Increasingly medical practice is coming under intense scrutiny as to what is appropriate and affordable care, including serious considerations of patient safety issues and protection. Medical professionalism must be consciously adhered to as we try and find the best health care for our patients at the best value and outcomes for our patients themselves, and also for society at large. In view of escalating health care costs, physician autonomy to practice as he or she likes or deems fit has now come under siege with more and more performance monitoring, not just for appropriateness, but also for outcomes, necessity and cost-effectiveness. Physician' vested interests must be tempered with evidence-based benefits or at least be associated with no increase in harm or incur affordability issues. Fraudulent physician malfeasance are now being uncovered via whistle-blowers, or through greater more meticulous audit of various validated performance measures, and those physicians found to have flouted these due to pecuniary self-interests, overuse of tests or procedures have been found guilty and sanctioned with heavy fines, return of reimbursements as well as imprisonment, and erasure from medical registries and the removal of license to practice.

1. Dr David KL Quek,KMN
MBBS (Mal), MRCP (UK), FRCP (London), FAMM (Mal), FCCP (USA),
FNHAM (Mal), FASCC (ASEAN), FAPSC (Asia Pacific) FACC (USA), FAFPM (Hon)
Senior Consultant Cardiologist
Chair, Medical & Dental Advisory Committee
Pantai Hospital Kuala Lumpur
Malaysia
10th MOH-AMM Scientific Meeting (16th Scientific Meeting of the National Institutes of Health and National Ethics Seminar)
Symposium 2 ~ Ethics; 30 September 2013 (0915-1030h)

2. BioMedical-Ethics:
Elements of Spheres of Well-being
Organic
Wellbeing
Preserve
Life
Cure
Disease
(From Robert M. Veatch, Basics of Bioethics, Upper
Saddle River, NJ: Prentice-Hall, 2003, p. 52.)
Promote
Health
Relieve
Suffering

3. Preserve Life
Promote Health
Relieve Suffering
Cure Disease
The contribution of the
medical practitioner or the
physician in influencing
health and well-being is
rather circumscribed, and
not as large as we
sometimes think!
Organic Well-being

4. Nearly 40000 provisionally
& fully registered doctors
in MMC Register
MMC: 250 to 300
complaints/inquiries /year

5. Public perception of Doctors are changing…
Many doctors
still cling to the
perceived
stagnant
inviolability of
physician
autonomy to
practice as he or
she believes is
right…

6. Doctors in society
Medical professionalism in a changing world
“What is medical professionalism and does
it matter to patients?
Although evidence is lacking that more
robust professionalism will inevitably lead
to better health outcomes, patients
certainly understand the meaning of poor
professionalism and associate it with poor
medical care.
The public is well aware that an absence
of professionalism is harmful to their
interests.” RCP (London) Report of a Working Party, December 2005

7. Medical Professionalism
 What‟s
a good doctor?
RCP (London) Report of a Working Party, December 2005

8. Medical Professionalism

In day-to-day practice, doctors are
committedto (or are exhorted to have):
•
•
•
•
•
•
integrity
compassion
altruism
continuous improvement
excellence
working in partnership with members
of the wider healthcare team.
RCP (London) Report of a Working Party, December 2005

9. Medical Professionalism
These values, which underpin the
science and practice of medicine,
form the basis for a moral contract
between the medical profession and
society.
 Each party has a duty to work to
strengthen the system of healthcare
on which our collective human dignity
depends.

RCP (London) Report of a Working Party, December 2005

10. As Doctors, we do have a
Professional Mission!
“Physicians are the stewards for quality,
and they must aggressively develop an
agenda for improvement …we are at a
critical cusp of time in which we have a
last chance to retain our professional
role, and to do so we must become
protectors of quality.
“Activism must persist and grow if we
are to promote the professional/quality
link at the level of patient care. This
responsibility reaches to every
physician.”
Troyen Brennan, Physicians‘ professional responsibility to
improve the quality of care. Acad Med 2002;77:973–80.

