply letter, indicating of sending back the pt with the follow up plan or instructions.

  1. May be I have worked in Myanmar and Malaysia only and this two countries’ Medical Systems and code of practices are different from UK.
  2. 

  3. Or maybe the consultants here misunderstood our referrals as totally transferring the patients to them.
  4. Or maybe they doubted that GPs are incompetent, would not even read their letters if they instruct us with Follow Up plans.
  5. Or maybe they are not sure that GPs have the ability, skills or will to strictly follow up with their instructions for the continuous welfare of the pts
  6. Or maybe they are selfish and wish to snatch our pts for good.

In Malaysia_

  1. the Health Management Organizations (Companies),
  2. some Public Referral Hospitals (especially OPD of Specialist or Sub-specialist clinics),
  3. Insurance Companies
  4. and many private and public companies

are practicing a policy of keeping us, the Panel GPs as “Gatekeepers”.

It is as a check and balance system” to prevent the abusing of some patients from unnecessarily seeing Specialists and admitting to the Hospitals for minor ailments or just for the health screening without any disease.

  1. It is surprising that even with that very good control system in Malaysia, some specialists have a gall to instruct or advice our patients, whom we referred to them earlier, to go back to their GPs for the new referral letters, authorizing their follow up examinations and treatments.
  2. It is more awkward when they just sent the patients on verbal advise to get the referral letter when the relevant specialists had never sent any communicating letters, reports, instructions for follow up. We are in the total darkness and need to ask back the patients what those consultants had done what kind of procedures on them and the real purpose of their present request for another referral letter.
  3. If the patients pay themselves, the original GP would not even know anything about the patient’s progress but just lost their patients to those unscrupulous consultants.

But we need to give a big credit to the Government Hospitals for issuing the_

  1. Discharge Certificate
  2. and Case Summary to all its patients, which facilitate the Follow Up treatment.
  3. I have received on numerous times, a short note with, “To whom it may concern, or just dr” to do,
    1. dressing using what chemical or just normal saline only,
    2. or to monitor and record BP
    3. or to check the FBS (Fasting Blood Sugar)
    4. or to do STO (stitch Out) etc. These are quite helpful for all of us.
  4. And the HKL usually allow the OPD patients to keep its Medical Record Cards to facilitate their treatments at other places or if just go back to them.

IJN is the only hospital where there is no reply at all (to me). And for the record, I have never received a reply letter from any Paediatricians.

The reader could understand why I am writing this posting if they care to read my previous article, “Some unethical specialists in Myanmar and Malaysia.” 

The General Practitioners or GPs

The General Practitioners or GPs or Family doctors or Primary care doctors or family physicians are used to be the first person the patient consult.

  1. It is the basic health services that play a central role in the local community.
  2. They act as a first point of consultation for all patients.
  3. In some countries, they are effectively used as Gatekeepers to control the expenses and overcrowding at Public Hospitals which are more effectively used as referral hospitals.
  4. The Health Insurance Companies and Managed Health Care providers also used to pay the hospital bills and specialist fees only when referred by their appointed Panel GPs.

But nowadays some patients who could pay or willing to pay would go and see the specialists or subspecialists or Private / Public hospitals of their choices directly for any illness or even without any disease but just for ‘health screening’.

Referrals

Referral is the transfer of care for a patient from the doctor who is consulting the patient to another specialist or consultant or hospital. Sometimes even one specialist may need to refer his pt to another relevant specialist.

There is a professional etiquette by which a primary doctor refers a patient to a specialist for further diagnosis and treatment.

The fundamental principle in medical ethics is that_

  1. The referrals must be solely done for the benefit of a patient. The wellbeing of the patient must be the only reason for this referral.  
  2. And not for the hidden agendas of kickbacks, personal interest (ownership) in the referred facility e.g. hospital, lab, X-Ray or Imaging Centres.
  3. The patient’s right might not be violated and always respect the pt’s rights, value, status and dignity as a respectable human being but not just another CASE in our Medical Records.
  4. Once referred, another third person is automatically involved between the patient and his GP.
  5. There must be justifiable reasons regarding the conditions of the patient and the need for another supportive or additional expertise.

If this is a consultation between a general practitioner and a specialist, the GP naturally expects:

  1. 1.   To maintain the right to continue to be the health care provider for his patient.
  2. The good and responsible GP usually wishes to be informed about the progress of his patient.
  3. GP’s wish to know whether his tentative Provisional Diagnosis is right, whether he missed some signs and symptoms or his process and way of referral was right.
  4. He also wishes to know the plan of treatment, prognosis and if possible prognosis.
  5. GP’s wish to be given back the responsibility to continued treatment and Follow Up guide or instructions is also reasonable.
  6. Patient should be returned to the GP when the specialist has concluded with the problem referred or related to that.
  7. The GP should then merely follows the advice of the consultant, and must report back about the progress of the patient and do further discussion or referred back to the consultant in order to modify therapy or obtain further instructions with regard to continued welfare of the patient.
  8. If the referral problem needs the patient to be transferred to the care of the consultant, usually the GP needs to move aside. Even in those cases, the consultant keeps the referring doctor informed of the progress of the patient as a courtesy or as etiquette. Once the immediate specialised care is completed, the patient should be returned to the GP for Follow Up care, with the necessary advice.

