Baik dan buruk Vape

Oleh: DR NORSIAH ALI.

Pakar Perunding Perubatan Keluarga ( Pengkhususan: Perubatan Ketagihan)

Presiden Persatuan Pakar-Pakar Perubatan Keluarga Malaysia (FMSA)

Ahli Majlis Persatuan Perubatan Ketagihan Malaysia (AMAM)

 

Semenjak akhir-akhir ini pelbagai reaksi ditunjukkan tentang tren penggunaan vape di negara ini. Amat merisaukan apabila menerima what apps gambar kanak-kanak, remaja dan wanita yang sedang menggunakan vape. Mereka kelihatan begitu seronok mengikuti tren terkini dan berkongsi rasa bangga mereka di media sosial tanpa menyedari implikasinya. Sekali pandang, perlakuan menyedut vape mencalar mata yang memandang kerana kelihatan sumbang dari aspek budaya.

Vape mula dipelopori di Negara China semenjak tahun 2003. Tujuan asal orang yang mencipta vape adalah untuk menggunakan kaedah merokok yang jauh lebih selamat dari rokok biasa. Rokok biasa memang telah diketahui mengandungi sekitar 4000 bahan kimia beracun yang boleh menyebabkan pelbagai jenis penyakit berbanding vape yang disifatkan oleh penggunanya sebagai jauh lebih selamat. Cecair vape juga pada asalnya didakwa selamat dan bebas dari nikotin. Namun, dewasa ini terdapat cecair vape yang mengandungi bahan dadah nikotin tulin. Isi kandungan sebenar setiap botol cecair vape juga diragui kerana tiada label kandungan bahan yang mengikuti piawai apatah lagi wujud keraguan tentang pencampuran bahan-bahan yang tidak diketahui apabila tiada peraturan pengilangan yang sewajarnya.

Penggunaan vape di Malaysia mula dirasai semenjak beberapa tahun kebelakangan ini. Baru-baru ini wujud pelbagai reaksi apabila kerajaan mengambil keputusan untuk tidak mengharamkan penggunaan vape. Persoalannya, adakah vape benar-benar selamat kepada penggunanya dan alam sekitar termasuklah orang-orang yang tidak menggunakan vape? Setakat yang diketahui cecair vape mengandungi perisa tertentu seperti vanilla, strawberi, mangga dan mint yang turut boleh menarik perhatian kanak-kanak. Cecair vape juga didapati ada yang mengandungi nikotin dan beberapa bahan seperti prophylene glycol yang apabila dibakar bertukar menjadi formaldehyde, sejenis bahan kimia penyebab kanser. Begitu juga dengan bahan-bahan logam dari kaedah pembakaran alat vape yang turut boleh mendatangkan kesat mudarat. Ada juga kejadian letupan dan kebakaran kecil kerana alat ini. Turut merisaukan apabila alat vape ini turut boleh digunakan untuk mengambil bahan dadah terlarang seperti heroin dan syabu.

Di samping dibeli di kedai-kedai, cecair vape juga boleh diperolehi secara dalam talian dan dipos kepada pembeli. Pembeli boleh jadi terdiri dari remaja yang masih bersekolah kerana terpengaruh dan ingin mencuba pelbagai perisa tren baru yang melanda ini. Walaupun harganya ratusan ringgit, remaja sanggup mengikat perut mengumpul duit untuk membeli vape. Lebih membimbangkan lagi, baru-baru ini ada laporan yang menyatakan cecair vape mengandungi sekurang-kurangnya mengandungi 12 bahan kimia beracun termasuklah bahan ganja semulajadi iaitu cannabinoid dan canabidiol serta ganja sintetik jenis dronabinol (Kosmo 17 November 2015). Perkembangan ini amatlah merbahayakan remaja yang diharapkan akan menjadi tonggak negara di masa hadapan.