11. OTHERWISE, MORE AND MORE OF PRACTICE ISSUES & MEDICOLEGAL CHALLENGES COULD OVERWHELM OUR HEALTH SERVICES!

12. Increases in
public‟s
expectations of
access and
outcomes of
clinical care,
including party
political
expectations!!!
Doctors in society. Medical professionalism in a changing world.
RCP (London) Report of a Working Party, December 2005

13. Principles of medical ethics
1. A physician shall be dedicated to providing competent medical
care, with compassion and respect for human dignity and rights.
2. A physician shall uphold the standards of professionalism, be
honest in all professional interactions, and strive to report
physicians deficient in character or competence, or engaging in
fraud or deception, to appropriate entities.
3. A physician shall respect the law and also recognize a
responsibility to seek changes in those requirements which are
contrary to the best interests of the patient.
4. A physician shall respect the rights of patients, colleagues, and
other health professionals, and shall safeguard patient
confidences and privacy within the constraints of the law.
AMA: Adopted June 1957; revised June 1980; revised June 2001.

14. Principles of medical ethics
5. A physician shall continue to study, apply, and advance scientific
knowledge, maintain a commitment to medical education, make
relevant information available to patients, colleagues, and the public,
obtain consultation, and use the talents of other health professionals
when indicated.
6. A physician shall, in the provision of appropriate patient care, except in
emergencies, be free to choose whom to serve, with whom to
associate, and the environment in which to provide medical care.
7. A physician shall recognize a responsibility to participate in activities
contributing to the improvement of the community and the betterment
of public health.
8. A physician shall, while caring for a patient, regard responsibility to the
patient as paramount.
9. A physician shall support access to medical care for all people.
AMA: Adopted June 1957; revised June 1980; revised June 2001.

15. Adherence to such ethics…




Implies more rigorous application of discipline
Often these run counter to real-life Physician
Practice, Autonomy & Self-regulation…
The private sector is a different ‗animal‘ altogether,
because services are not delimited by constraints of
public resources (accessible tests, amenities, costlier
drugs, perhaps lack of certain subspecialty doctors) or
the lure of easier access for some demanded
services, based on market forces… over-utilisation
of services occurs!
So under such circumstances, does self-regulation
work?

16. Adherence to such ethics…
Is physician autonomy(to do as one pleases
or opines), sacrosanct or absolute?
 Despite well-established and oftentimes selfevident professional ethics (mandated upon
medical practitioners), how many of us doctors
are conscious of our supposed aspirational
ethos within which a medical doctor should
practice: that he or she knows inherently
what is ‘good’, proper and fair, i.e. what is
professionally beneficent and ethical!?


17. Adherence to such ethics…



Clearly, there have been mounting concerns that
doctors—like everyone else in today‘s market-driven
economy—are increasingly business-like and venal!
Increasingly therefore, many oversight authorities
including regulatory boards and councils are veering
towards a more consistent and perhaps better
enunciated “virtue based ethos of medical
professionalism” that exhibits “transparency and
sincerity with regard to achieving uniform quality and
safety of health care.”
There is a need to temper our inbuilt human „moral
hazard‟ of self-interest vs. public good!

18. Adherence to such ethics, implies…
Physician Autonomy & Self-regulation

In other words, there is greater expectation
 that the medical professional delivers as he or she should as per




his professional duties and expertise or training, with integrity
and trustworthiness
that these health encounters and care outcomes are comparable
with the ―best‖ expected or estimated standards, quality and safety
that diagnostic or therapeutic harms or malfeasance are kept at
an informed minimum, and
that these services are transacted/purchased as per need and
prudence, at reasonable costs not just for the individual patient, but
also for society at large!
That there should be an ideal balance between prudent
„parsimonious‟ care over unnecessary or even fraudulent overutilisation of services, especially when these are for personal
gain!

19. SOCIETAL JUSTICE
FAIR PLAY
PATIENT SAFETY
COST-EFFICIENCY
DUE DILIGENCE ON
PRODUCT/SERVICES
OFFERED &
DELIVERED
REASONABLE INDIVIDUAL / SOCIETAL
EXPECTATION OF STANDARDS, SAFETY, QUALITY,
OF TRULY NECESSARY TREATMENT RENDERED
OUTCOMES AND COST OF EVERY HEALTH CARE
ENCOUNTER SHOULD BE TOLERABLY GOOD & FAIR

21. Monitoring
Performance…
Some scenarios as examples:
 Over-utilisation/testing/
unnecessary procedures/
therapies: Who checks this type
of physician/practice?
 Poor therapeutic results: high
morbidity-mortality outcomes:
Bad outcomes?
 Callous indifferent attitude:
Beyond skills/training expertise:
who should set the limits?
 Fraudulent practices, dishonest
reporting, involuntary
manslaughter for wrongful death
due to gross negligence or
incompetence…

24. Ethical dilemmas:

So, is there a need for monitoring
healthcare services, for physicians,
facilities?

