Document Information
Clinic Procedures and Guidelines
Code of Ethics for Infant Formula Products in Malaysia
Code of Practice for Access for Disabled People to Public Buildings
Disposal of Syringes from Ministry of Health, Malaysia
Guidelines for the Clinical Use of Electronic Mail with Patients (Source: AMIA)
Guidelines for the Referral of Patients
Good Medical Practice from the Malaysian Medical Council (MMC)
Guidelines on Pilgrims Health Screening
Immunisation Schedule (Childhood)
Medical Examination for Vocational Licence (PSV and GDL)
SARS - Guidelines for Outpatient Clinics
Suggested Principles of Professional Ethics for the Online Provision of Mental Health Services Management of Possible Avian Influenza in Private Healthcare Facilities
Avian Flu Alert - Letter from MOH (22 Feb 2006) - pdf format. Related website: Communicable Disease Surveillance Section, Disease Control Division, Ministry of Health
CME (Continuing Medical Education) Issues
This editorial in the BMJ on Continuing medical education suggests that CME in its present form is "unfit for the millennium" and "needs to be more effective, accountable and responsive". Concern about the vast "CME industry" and their heavy dependency on pharmaceutical industry sponsorship leads to calls for evidence based CME programmes that not only improve doctors' performance but also health care outcomes. This needs good methods of continuous assessment of performance. The following series of articles on CME from the BMJ look at international trends and forces in doctors' continuing professional development.
Changes in health care and continuing medical education for the 21st century - This is the 1st in the series.
Global health, global learning - This is the 2nd in the series.
Learning and change: implications for continuing medical education - This is the 3rd in the series.
Recertification and the maintenance of competence - This is the 4th in the series.
Quality issues in continuing medical education - This is the 5th in the series.
Maintaining standards in British and Canadian medicine: the developing role of the regulatory body - This is the sixth in the series.
Interprofessional working and continuing medical education - This is the last in a series of seven articles.
Continuing medical education: where next? - Doctors must manage their own education.
Healthcare and the information age: implications for medical education. This article identifies a number of imperatives for medical education and describes some practical changes to a medical curriculum. The information age, rapidly developing information technology and massive growth in biomedical and clinical data together with the radical changes in access to information in the society necessitate a new approach to primary and continuing medical education.
Medical informatics meets medical education. This article illustrates the difference between the teaching of practising clinicians or medical students to use IT and the ability to surf the Web and to being skilled in the understanding of the principled use of information in medical practice. The emphasis on evidence-based practice highlights the skills needed to collate, distil and apply clinical research, an example of the application of information and communication skills needed in healthcare. It is conceivable that, in the future, failure to use such tools could come to be regarded as negligent practice.
Recent articles in the BMJ covers various issues on CME, ranging from the Editorial Time for evidence based medical education to the Editor's Choice, "I don't know": the three most important words in education. Other topics that relate to CME issues that are linked to the latter article are Guidelines for evaluating papers on educational interventions, Evaluating and researching the effectiveness of educational interventions, Evaluating educational interventions, Trend spotting: fashions in medical education and Learner centred approaches in medical education. Whether continuing medical education make a difference in general practice was also covered.
Changing the doctor-patient relationship - Are we providing doctors with the training and tools for lifelong learning? "Lecture and test" teaching methods arm learners with plenty of information but not the skills to update and replace it. Although computers put information at everyone's fingertips, insufficient attention has been paid to how this information is delivered. Traditional evidence based medicine focuses primarily on identifying and validating written information; this is unrealistic and too time consuming for most doctors. Efforts to increase the use of the best available evidence at the point of care must focus on the relevance of the information to patients and clinicians. Doctors need a first alert method - a bulletin board - for relevant new information as it becomes available and a way of retrieving the information about which they have been alerted.
The primary care clinic as a setting for continuing medical education: program description
This editorial in the BMJ on Continuing medical education suggests that CME in its present form is "unfit for the millennium" and "needs to be more effective, accountable and responsive". Concern about the vast "CME industry" and their heavy dependency on pharmaceutical industry sponsorship leads to calls for evidence based CME programmes that not only improve doctors' performance but also health care outcomes. This needs good methods of continuous assessment of performance. The following series of articles on CME from the BMJ look at international trends and forces in doctors' continuing professional development.
Changes in health care and continuing medical education for the 21st century - This is the 1st in the series.
Global health, global learning - This is the 2nd in the series.
Learning and change: implications for continuing medical education - This is the 3rd in the series.
Recertification and the maintenance of competence - This is the 4th in the series.