Menurut Pusat Racun Negara, 1 ml cecair vape bernikotin mengandungi 4 mg nikotin dan sebotol kecil 25ml mengandungi 100mg nikotin tulin. Sekiranya terminum oleh kanak-kanak, 6-10 mg (1.5-2.5ml) boleh membunuh manakala dos yang boleh membawa maut untuk orang dewasa adalah sebanyak 40-60mg (10-15ml). Pada tahun 2014, sebanyak 3000 kes keracunan kerana cecair vape dilaporkan di Amerika Syarikat dengan 1 kematian kanak-kanak. Nikotin dalam cecair vape boleh menyebabkan ketagihan dan meningkatkan statistik perokok di negara ini. Menurut Global Adult Tobacco Survey 2015, 22.8% ( 5 Juta) rakyat Malaysia berumur 15 tahun ke atas adalah perokok. Dari segi jantina, 43% lelaki dan 1.4% wanita di Malaysia merokok. Rokok telah dikenalpasti sebagai pintu masuk (gateway) kepada pengambilan bahan-bahan lain seperti alkohol, ganja dan dadah-dadah lain.

Nikotin mendatangkan kesan yang buruk terutamanya kepada kesihatan. Ketagihan nikotin menyebabkan perokok mengalami gangguan perasaan semasa paras nikotin dalam darah berkurangan (sindrom tarikan atau gian) yang kebiasaannya berlaku 2 jam setelah merokok. Perokok boleh berasa resah gelisah, tidak boleh memberikan tumpuan, berasa lesu, mengantuk serta mudah marah. Pada jangkamasa yang panjang, nikotin menyebabkan pelbagai jenis kanser, penyakit paru-paru kronik, gastritis, pengerasan salur darah (artherosclerosis) yang menyumbang kepada penyakit sistem kardiovaskular seperti penyakit darah tinggi dan penyakit jantung. Nikotin juga boleh menyebabkan pembekuan darah yang boleh menyumbat salur darah justeru mendatangkan gejala seperti strok pada otak dan kehitaman pada jari kerana tidak mendapat bekalan darah yang berkesudahan dengan perlu pemotongan jari tersebut (dry gangrene). Tahap kesuburan sistem reproduktif juga boleh terjejas iaitu pengurangan bilangan benih lelaki (sperma). Nikotin boleh mendatangkan kesan mudarat kepada wanita hamil. Ia boleh menyebabkan keguguran, terencat tumbesaran janin dan kematian bayi dalam kandungan. Kesan buruk ini bukan sahaja boleh dialami oleh perokok dan orang yang tidak merokok namun terdedah dengan asap rokok.

Kebarangkalian untuk mendapat kanser kerana merokok dan terdedah kepada asap rokok adalah 20X ganda lebih tinggi berbanding orang yang tidak merokok. Begitu juga dengan risiko mendapat penyakit paru-paru kronik dan penyakit kardiovaskular yang 3X ganda lebih tinggi di kalangan perokok dan orang yang terdedah dengan asap rokok.

Isu kebergantungan (ketagihan) kepada dadah nikotin dalam rokoklah yang menjadi punca utama berlakunya perbezaan pendapat mengenai penggunaan vape di negara ini disamping pengaruh pihak yang berkepentingan dalam industri ini. Isu rokok telah lama wujud semenjak sebelum negara merdeka lagi. Isu menghisap rokok dipandang remeh oleh sesetengah pihak malah ada yang berasa marah dan menafikan rasa kebergantungan terhadap dadah nikotin. Ada juga yang memperlekehkan dan mempersendakan usaha-usaha untuk memberi kesedaran kepada masyarakat tentang bahaya rokok.