CLEARLY the answer in this modern age is a
resounding YES!

Modern Parlance: Performance Management

Performance Monitoring for physicians?

Even more so, as public doubts, distrust and
patient empowerment demands greater
accountability, shared responsibility in mutual
decision making,

Even if disagreeable patient choice—Patient
autonomy trumps paternalistic care/unilateral
decision making
Who‟s watching?
Who‟s listening?

25. The lure of money and personal
lucre is a dizzying deflector and
obscurer of conscience,
integrity and professional

26. The uses of monitoring
information

Understanding the health
situation in your community
and how the health
services are performing.

Determining whether the
resources in the health
services are being well
used.

Ensuring that all
activities are carried out
properly by the right
people and at the right
time.

27. The uses of monitoring
information

Ensuring that activities
and tasks are performed
in accordance with set
standards.

Identifying health problems
facing the community and
starting to find solutions.

Ensuring community groups
and local individuals
participate appropriately in
health activities.

28. “DOCTOR KNOWS BEST” ATTITUDE AND PATERNALISTIC
APPROACH TO PATIENT CARE IS PASSÉ…

30. Pseudo-rationalisation to justify actions,
which may be driven by the lure of
personal profit, extra income and/or
professional reputation, standing or
arrogance… are ethically unsound…

31. Ethical dilemmas:
Real Practice Issues:
 Private practice institutions
reward volume of testing,
diagnostic procedures and
therapies
 Physicians are rewarded with
incentives, bonuses for higher
volumes of services rendered!
 Fee-for-service also rewards
physicians for their work… the
more tests, procedures, surgeries,
carried out and drugs used, the
higher the income or earnings
Moral Hazard:
Conflicts of Duty
Patient benefit vs.
Self-interest,
Personal gain

32. Ethical dilemmas:
Real Practice Issues:
 Large GLCs encourage and actually rate
higher, sanction and approve physicians or
surgeons who carry out more and earn
more for the hospitals… more tests, more
drugs, more disposables, more surgeries =
GREATER TURNOVER & RETURN OF
INVESTMENTS!
 Recent IHH IPO example: pink forms…
 In fact, sometimes ironically, more
complications and use of ICU/CCU beget
greater institutional profits!
 But bad/poor outcomes lead to higher
medico-legal costs which may override all
profits!
Moral Hazard:
Conflicts of Duty
Patient benefit vs.
Self-interest,
Personal gain

33. Deaths Linked to Cardiac Stents Rise
as a Third Called Unneeded
When stents are used to restore blood flow in heart attack patients, few dispute
they are beneficial. These and other acute life-or-death cases account for about
half of the 700,000 Americans who get stents annually.

34. Rate of Stent-Related procedures:
Number of PCIs for every 1000 Medicare enrollees

35. Procedures per angiographies: Doctors use angiography scans to look
for blockages; they implant stents afterward about half the time. A higher ratio of PCIs
per 1,000 scans may show locales where doctors are more inclined to use stents.

36. A Heart With 67 Stents,
N. Khouzam, RajvirDahiya, Richard
Schwartz,J Am CollCardiol. 2010;56(19):1605-1605. doi:10.1016/j.jacc.2010.02.077

37. Elective Coronary Stenting
not Harmless…


Cardiac stents were linked to at least 773 deaths in
incident reports to the U.S. Food and Drug Administration last
year, according to a review by Bloomberg News. That was 71
percent higher than the number found in the FDA‘s public
files for 2008. The 4,135 non-fatal stent injuries reported to
the FDA last year – including perforated arteries, blood clots
and other incidents – were 33 percent higher than 2008
levels.
2011 study in the Journal of the American Medical
Association that found only half of elective stent
procedures nationally were appropriate under usage
guidelines written by societies of heart specialists. The study
found 12 percent were inappropriate, and 38
percent fell into the uncertain category of the
guidelines.