Or if the patient wishes and decides to repeat seeing the consultant, no one can do anything in Myanmar and Malaysia, except where in some countries like UK with strict rules that the patients could not see the consultants without a referral letter.

  1. This may be regarded by the relevant GPs as snatching their patients and once they noticed, they will avoid referring to those BLACK SHEEP consultants and Medical Faculties.
  2. The worse scenario is, some selfish GPs may become paranoid, lost trusts in the consultants and try to avoid referring the patients in time. In that case, the GP is unquestionably wrong but the patient snatching consultants are also partly responsible. The ultimate looser is the patient.
  3. All the health care personals’ ultimate duty and responsibility should be the welfare of his or her patients. So for the sake of the pts all the GPs and Consultant Specialists should follow the Medical Ethics or Etiquettes in handling the referral of or referred patients. 
  4. 

How long should a referral last?

When is a referral over?

If the patient does not wish to report back to the GP and insists to continue seeing the consultant, some fair minded and reputable consultants refused to see that pt and insist to go back to the original GP and bring back a new referral letter.

If the patient decides to directly see his own choice of consultant specialist or department or public and private hospitals without referral,

  1. there may be a waste of time,
  2. unnecessary overcrowding
  3. and delays for other pts as they lengthen the queue
  4. thus adding the unnecessary burden on National Health care systems.
  5. Undue adding of expenses and the unnecessary shuffling of a patient from one consultant to another may occur.

Sometimes the patient will ask for a second opinion.

  1. But in this part of the word in order to avoid the uneasy condition of possible misunderstanding if the relevant doctor would take it as an offence, some patients just secretly consult another consultant
  2. or some patients just ‘shops around’ for doctors.
  3. 3.   We should not look at this seeking of second opinion as an offence or looking down on us but should respect the patient’s right and give our consent if they asked.

Sometimes patients secretly changed or switch doctors after few consultations without revealing the whole history of treatment.

  1. Sometimes they may tell their dissatisfaction with the previous doctors but the present doctor should follow the Medical Ethic and avoid unnecessary running down the reputation of the previous doctors.
  2. Even if the second opinion reveals some faults of the previous doctors, consultants or subspecialists, the last doctor should handle professionally with care not to unnecessarily inflate or blown up the situation.
  3. We must understand that our patients are human beings under the burden of sickness and sometimes feel guilty conscious of treating with others and try to please the latest doctor for not consulting earlier.

One problem with GPs is sometimes they are angry when the patients asked them to write a referral letter. When I was working in UHKL, I got some referral letters, written on it just, “Please take over the patient!”

Pushing out the patients from the Private Hospitals to the Government Hospitals after patients have exhausted their funds is beyond the scope of my present posting.

GMC guideline extracts:

Good Medical Practice: Sharing information with colleagues

50. Sharing information with other healthcare professionals is important for safe and effective patient care.

51. When you refer a patient, you should provide all relevant information about the patient, including their medical history and current condition.

52. If you provide treatment or advice for a patient, but are not the patient’s general practitioner, you should tell the general practitioner the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects.

53. If a patient has not been referred to you by a general practitioner, you should ask for the patient’s consent to inform their general practitioner before starting treatment, except in emergencies or when it is impractical to do so. If you do not inform the patient’s general practitioner, you will be responsible for providing or arranging all necessary after-care.

Good Medical Practice: Providing good clinical care

2. Good clinical care must include:

a. adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient

b. providing or arranging advice, investigations or treatment where necessary

c. referring a patient to another practitioner, when this is in the patient’s best interests

3. In providing care you must:

a. recognise and work within the limits of your competence

b. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs

c. provide effective treatments based on the best available evidence

d. take steps to alleviate pain and distress whether or not a cure may be possible

e. respect the patient’s right to seek a second opinion;

f. keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment

g. make records at the same time as the events you are recording or as soon as possible afterwards

h. be readily accessible when you are on duty;

i. consult and take advice from colleagues, where appropriate;

j. make good use of the resources available to you.

Written this posting after reading the following as reference_

  1. the GMC Medical Ethics (UK)
  2. Indian Medical Websites
  3. South Africa GPs webpage and
  4. http://www.issuesinmedicalethics.org/053mi078.html
  5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146049/pdf/canfamphys00121-0076.pdf

 

 

 

 

 

 

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2 Responses to “The withered “Medical Referral Ethics” in Myanmar and Malaysia?”

  1. kyawkyawoo Says:

    Ethics, Specialist and GP relationship was taught as series of lectures when I was in Institute of Medicine 2 more than 25 years ago.
    I am not so sure current curriculum for the medical students in both countries still pay attention to this important topic, for the good sake of patients. Thank you for a well written , and thought provoking post.
    rgds,

  2. Rebuttal to the Racist Bama Buddhist attacking my fellow Muslim doctor cum Human Rights Activist | Dr. Abdul Rahman Zafrudin @ Ko Ko Gyi Says:

    […] The withered “Medical Referral Ethics” in Myanmar and Malaysia? […]

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