Fenomena ini mungkin berlaku kerana perokok tidak mampu untuk berhenti kerana kebergantungan yang kuat. Merokok pada suatu ketika dahulu tidak dianggap sesuatu yang salah disisi agama & kesihatan malahan mudah didapati. Ada juga segelintir yang kelihatan tidak terjejas kesihatannya walaupun merokok. Di samping itu, kesan buruk merokok tidak begitu ketara di peringkat awal penggunaannya. Namun, reaksi menidakkan fakta dan memberi pelbagai alasan sebenarnya adalah salah satu sifat utama orang yang mengalami kebergantungan dadah nikotin (denial). Kebergantungan kepada bahan-bahan dadah adalah sejenis penyakit yang memberi pengaruh yang mendalam kepada sistem saraf pusat otak manusia. Bahagian otak yang mendapat kesan utama bahan-bahan ini adalah sistem mesolimbik yang melibatkan pusat seronok ( reward center) seperti rajah 1.

brainRajah 1: Ilustrasi keratan rentas system mesolimbik otak manusia dirangsang oleh bahan-bahan yang mendatangkan ketagihan.

Sumber: The addicted brain. Scientific American 2004.

Bahan-bahan seperti nikotin, alkohol, heroin dan amphetamine merangsang pengeluaran beberapa jenis hormon terutamanya hormon dopamin. Hormon dopamin mendatangkan rasa keselesaan dan kesejahteraan di dalam badan manusia. Namun apabila paras hormon ini dirangsang penghasilannya dengan lebih banyak oleh bahan bahan lain, kesan keselesaan dirasai sangat kuat dan mengujakan (‘high’). Sel saraf otak mengenalpasti fenomena ini dan mempunyai memori yang sangat kuat terhadap kesan seronok dan selesa yang dirasai akibat pengambilan bahan bahan ini (positif reinforcing effect). Apabila paras bahan bahan ini menjadi separuh dari paras yang mendatangkan kesan keterujaan dan keselesaan, pengguna yang telah bergantung akan merasai kesan yang sebaliknya iaitu sangat tidak selesa, kusut fikiran, sakit kepada, sukar member penumpuan dan mudah rasa marah. Fenomena ini dipanggil sebagai sindrom tarikan atau gian (withdrawal syndrome).

Kebiasaannya merokok bermula di zaman remaja kerana sifat remaja seperti naluri ingin mencuba, pengaruh rakan sebaya dan kurang keupayaan menyelesaikan masalah dan mengadaptasi dengan suasana. Namun, haruslah difahami sel saraf otak remaja hanyalah sempurna pembentukannya ketika berumur lingkungan 20 tahun. Bahagian otak depan ( frontal lobe) yang membantu berfikir secara waras dan matang adalah bahagiaan yang paling lambat terbentuk dengan sempurna.Tindakan remaja adalah berdasarkan kawalan pemikiran yang belum cukup matang. Justeru, mereka perlu diselia dan dibimbing oleh orang dewasa dengan sebaiknya.

Pendedahan kepada bahan-bahan yang mendatangkan rasa teruja dan keseronokan terutamanya sewaktu zaman remaja boleh mendatangkan kesan yang serius. Ini kerana otak remaja mengalami fasa kritikal yang dipanggil proses pencantasan (pruning process). Melalui fenomena ini, pengaruh kepada sel otak yang sedang berkembang yang biasa diterima semasa remaja adalah amat kuat dan mendatangkan kesan yang berpanjangan sehingga dewasa. Bilangan tapak penerima tindakan hormon (receptor) pada sel otak orang yang menggunakan bahan-bahan ini menjadi lebih banyak berbanding dengan orang yang tidak terjebak dengan nikotin, alkohol dan bahan-bahan dadah yang lain ( Rujuk Rajah 2). Tanpa pengambilan bahan-bahan ini secukupnya, wujud kekosongan pada tapak penerima tindakan hormon yang mendatangkan rasa keinginan yang amat sangat (strong craving).

Rajah 2a & 2b : Gambar electron micrograph perbezaan rupa sel-sel otak antara orang yang mengambil bahan yang mendatangkan ketagihan seperti nikotin berbanding sebaliknya

 

rajah 2aRajah 2a: Sel otak yang tidak terdedah               rajah 2bRajah 2b: Sel otak yang terdedah

dengan kesan bahan ketagihan                          kepada bahan ketagihan

Sumber: The addicted brain. Scientific American 2004.