Quality issues in continuing medical education - This is the 5th in the series.
Maintaining standards in British and Canadian medicine: the developing role of the regulatory body - This is the sixth in the series.
Interprofessional working and continuing medical education - This is the last in a series of seven articles.
Continuing medical education: where next? - Doctors must manage their own education.
Healthcare and the information age: implications for medical education. This article identifies a number of imperatives for medical education and describes some practical changes to a medical curriculum. The information age, rapidly developing information technology and massive growth in biomedical and clinical data together with the radical changes in access to information in the society necessitate a new approach to primary and continuing medical education.
Medical informatics meets medical education. This article illustrates the difference between the teaching of practising clinicians or medical students to use IT and the ability to surf the Web and to being skilled in the understanding of the principled use of information in medical practice. The emphasis on evidence-based practice highlights the skills needed to collate, distil and apply clinical research, an example of the application of information and communication skills needed in healthcare. It is conceivable that, in the future, failure to use such tools could come to be regarded as negligent practice.
Recent articles in the BMJ covers various issues on CME, ranging from the Editorial Time for evidence based medical education to the Editor's Choice, "I don't know": the three most important words in education. Other topics that relate to CME issues that are linked to the latter article are Guidelines for evaluating papers on educational interventions, Evaluating and researching the effectiveness of educational interventions, Evaluating educational interventions, Trend spotting: fashions in medical education and Learner centred approaches in medical education. Whether continuing medical education make a difference in general practice was also covered.
Changing the doctor-patient relationship - Are we providing doctors with the training and tools for lifelong learning? "Lecture and test" teaching methods arm learners with plenty of information but not the skills to update and replace it. Although computers put information at everyone's fingertips, insufficient attention has been paid to how this information is delivered. Traditional evidence based medicine focuses primarily on identifying and validating written information; this is unrealistic and too time consuming for most doctors. Efforts to increase the use of the best available evidence at the point of care must focus on the relevance of the information to patients and clinicians. Doctors need a first alert method - a bulletin board - for relevant new information as it becomes available and a way of retrieving the information about which they have been alerted.
The primary care clinic as a setting for continuing medical education: program description
CPG (Clinical Practice Guideline) Issues
It is well known that the mere spread of clinical guidelines has limited impact on practice. Combining guidelines with other measures may increase the effect of professional conduct. Such measures may be local adaptation of guidelines, courses and other educational programs. Peer support is important for quality development among general practitioners. However, efforts to improve knowledge and motivation do not suffice. It is important that working conditions of the practitioner must be adapted towards reinforcing change of behaviour. There are reports of the effect of reminders linked to specific clinical situations, i.e. through the electronic record system.
Despite the rapid promulgation of guidelines around the world, there are still disparate sentiments and the growing awareness of their limitations and harms. "The unbridled enthusiasm for guidelines, and the unrealistic expectations about what they will accomplish, frequently betrays inexperience and unfamiliarity with their limitations and potential hazards. Naive consumers of guidelines accept official recommendations on face value, especially when they carry the imprimatur of prominent professional groups or government bodies."
This is the first in a new series of four articles on issues in the development and use of Clinical guidelines - Potential benefits, limitations, and harms of clinical guidelines.
Clinical guidelines - Developing guidelines This is the second in a series of four articles on issues in the development and use of clinical guidelines
Clinical guidelines - Legal and political considerations of clinical practice guidelines This is the second in a series of four articles on issues in the development and use of clinical guidelines
Clinical guidelines - Using clinical guidelines This is the last in a series of four articles on issues in the development and use of clinical guidelines
Clinical guidelines - the hidden costs. Implementation of evidence based guidelines may limit doctors' discretion and the autonomy of local commissioners Guidelines allow narrow interest groups to impose their priorities on the health service Implications for resources and the real effects of proposals must be evaluated thoroughly if guidelines are to be of value Failure to do this may distort decision making in health care; this, in turn, can lead to unbalanced structures that do not serve the best interests of patients.
It is interesting that the New Zealand Guidelines Group (NZGG) has a different approach in getting Consumer Involvement in Guidelines Work The NZGG's commitment to involving consumers in guidelines development and implementation resulted in the first guidelines consumer workshop held in Wellington in June 1997. This draft paper entitled Guidelines for the involvement of consumers in guideline development was prepared and presented.
Canadian physicians' attitudes about and preferences regarding CPGs
Clinical practice guidelines on trial
Guideline Appraisal Project (GAP). Improving access to and use of evidence-based practice guidelines
Clinical Guidelines - An ambitious national strategy from the NHS Executive.