Kickbacks: At least five hospitals have reached settlements
with the Justice Department over allegations that they paid
illegal kickbacks to doctors for patient referrals to their cath
labs. St. Joseph Medical Center in Towson, Maryland, paid
the government $22 million without admitting liability.

38. Elective Coronary Stenting not Harmless…
Case in Point: Multiple Stents by a DrPatil
 Catheterization and stents at St. Joseph in London (after a DrPatilbegan practicing
there), climbed from 210 to 929 from 2000 - 2009
 Stenting income from Medicare alone >1/6 of the hospital‟s 2009 operating income
 When Patil left in 2010, catheterization procedures fell 34 percent from their 2009 high;
the decline would have cost the hospital about $15 million.
RM, one of Patil‘s patients, had her arteries catheterized 18 times and received 8
cardiac stents over four years, according to a lawsuit she and 361 other patients
have brought against Patil, St. Joseph and other doctors who practiced there. The
defendants deny the negligence and fraud allegations against them.
Short of Breath
 RM said she suffers from chest pain and shortness of breath, and has been told by her
new doctor that she may need more stents and surgery to keep her coronary arteries
from closing. She said she gets so tired she needs to sit and rest after walking down the
stairs.
Penalties


St. Joseph-London repaid Medicare $256,800 for unnecessary procedures.
Patil lost his privileges to practice in December 2010.

Under his plea bargain, Patil agreed to serve 30 to 37 months in federal prison.

He forfeited his Kentucky medical license for five years. In 2012, he told a
family court judge his monthly income was $53,300.

39. The Lure of Lucre
High Median Income
 Interventional cardiologists earn a median
income of $562,855 a year, as compared to
$207,117 for family doctors, according to
Medical Group Management Association,
which surveys physician practices.
 Interventionalistsranked 13th among 118
specialties tracked by MGMA.

Recent data „leaked‟ from hospital sources
estimate that some top earning
physicians/surgeons in Malaysia gross in
excess of RM 4-5 million (USD 1.2-1.5
million) per year… i.e. 300k to 400k/mo

40. Elective Coronary Stenting not Harmless…
Michigan Deaths and Malfeasance

1. MehmoodPatel, a Lafayette, Louisiana, cardiologist was jailed last year on 51 counts of
charging for needless stents, made over $16 million in one three-year span. Prosecutors
said he was ―driven by the desire to be the busiest cardiologist in town‖.

He unsuccessfully argued/appealed that he used his best medical judgment in every case and lost.

Patel is serving a 10-year sentence in a federal penitentiary.
2. JashuPatel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures
in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation
to Mehmood Patel).
Needless Stents
The suit alleged Patel implanted needless stents in at least two patients, including
one that led to a blood clot that killed an unnamed woman who had reported no
symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in
her file said she didn‘t want interventions, said Julie Kovach, a cardiologist who worked with Patel
and brought the case to the government‘s attention. ―It was appalling,‖ Kovach said in an interview.
―Patel coerced her into getting a stent she didn‘t need, which killed her.‖
False Claims

―He‘s their cash cow,‖ said Kovach, now co-director of a clinic at the Detroit Medical Center.
―They‘re not about to turn him in.‖

Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of $4 million to settle the
federal charges. Kovach was awarded $760,000 as a whistle-blower under the U.S. False Claims
Act. Allegiance disagreed with the allegations and settled the claims to avoid ―lengthy litigation.‖


41. Elective Coronary Stenting not Harmless…
Cleveland Raid
In Ohio, Simecek, a worker at the Ford dealership, grew suspicious after his sixth stent from
cardiologist Harry Persaud at the Cleveland Clinic‘s Fairview Hospital in 2011. Simecek said he
went for a second opinion and was told he didn‟t need any of the stents. Now he
said he has to take blood thinners the rest of his life.

Persaudis under criminal investigation for health care fraud, mail fraud and money laundering,
according to federal court filings. Last October, Federal Bureau of Investigation agents
raided his office and removed financial records and patient files for procedures at 3 Cleveland-area
hospitals. The government has seized $343,634 from his and his wife‟s bank
accounts, alleging the funds represent the proceeds of fraud related to a ―significant number‖ of
unnecessary stent procedures.
Multiple, Elongated Full-Metal Jacket

The Cleveland Clinic found ―problems related to the use of stents in some patients‖ at Fairview and
reported them to the government, according to spokeswoman Eileen Sheil. She would not say how
many patients were affected. Persaud resigned from the hospital staff last year.