 

Sel-sel neuron dalam rajah 2b kelihatan lebih tebal kerana mempunyai tapak penerima tindakan hormon (nicotin receptor yang telah terbentuk dengan lebih banyak dari biasa). Perubahan struktur ini adalah kekal. Inilah penjelasan kenapa pengguna bahan yang mendatangkan ketagihan mengalami kesukaran yang amat sangat untuk berhenti.

Pengalaman melalui rasa ketidakselesaan yang bukan calang-calang atau gian (withdrawal syndrome) dan keinginan yang amat sangat (strong craving) menyebabkan pengguna tetap mengambil bahan bahan tersebut walau mengetahui bahaya dan gejalanya malah meningkatkan dos penggunaan bagi mendapatkan kesan yang sama kerana fenomena lali (toleran). Malah rata-rata merasionalkan tabiat mereka. Akibatnya sebahagian besar kehidupan dihabiskan dengan aktiviti berkaitan mendapatkan bahan tersebut (seperti nikotin, alkohol dan heroin), mengambil / menikmatinya dan pengambilan yang berterusan bagi mengelakkan fenomena gian. Pada tahap ini, mereka telah mengalami fenomena ketagihan terhadap bahan yang digunakan. Rata-rata pengguna dadah tegar mempunyai sejarah penagihan yang bermula dengan merokok.

Penyakit ketagihan kepada bahan seperti nikotin amatlah menyeksakan. Pengguna akan berulang-ulang terganggu kerana keinginan yang amat dalam untuk merokok semula bagi memenuhi tapak-tapak penerima tindakan hormone di otak (receptor). Akibatnya pengguna yang telah bergantung akan memberikan pelbagai alasan serta penjelasan bagi menidakkan keadaan sebenar mereka. Kebergantungan adalah sejenis penyakit yang perlu dirawat menggunakan pendekatan pelbagai sudut seperti ubatan, psikologi, sosial dan kerohanian (biopsychosocial & spiritual). Mereka memerlukan sokong bantu yang berpanjangan kerana penyakit ketagihan menghantui hidup mereka di sepanjang hayat. Risiko untuk jatuh semula kepada mengulangi tabiat lama amatlah tinggi malah merupakan salah satu sifat penyakit kebergantungan ini. Dalam konteks nikotin, 80% pesakit ketagihan nikotin merokok semula dalam temboh sebulan setelah berhenti seketika. Ini adalah fenomena biasa dalam masalah ketagihan bahan dan tidak harus dijadikan sebab untuk tidak mencuba semula untuk berhenti sekali lagi. Ada di kalangan pesakit yang telah bergantung hanya akhirnya berjaya berhenti setelah beberapa kali mencuba.

Oleh itu, rawatan perubatan yang menyeluruh perlu diberikan untuk membantu pesakit berhenti yang melibatkan aspek penilaian terperinci, rawatan tanpa ubatan menggunakan strategi menangani rasa ingin merokok seperti petua 10M (Rajah 3), strategi mengenalpasti halangan untuk berhenti merokok dan kaedah menanganinya serta strategi mengekalkan status tidak merokok. Bagi perokok yang berada ditahap ketagihan sederhana atau kuat, rawatan ubatan boleh membantu untuk menangani rasa gian ingin merokok. Contoh rawatan ubat adalah seperti ubat verenicline tartrate, bupropion dan persediaan nikotin pada dos tertentu dalam chewing gum, lozenges, tampalan (patch) dan sedutan (inhaler). Perokok perlu menjalani sesi sokong bantu serta rawatan susulan dalam tempoh yang lama. Berhenti merokok didefinasikan sebagai tidak lagi mengambil bahan –bahan yang mengandungi nikotin selama sekurang-kurangnya 6 bulan.