Guidelines for clinical guidelines - A simple, pragmatic strategy for guideline development. With thousands of guidelines mushrooming everywhere and produced by different sources, some of which offer contrasting views, is there a need for a strategy for the development of Clinical Guidelines?
Guidelines in general practice: the new Tower of Babel? There is anecdotal evidence that general practitioners are being flooded with guidelines. The mass of paper collected in the studies represents a large amount of information, but it is in an unmanageable form that does little to aid decision making. Information must not be hidden in a load of paper but should be readily accessible and easy to use.
Why Don't Physicians Follow Clinical Practice Guidelines? - A Framework for Improvement. Clinical practice guidelines have had limited effect on changing physician behaviour. Little is known about the process and factors involved in changing physician practices in response to guidelines. What are the barriers to physician adherence to cpgs?
A review of 76 published studies "offers a differential diagnosis for why physicians do not follow practice guidelines" (pp. 1458–65). Among the 293 potential barriers were awareness, familiarity, agreement, self-efficacy, outcome expectancy, ability to overcome the inertia of previous practice, and absence of external barriers to perform recommendations. The authors note that "studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another." They conclude by offering a "rational approach toward improving guideline adherence."
The CPP Perceptions Library - A Catalogue of survey items and instruments that have been used to assess health professionals’ attitudes towards clinical practice guidelines and the factors which they perceive to be barriers and facilitators to guideline implementation". It also contains a Bibliography of studies of perceptions in guideline implementation.
Directories
Addresses & Contact Nos. of State Health Directors
Addresses & Contact Nos. of Health Departments
Directory of Services by NGOs in Malaysia
Ethics and Professionalism
Historical Perspectives .... Chinese Confucian Culture And The Medical ethical tradition
Are "tomorrow's doctors" honest? Questionnaire study exploring medical students' attitudes and reported behaviour on academic misconduct
S C Rennie and J R Crosby BMJ 2001;322 274-275
Medical Ethics - Recent Advances In this article, the author puts forward the concept of recent advances in relation to medical ethics' goal to improve the quality of patient care by identifying, analysing, and attempting to resolve the ethical problems that arise in the practice of clinical medicine. He reviews advances in medical ethics in five areas - end of life care, medical error, priority setting, biotechnology, and medical ethics education - and anticipate two future issues, "eHealth" and global bioethics. Most of the changes seem to reflect thinking on ethics at a societal level: new guidance for setting priorities, new developments in biotechnology, and new awareness of error, driven to the forefront by an American report, To Err is Human. The Canadian Medical Association Journal's excellent collection of materials on ethics is at www.cma.ca/cmaj/series/bioethic.htm. These teach basic principles such as truth telling, voluntariness, and confidentiality, as well as recent advances.
Guidelines on Confidentiality and Good Medical Practice from the Malaysian Medical Council (MMC)
Suggested Principles of Professional Ethics for the Online Provision of Mental Health Services These principles are being developed by a joint committee, co-chaired by Martha Ainsworth and Robert Hsiung, of the International Society for Mental Health Online and the Psychiatric Society for Informatics. The hope is that these principles will guide both counselors who provide and clients who receive online mental health services.
Concerns had been expressed worldwide of doctors' ability to exercise ethical responsibility towards protecting patients' interest. Condensed MPS case reports from the Medical Protection Society are intended to highlight some of the areas of medical practice where problems occur - and recur - and to remind doctors that many medico-legal problems can be avoided if doctors exercise the necessary caution and vigilance. In the same vein, such responsibility be expressed in the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines which should be followed to assure that such research is conducted in accordance with those principles. This Belmont Report attempts to summarize the basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research created when the National Research Act (Pub. L. 93-348) was signed into law on July 12, 1974.
The following articles discuss the issues of medical professionalism, self regulation and maintaining good practice in relation to doctors' performance. Getting Doctors to Listen: Ethics and Outcomes Data in Context. The New England Journal of Medicine.
Beyond conflict of interest - Transparency is the key. This editorial from the BMJ commented on some of the recent failure of authors of reputable publication and media to declare possible conflicts of interest and discussed the implications of the increasing expectation for transparency and accountability in all aspects of society. In relation to the topic, this Ethical debate: Should industry sponsor research? makes interesting reading and these responses more interesting. The Declaration of Helsinki : revising ethical research guidelines for the 21st century become necessary. Competence, professional self regulation, and the public interest. This article in the BMJ discusses the requirement by the Government to publicise hospitals' death rates and the performance of NHS doctors to be subjected to closer scrutiny in the public interest. This is in the light of reports and investigations of "unacceptably high death rates" following operations performed by certain doctors, infamously known as the "Bristol Affair". After Bristol is an article that provides the discussion following The Bristol Royal Infirmary Inquiry
Managing Care - Should We Adopt a New Ethic? The author noted that the emphasis in the practice of medicine has shifted from the individual to the community and often with group capitation as reimbursement, should ethical consideration also be shifted from the individual to the community? Providers of health care are also delivering services as a team. Should there be Shared ethical principles for everybody in health care? This is a working draft from the Tavistock Group.