At least 64 of Persaud‘s patients at St. John Medical Center in suburban Westlake received letters
from the hospital saying they may have received an unnecessary stent between 2010 and 2012,
according to spokesman Patrick Garmone, who said Persaud no longer practices there.

Persaud denied wrongdoing in court filings and said his stent procedures were proper. Neil
Freund, his attorney in lawsuits filed by patients alleging unwarranted stents, said ―it is our intent to
defend these cases.‖ He had no comment on the federal investigation.


Another case: “Excessive” stent work… included 31 stents stretching for 14
inches inside the arteries of a Patient B.

42. Also, Elective Endoscopies not Harmless…
Hospital A in Selangor
 A gastroenterologist does some 20-25 scopes per working day,
averaging some 450 - 500 OGDS and Colonoscopies per month,
income ~ RM400,000; drives a Ferrari and Bentley
 Some peers complain ‗quietly‘ that he scopes just about anyone that
walks into his clinic before he even sees or examines them… YES
physician envy and oversight is coming…
 Management has been relatively quiet, as he is the highest
performing physician in terms of use of facility and other disposables
and OR times. MDAC not able to act based on lack of formal
complaints or incidents…
Hospital B in Selangor
 A physician-gastroenterologist walks around his wards, then points
out to his inpatients for urgent OGDS/colonoscopies to ‗top up‘ his
weekly performance; and was heard to exclaim (by nurses) that his
‗quota‘ for the month of scopes has notyet been reached, which
usually is around 60-70 per week; estimated income averages
RM300,000+ per month…
http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp#TopOfPage.

43. Also, Elective Endoscopies not Harmless…
Hospital C in KL
 Senior gastroenterologist from Penang, charged in MMC
for having perforated a gut due to negligence and
unethical behaviour for unconvincing indication, and not
giving adequate informed consent about possible adverse
outcomes and risks of complications. Reprimanded as he
could not satisfactorily convince the MMC of his standard
of care, proper documentation and his standard operating
protocols; slip-shod work ethic etc.
 What‟s fair physician income and remuneration?
 Who decides whom to treat or perform some of these
self-referred procedures and surgeries?
 Stark Law obviously breached but not applicable
here; no oversight… Should there be?
http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp#TopOfPage.

44. Ethical dilemmas:
Real Practice Issues:
 Who monitors and ensures standards and
quality of care?
 Patient safety compliance?
 Competence: Missed/delayed treatment
 Incompetence & Poor skills/performance
 Dubious indications for tests /therapies
 Adverse outcomes/Complications of
therapy/lack of informed consent
 Chronic disease management and outcome
 Pay for performance or goal-directed
outcomes?

45. Ethical dilemmas:
Real Practice Issues:
 In-built venal interests vs. public good
 Moral hazards: self-referral for testing,
skewed diagnostic &therapeutic choices…
 Too Much Rx: Over testing, overtreatment, EBM?
 Defensive medical practice… fear of
medico-legal litigation
 Harms associated with such decisions
 Outdated Knowledge base: Inadequate
attention to CME/CPD
 Peer review and oversight
 Appropriateness of Care: Fair deal for
patients, for payers
 Prudent or Parsimonious Care for all
patients, society

46. Ethical dilemmas:
"Is it ethical for hospital management, peer specialist societies or
regulatory authorities (MOH, MMC) to evaluate the performance of
a medical practitioner using clinical outcomes or electronic
performance monitoring data gathered on that individual?“
 Is it time to consider such approaches to improve
patient outcomes & safety?


Ultimately will such monitoring help to
 reduce system failures,
 weed out or curtail poor performance,
 stem fraud, and/or
 help reduce overall healthcare costs escalation?

Or does this impinge on the rights and
physician autonomy and practice of the
medical professional?

47. WHAT SHOULD WE DO WITH
THIS “ETHICS” THING ABOUT
PERFORMANCE MONITORING?
,
HOW MUCH OF WHAT WE DO AS DOCTORS CAN STAND UP TO
CLOSE SCRUTINY AND AUDIT TO QUALIFY AS GOOD, BEST OR EVEN
APPROPRIATE PRACTICES? ARE OUR OUTCOMES UP TO THE MARK?