Definasi berjaya berhenti dari rokok adalah bebas dari pengambilan nikotin selama sekurang-kurangnya 6 bulan. Bertukar kaedah pengambilan nikotin dari merokok kepada menggunakan vape bagi mengatasi fenomena gian bukanlah telah berjaya berhenti merokok sepenuhnya.

 

Rajah 3: Petua 10 M

Mengunyah sesuatu

Membasuh muka

Melengahkan

Menarik nafas dalam-dalam

Mandi

Mengelak pergi ke tempat orang merokok

Mengelak pelawaan perokok percuma

Memohon doa

 

Banyak faedah yang diperolehi setelah berhenti merokok. Antaranya risiko penyakit akan berkurangan. Tapak penerima tindakan hormon dopamin di otak seperti dalam rajah 2b juga akan turut berkurangan. Malah setelah 15 tahun berhenti merokok, risiko untuk mendapat penyakit kardiovaskular menjadi sama seperti orang yang tidak pernah merokok.

Berbalik kepada persoalan wajarkah vape berada di pasaran?

Jika dikaji secara mendalam, lebih banyak kesan buruk berbanding faedah penggunaan vape. Jikalau cecair vape benar-benar dipastikan bebas dari nikotin, tren meniru cara merokok dan menghembus asap berkepul-kepul dari mulut dan hidung boleh mendatangkan sumbang di mata yang melihat terutama apabila digunakan oleh kanak-kanak, remaja dan wanita di negara ini yang masih menitik beratkan nilai-nilai ketimuran. Terdapat kajian yang mendapati vape berperisa yang tidak mengandungi nikotin juga boleh menyebabkan kesan radang dan kerosakan (cytotoxicity) terhadap tisu paru-paru yang diuji di makmal. Fenomena yang amat menakutkan adalah kebarangkalian penggunaan dadah terlarang melalui penggunaan peranti vape tanpa mudah dikesan oleh pihak berkuasa perundangan di samping risiko peningkatan bilangan yang akan mengalami penyakit ketagihan nikotin terutama di kalangan kanak-kanak, remaja dan wanita.

Walaupun vape dijadikan kaedah alternatif untuk menghentikan penggunaan rokok biasa, terdapat pendekatan lain yang jauh lebih selamat seperti yang telah dinyatakan. Setakat ini tiada bukti saintifik yang vape boleh menbantu perokok berhenti merokok (Christopher Bullen, The Lancet 2013).

Impak vape untuk jangka masa panjang kepada penggunanya serta masyarakat sekeliling yang terdedah kepada bahaya yang sama dijangkakan boleh mengundang kepada kos yang tinggi untuk merawat penyakit dan secafa tidak langsung akan menambah beban kewangan negara. Kemungkinan kecederaan sel saraf otak yang berpanjangan akibat terdedah kepada bahan racun tidak boleh dipandang remeh. Generasi muda haruslah dilindungi agar mereka membesar secara sihat mental dan fizikal.

Promosi kaedah selamat untuk berhenti merokok perlu ditingkatkan. Pendekatan yang digunakan hendaklah boleh menarik perhatian pesakit yang telah bergantung untuk tampil mendapatkan bantuan. Kaedah tanpa rawatan ubat sahaja tidak terpakai untuk semua pesakit. Setiap orang mempunyai tahap kesediaan untuk berubah dan pengalaman yang berbeza. Justeru pusat-pusat rawatan perkhidmatan berhenti merokok perlu dipertingkatkan dari segi bilangan dan kemudahan yang diberikan. Ini kerana sebenarnya rata-rata perokok ingin berhenti dari belenggu penyakit ketagihan ini.