Medicine needs its MI5. This article in the BMJ was written by an investigative journalist. He suggested that there was a need for new ways of policing medicine and discussed the reasons why complaints currently fail. He further elaborated on the shortcomings of the General Medical Council (GMC) in its process of self-regulating the profession and noted that "Everywhere in Medical Regulation, there is inconsistency and muddle". Or was it "institutionalised conspiracy?".
Professionalism must be taught. This article suggests that most doctors do not fully understand the obligations they must fulfil to satisfy public expectations and maintain professional status. Do doctors understand what it means to be a professional when they make decisions in their private (including business) and professional lives? The authors go on to say that doctors will meet their obligations if they understand their origins and their nature. Thus, "professionalism" must be reaffirmed and must be taught, including
Medical ethics and law as a core subject in medical education
Role Models -- Guiding the Future of Medicine. In this article, the authors present provocative evidence that many physician-teachers do not exhibit the professional characteristics that residents desire to emulate.
Medical Professionalism in Society was discussed in this article in the NEJM. The authors proposed that the three core elements of medical professionalism: devotion to service, profession of values, and negotiation within society are essential roles. However each element may be misapplied, but in balance they offer normative guidance. The model discussed calls on physicians to engage in professional activities along a spectrum of advocacy, thereby helping to preserve the decency and stability that are essential to civilized society. The acceptibility of the intepretation of the Hippocratic Oath for the present times is currently being addressed. It is also interesting to note that the International Conference on Islamic Medicine had addressed the Oath of the Muslim Doctor in 1981.
Medical Professionalism -- Focusing on the Real Issues. This is the latest article that appeared in the NEJM. It focusses on an analysis of historical records of issues of professionalism shifting attention from managed care to the more fundamental problem of professionalism in American medicine.
Uneasy Alliance -- Clinical Investigators and the Pharmaceutical Industry
Is Academic Medicine for Sale? "It is well to remember that the costs of the industry-sponsored trips, meals, gifts, conferences, and symposiums and the honorariums, consulting fees, and research grants are simply added to the prices of drugs and devices. The Clinton administration and Congress are now grappling with the serious problem of escalating drug prices in this country. In these difficult times, academic medicine depends more than ever on the public's trust and goodwill. If the public begins to perceive academic medical institutions and clinical researchers as gaining inappropriately from cozy relations with industry -- relations that create conflicts of interest and contribute to rising drug prices -- there will be little sympathy for their difficulties. Academic institutions and their clinical faculty members must take care not to be open to the charge that they are for sale."
The performance of doctors.
I: Professionalism and self regulation in a changing world
II: Maintaining good practice, protecting patients from poor performance
Medical Associations: guilds or leaders? - Either play the role of victim or actively work to improve healthcare systems
"When doctors might kill their patients" were two articles that appeared in the editorial of the BMJ recently. The medical profession sighed with relief the acquital of an English GP of murder, when he was found to have given his dying patient a lethal dose of a pain killer to relieve him of pain. It was argued in this first article that foreseeing is not the same as intending and that this is true whether or not voluntary euthanasia is legalised, for voluntary euthanasia is a different issue. This second article discussed the doctrine of "double effect", a formulation that offers a way out of the moral dilemmas that often arise when patients die as a result of medical ministrations. The argument is that such deaths are morally acceptable if the intervention which led to them was designed for another acceptable purpose. Here are some of the letters that relate to the the same topic.
On Wednesday, May 24, 2000 the eHealth Ethics Initiative introduced an International Code of Ethics for health care sites and services on the Internet. The event took place at the Dirksen Senate Building in Washington, DC. The Internet Healthcare Coalition endorsed International e-Health Code of Ethics had been unveiled and can be fully accessed with additional notes and definitions. This Code had represented both the insights and reflections of the e-Health Ethics Summit which was convened in Washington, D.C. 31 January - 2 February 2000. The code had been formally endorsed by the e-Health Ethics Summit after an eight-week period of public comment and consultation.