48. The critical attitude in medicine:
the need for a new ethics
NEIL McINTYRE, KARL POPPER



“These standards of objective truth and criticism may teach
him (the individual man) to try again and to think again; to
challenge his own conclusions, and to use his imagination in
trying to find whether and where his own conclusions are at
fault.
They may teach him to apply the method of trial and error in
every field, and especially in science; and thus they may teach
him how to learn from his mistakes, and how to search for
them.
These standards may help him to discover how little he knows
and how much there is he does not know. They may help him to
grow in knowledge, and also to realise that he is growing. They
may help him to become aware of the fact that he owes his
growth to other people's criticism and that reasonableness is
readiness to listen to criticism.”
KARL POPPER, 1978

49. Always act in the best
interests of your patients
Primum Non Nocere, First Do No Harm…
 You are personally responsible for making sure that you
promote and protect the best interests of your service
users/patients.
 You must respect and take account of these factors when
providing care or a service, and must not abuse the
relationship you have with a patient.
 You must not allow your views about a patient‘s sex, age,
colour, race, disability, sexuality, social or economic status,
lifestyle, culture, religion or beliefs to affect the way you deal
with them or the professional advice you give.
 You must treat patientswith respect and dignity.
 If you are providing care, you must work in partnership with
your patients and involve them in their care as appropriate.

50. In the UK when you commence service in the health sector,
you‟re provided with some set of rules and conduct…
In Malaysia too, we have our Code of
Professional Conduct via the MMC

51. Act in best interests of patients, always
Primum Non Nocere, First Do No Harm…
 You must not do anything, or allow
someone else to do anything, that you have
good reason to believe will put the health,
safety or wellbeing of a service user in
danger. This includes both your own actions
and those of other people.
 You should take appropriate action to protect
the rights of children and vulnerable adults if
you believe they are at risk, including following
national and local policies.
 You are responsible for your professional
conduct, any care or advice you provide, and
any failure to act.

52. Act in best interests of patients, always
Primum Non Nocere, First Do No Harm…
 You are responsible for the appropriateness of your
decision to delegate a task.
 You must be able to justify your decisions if asked
to.
 You must protect patients if you believe that any
situation puts them in danger. This includes the
conduct, performance or health of a colleague.
 The safety of patients must come before any
personal or professional loyalties at all times. As
soon as you become aware of a situation that puts a
service user in danger, you should discuss the
matter with a senior colleague or another
appropriate person.

53. Keep high standards of
personal conduct.
You must keep high standards
of personal conduct, as well as
professional conduct.
 You should be aware that poor
conduct outside of your
professional life may still affect
someone‘s confidence in you
and your profession.


54. Keep professional knowledge
and skills up up to date.





You must make sure that your knowledge, skills and
performance are of a good quality, up to date, and
relevant to your scope of practice.
You must be capable of meeting the standards of
proficiency that apply to your scope of practice. We
recognise that your scope of practice may change over
time.
We acknowledge that our registrants work in a range of
different settings, including direct practice, management,
education or research.
You need to make sure that whatever your area of
practice, you are capable of practising safely and
effectively.
Our standards for continuing professional development
link your learning and development to your continued
registration. You also need to meet these standards.

55. Act within your limits, skills and
experience
You must keep within your scope of practice. This
means that you should only practise in the areas in
which you have appropriate education, training
and experience.
 We recognise that your scope of practice may
change over time.
 When accepting a patient, you have a duty of care.
Inclduing the duty to refer to others for care or
services if it becomes clear that the task is beyond
your own scope of practice.
 If you refer a patient to another practitioner, you
must make sure that the referral is appropriate and
that, so far as possible, the patient understands
why you are making the referral.


56. Communicate properly and
effectively
You must take all reasonable steps
to make sure that you can
communicate properly and
effectively with patients.
 Youmust communicate
appropriately, cooperate, and share
your knowledge and expertise with
other practitioners, for the benefit of
patients.


57. Effective Care, Supervision and
Referral

People who receive care or services from you
are entitled to assume that you have the
appropriate knowledge and skills to provide
them safely and effectively.