Perokok yang mengalami ketagihan nikotin tidak harus berasa terseksa untuk berhenti merokok. Dengan bantuan ahli profesional seperti doktor, ahli farmasi di klinik-klinik, hospital dan farmasi komuniti, perokok boleh melalui rawatan pemulihan dalam keadaan mental dan fizikal yang selesa, tidak terganggu serta mampu berfikiran positif bagi mencapai matlamat untuk hidup lebih sihat. Kejayaan berhenti merokok mungkin tidak dicapai dengan sekali cubaan. Ada yang mungkin berjaya setelah mencuba berkali-kali. Pengalaman kegagalan untuk berhenti merokok di masa lalu haruslah dijadikan panduan untuk lebih berjaya dalam cubaan berhenti merokok yang seterusnya.

Malaysia telah dikenalpasti sebagai pengeluar vape ke dua terbesar di dunia selepas Amerika Syarikat. Amat merisaukan apabila Amerika Syarikat juga sekarang merekodkan peningkatan penemuan pengambilan dadah terlarang melalui penggunaan vape. Pada tahun 2006, kilang pemprosesan dadah syabu yang terbesar di dunia telah ditemui di Lunas , Kedah. Hasrat negara untuk bebas dari ancaman dadah pada tahun 2015 juga tidak kesampaian. Dari segi hukum agama Islam sebagai agama rasmi negara, rokok dan vape adalah jelas haram dari segi fatwa. Kesan baik vape masih diragukan manakala kesan sosial, kesan kesihatan dan impak negatif terhadap ekonomi negara di masa akan datang akibat dari tren baru ini amatlah ketara.

Fenomena penggunaan vape adalah bertentangan dengan dasar dan polisi Kementerian Kesihatan Malaysia iaitu menjadikan Malaysia sebagai sebuah negara yang bebas dari sebarang bentuk amalan merokok. Ia juga tidak selari dengan perjanjian WHO Framework Convention on Tobacco Control (WHO FCTC) yang telah ditandatangani oleh Malaysia semenjak tahun 2005.

Negara jiran seperti Singapura, Brunei dan Thailand telah mengharamkan vape atas faktor keselamatan dan kesihatan. Justeru, adalah diharapkan status penggunaan vape di negara ini perlu dikaji semula. Tren baru ini haruslah dibendung dengan cepat dan sebaiknya. Perokok perlu dibantu dengan kaedah yang selamat untuk menangani penyakit ketagihan yang sukar namun boleh diubati.

What We Should Know About Vaping?

WHAT WE SHOULD KNOW ABOUT VAPING?
Smoking is a known health issue. Evidence has shown that besides the nicotine which is responsible for the addiction to smoking, each cigarette stick contains over 4000 chemicals which are toxicants and carcinogen (can cause cancer). Smoking has been related with many diseases like COPD, ischaemic heart disease cancer of the lungs, prostate, breast and in asthmatics it worsens the condition. All these effects are also seen amongst the second hand smoke ii the people who breathes in the smokes produced by the people smoking around them.
Smoking evolves from burning tobacco which is wrapped with a leaf (rokok daun) to what is available now. Similarly interventions and activities to quit smoking evolve. From counselling and behaviour therapy to NRT (Nicotine replacement therapy) and pharmacotherapy (eg: varenicline). Along the way E cigarettes has been produced and it too evolves from appearing exactly like a cigarette stick to the present e cigarette which is better known as Vape.
Why E cigarette or Vape?
Majority uses E cigarettes because they:
1. Want to stop or quit smoking
2. Feel Vaping or e cigarette is safer
3. Believe Less addictive
4. Want to flow with the currents trend
5. Have more freedom to use in public places
6. Think it has Less effect to people around them (second hand vapers)
7. Believe it is Cheaper,
And for various other reasons like for fun, it’s the technology and youngsters used it out of curiosity!
Facts on vaping.
A. Is it true that Vaping or smoking e cigarette is safe
o Vaping is still not safe, even though it contains lesser harmful chemicals (toxicants & carcinogens) compared to conventional cigarettes. The prophylene glycol which is responsible in producing the vapours, will be converted to acetaldehyde (ex: formaldehyde which is used to preserve dead body) when burnt. There are studies on industrial use of propylene glycol and exposure to theatre fog (produced from prophylene glycol) that show negative health effects. These effects include throat and eye irritation, cough, mild airway obstruction, headache, and dizziness. So, inhalation of this humectant is not as safe as most people think.
o The problems with the labs studies that examined the presence of toxicants & carcinogens in e-cigarettes only tested for known toxicants and carcinogens of conventional cigarettes. Other impurities or by-products of heating e-juices are not known.
o You can become a drug addict by vaping! There has been a recent news about the juices has drugs added to it to increase its effects when used. You may start vaping to quit smoking or out of curiosity but end up a drug addict.

B. People can get addicted to vaping
As mentioned earlier the chemical responsible for addiction is nicotine. It has been found that even the e juice labelled as nicotine free contain certain amount of nicotine. Studies have shown that people do not use vape forever. Majority quit vape. They end up smoking conventional cigarettes.

C. Are people around the e cigarette vaping affected?
There are studies which show that vaping changed the air quality around them. The concentration of PAH (polycyclic aromatic hydrocarbon) increases. Another study also found an increase in serum cotinine in the ‘second hand’ vaping. Unfortunately there are no studies to confirm the long term impact of vaping to the people around them. Let’s make sure our children and spouses are not the ‘guinea pigs’ for this study.
D. What is the issue with our children and adolescents?
Adults may vape to quit smoking. However adolescents do it out of curiosity, to fit in with the peer group and to follow the trends. This will not be for long until they become dependent on nicotine and later become chain smoker although they might not have planned to smoke in the first place. This is actually another public health concern. Vaping can cause gateway to nicotine addiction/ smoking conventional cigarettes especially among adolescents’.
E. Can E cigarette be used to quit smoking?
o There are evidences that demonstrate ‘vaping can help smoking abstinence or cessation’. It showed that vapers had 2.2 times the chance to stop smoking conventional cigarettes for at least 6 months compared to smokers who do not vape. However, vaping still allows maintenance of nicotine addiction. Vapers still receive nicotine from e-cigarettes. Studies that examine its effectiveness as a treatment of smoking cessation (comparing with NRTs and Champix) are also lacking. So, it’s effectiveness as a treatment for smoking cessation (like nicotine replacement therapy) is still not proven. One of the possible reasons because the amount of nicotine that the vapers get from inhaling the vapours are varied, and it is quite difficult to titre down the concentration of nicotine. Even though they use the lowest concentration labelled on the bottles of e-juices, it is not guaranteed that they inhale nicotine of the stated concentration. The concentrations of nicotine are different from puff-to-puff, and across the brands and models of e-cigarettes. Furthermore, this smoking abstinence may not be sustainable as studies have shown that substantial number of vapers does relapse to smoking conventional cigarettes due to many reasons.