Whenever you give tasks to another person to
carry out on your behalf, you must be sure
that they have the knowledge, skills and
experience to carry out the tasks safely and
effectively.

You must not ask them to do work which is
outside their scope of practice.

58. Informed consent

You must explain to patients the care or services you
are planning to provide, any risks involved and any
other possible options.

You must make sure that you get their informed
consent to any treatment you do carry out.

You must make a record of the person's decisions
and pass this on to others involved in their care.

In some situations, such as emergencies or where a
person lacks decision-making capacity, it may not be
possible for you to explain what you propose, get
consent or pass on information. However, you should
still try to do all of these things as far as you can.

59. Informed consent

A person who is capable of giving their consent
has the right to refuse to receive care or
services. You must respect this right.

Youmust also make sure that they are fully
aware of the risks of refusing care or services,
particularly if you think that there is a significant
or immediate risk to their life.

You must keep to your employers‘ procedures
on consent and be aware of any guidance
issued by the appropriate authority in the
country you practise in.

60. Keep accurate records

Making and keeping records is an essential
part of providing care or services and you
must keep records for everyone you treat or
for whom you provide care or services.

You must complete all records promptly. If you
are using paper-based records, they must be
clearly written and easy to read, and you
should write, sign and date all entries.

You have a duty to make sure, as far as
possible, that records completed by students
under your supervision are clearly written,
accurate and appropriate.

61. Keep accurate records

Whenever you review records, you should update
them and include a record of any arrangements
you have made for the continuing care of the
service user.

You must protect information in records from being
lost, damaged, accessed by someone without
appropriate authority, or tampered with.

If you update a record, you must not delete
information that was previously there, or make that
information difficult to read. Instead, you must
mark it in some way (for example, by drawing a
line through the old information).

62. Limit your work or stop practising
if affected by ill-health…
You have a duty to take action if your
physical or mental health could be
harming your fitness to practise.
 You should get advice from a
consultant in occupational health or
another suitably qualified medical
practitioner and act on it.
 This advice should consider whether,
and in what ways, you should change
your practice, including stopping
practising if this is necessary.


63. Honesty and integrity
vs. public trust
You must justify the trust that other
people place in you by acting with
honesty and integrity at all times.
 You must not get involved in any
behaviour or activity which is likely
to damage the public‘s confidence
in you or your profession.


64. Basic Human Instinct for
Free-Market enterprise?
“Every individual necessarily labours to render the
annual revenue of the society as great as he can. He
generally, indeed, neither intends to promote the publick
interest, nor knows how much he is promoting it… He
intends only his own gain, and he is in this, as in many
other cases, led by the invisible hand to promote an end
which was no part of his intention.”
~Adam Smith, in The Wealth of Nations
“Purity of heart, if one could attain it, would be to see
clearly and to act with grace and self-command from
this point of view.” ~John Rawls, in A Theory of
Justice

65. Ethical behaviour and
practice can be nurtured…

66. Standards of Care
Assessment…

How can private hospitals/private sector
help to ensure that patient safety
measures as well as physician
performance are up to the mark
comparable to peers, standards in the
country or around the world?

67. Standards of Care Assessment…
MSQH and JCI are the technical accreditation benchmarks for
some sort of systems approach to ensure safety and
performance: e.g. PSG (Patient-safety goals)
 From the viewpoint of hospital management and peer groups,
patient safety measures and monitoring can be instituted…


68. Rating Doctors…

69. Some possible performance
measures to consider/monitor…
At PHKL, the MDAC has instituted a few preliminary
measures:
 Readmission rate within one week post-discharge
 Deaths within 24-h of admission or surgery or procedure
 Mortality assessment of all deaths, monthly audit,
including causes, co-morbidities, costs of admission
during last hospitalization
 Review:
 Hospital bills which run up beyond unexpected flagged targets,
e.g. >RM100k
 All hospitalizations extending beyond one week, for independent
review
 All surgeries that require > 2 re-surgical intervention

70. Some possible performance
measures to consider/monitor…
At PHKL, the MDAC has instituted some preliminary
measures: REVIEW:
 All unexpected outcomes where there is even an ‗implicit‘
potential patient or relative discomfort or complaint
 Inter-hospital data mining as to relative incident and
mortality rates of certain procedures and surgeries, e.g.
CABG, PCI, Infection rates, with review of practice of
physician outliers
 Review physicians/surgeons who have been involved with
repeated or recurrent incident reports
 We‘ve not looked at physician income and procedure
numbers or volumes… but we track intra-disciplinary
physician charges and overall cost per procedure/therapy
to detect outliers and possible deviant practices

71. US Mandatory Physician
Quality Reporting System
– linked to Payment to be
in place by 2015

72. Physician Quality Reporting System (PQRS)
We want to emphasize that if a group of physicians with 100 or more eligible
professionals does not self-nominate/register to participate in the PQRS GPRO
(Group practice reporting option web-interface or CMS-qualified registry) or
elect the PQRS Administrative Claims option for groups for PY 2013, its Value
Modifier in CY 2015 will be -1.0 percent.

73. Process Measures for Eligible Professionals and Group Practices Who
Report Using Administrative Claims for the 2015 PQRS Payment Adjustment

74. Process Measures for Eligible Professionals and Group Practices Who
Report Using Administrative Claims for the 2015 PQRS Payment Adjustment

75. Outcome Measures for Eligible Professionals and Group Practices Who Report Using
Administrative Claims for the 2015PQRS Payment Adjustment

76. Cost Measures
Section 1848(p)(3) of the Act requires physicians to evaluate
costs, to the extent practicable, based on a composite of
appropriate measures of costs. We adopted five per capita cost
measures in the quality-tiering election for the Value Modifier:
 Total per capita cost






Per capita cost for beneficiaries with four specific chronic conditions:
Chronic obstructive pulmonary disease (COPD),
Heart failure,
Coronary artery disease (CAD), and
Diabetes.

77. Relationship between Quality of Care
and Cost Composites & Value Modifier

78. Tavistock principles

Rights
 People have a right to health and health care.

Balance
 Care of individual patients is central, but the
health of populations is also our concern.

Comprehensiveness
 In addition to treating illness, we have an
obligation to ease suffering, minimise disability,
prevent disease, and promote health.

79. Tavistock principles

Cooperation
 Healthcare succeeds only if we cooperate with
those we serve, each other, and those in other
sectors.

Improvement
 Improving healthcare is a serious and continuing
responsibility.

Safety
 Do no harm.

Openness
 Being open, honest, and trustworthy is vital in
healthcare.

80. Why have such principles?

The most fundamental problems in health
care are ethical:




Who will live?
Who will die?
Who will decide and how?
How will we allocate resources?
There are ethical codes for individual
professions but not for everybody in health
care (owners, health care workers,
patients)
 We should have more explicit ethical codes
for all, including healthcare owners and
shareholders, even if GLCs!


81. “The practice of
medicine is an art,
not a trade;
a calling, not a
business;
a calling in which
your heart will be
exercised equally
with your head.”
Sir William Osler 1849-1919
Sir William Osler, Aequanimitas: With other addresses to medical
students... 2nd ed. (Philadelphia: Blakiston's Son, 1920) p.386

83. Discernment…
―But I AM ALWAYS WARY OF
DECISIONS MADE HASTILY.
―I am always wary of the first decision,
that is, the first thing that comes to my
mind if I have to make a decision.
This is usually the wrong thing.
―I have to wait and assess, looking
deep into myself, taking the
necessary time.
―The wisdom of discernment redeems
the necessary ambiguity of life and
helps us find the most appropriate
means, which do not always coincide
with what looks great and strong.‖
Pope Francis,
2013

84.  Most if not all doctors are smart, highly
intelligent but individualistic people, with low
tolerance of perceived „stupidity‟ or differing
opinions unless from a respected „authority‟.
 Most are dogmatic prima donnas, who
strongly believe in personal and professional
autonomy; some are inherently altruistic…
 But times have changed, and medical
regulatory authorities are invoked increasingly
to constrain even discourage such selfinterested activities and market-driven ethos!

85. In many respects, our world has
changed, and increasingly physicians
will see more and more oversight
activities and regulations including
punitive sanctions to circumscribe
some of our less than flattering actions
and decisions… our society and our
patients demand that we place their
interests and benefits first and
foremost, and not the other way round!
Individual
vs.
Societal
wants and
Needs…
We need
to strike a
prudent
balance!

86. Thank you!