F. Vaping can be hazardous
The latest news on the hazards caused by vaping is the fire in a flight which developed from a vape kept in the pocket in one of the passenger. It has been reported that the device explodes while using causing injuries to the users hand and face
Ingestion of the ejuice can be fatal. It can cause nicotine toxicity. The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, sweating, low blood pressure, increased heart rate, tremors, headache, dizziness, muscle fasciculation and seizures. Later the depressor effect will take place where it causes low blood pressure, low hear rate, muscle weakness/paralysis, difficulty in breathing, central nervous system depression and coma
To really combat problems with nicotine addiction, it must involve all bodies, organisations, employers, and even all Malaysians to create a norm that ‘smoking or vaping is unacceptable’. For those who have chosen a wrong step in the past and already addicted to nicotine, their struggle to free themselves from this addiction should not be undermined. We have to help them to treat their nicotine addiction by ensuring that they can appreciate their risks of smoking, helping them to overcome their barriers, providing them necessary skills to change their habits and psychological dependence, and prescribing the proven effective pharmacotherapy. As majority of the smokers are in pre-contemplation stage, doctors should be trained to provide counselling for these smokers so that they want to stop smoking. Doctors should be trained to provide effective interventions for smoking cessation. Doctors should also be provided with adequate medication and non-pharmacological assistance for treating nicotine addiction. Smokers need to be assisted adequately to quit and their difficulties in the battle must be taken care and intervened as best as possible. The most important thing is we should aim for no smoking and no vaping. Smokers need to come forward to seek help and get rid of their addiction problem.
As vaping device can also be used to inhale illicit drugs openly without being notice by narcotic enforcement team and our country Malaysia is well known to have strict drug law hence any possibility of facilitating illicit drug use must be taken action seriously. In fact it was recently discovered by the ESERI, Universiti Sultan Zainal Abidin Terengganu that vape liquid studied in the laboratory also contain cannabis precursor (both synthetic and natural).
In conclusion smoking conventional cigarette and vaping are both addictive and harmful. Although the cigarette and vape industries may create great wealth to some, we must always remember, our greatest wealth is health.
SAY NO TO NICOTINE. SAY NO TO TOBACCO
By,
Dr Salmah Nordin & Dr Hizlinda Tohid
Family Medicine Specialists Association Malaysia (FMSA)

An open letter to the Members of Parliament of Malaysia

13 November 2015

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An open letter to the Members of Parliament of Malaysia

We, the undersigned medical professional bodies and non-governmental organisations, would like to register our concern regarding the increasing presence of electronic cigarettes and vaping in our society. We note with dismay the Cabinet’s rejection of the Ministry of Health’s proposal to ban the sales and use of electronic cigarettes.

1. Malaysia proudly signed and ratified the World Health Organisation’s Framework Convention on Tobacco Control (FCTC). This is a reflection of the nation’s commitment to protect present and future generations from the devastating effects of tobacco, a product that kills 6 million users annually. In Malaysia alone, eight individuals are killed daily due to tobacco and many more are affected by the significant health, social, economic and environmental costs.

2. It is a commonly held but misleading view that electronic cigarettes and vaping are safe. However, due to the lack of any form of quality control, equipment malfunction (include explosions leading to death) have been reported. The content of electronic cigarette ‘juice’ also varies depending on the manufacturer, with studies demonstrating a huge variability in toxin content and nicotine delivery. Even claims that the colourings used are safe are misleading as most consist of industry-certified food dyes, which can be safely swallowed but not necessarily safely inhaled.

3. The increasing use of electronic cigarettes, ostensibly as a smoking cessation tool, is not backed by current scientific evidence. Although the potential for harm reduction is an opportunity not to be missed, we must be careful that we are not substituting one form of addiction for another. At present, scientific evidence indicates that most individuals end up being dual users – i.e. using electronic cigarettes and tobacco at the same time. We are cognisant of the harmful effects of nicotine dependence, which is why it is a Group C Poison under the Poisons Act 1952.

4. The use of electronic cigarettes does not solve the problem of nicotine addiction. This problem is compounded by the fact that electronic cigarettes are gaining popularity amongst youth. Studies from the United States have demonstrated that children are increasingly using electronic cigarettes and that these same children are more likely to eventually smoke tobacco. In other words, the use of electronic cigarettes is a gateway to lifelong nicotine addiction.

5. It is clear that many products are targeted at younger sections of society despite claims to the contrary. Electronic cigarettes are sold with attractive colours and flavours, with marketing very similar to that employed by the tobacco industry in decades gone by. The sexualisation of the product with advertisements consisting of scantily-clad women and flavours such as ‘the taste of a virgin’ and ‘nenen’ (breast milk) also points to a worrying trend that is against the cultural norms of our beloved nation.

6. It is because of these factors that we welcome the statement by the Health Minister, Datuk Seri S Subramaniam, regarding the Ministry of Health’s long-term aim to ban electronic cigarettes. We truly believe that this move is for the benefit of our rakyat’s health. It is also in keeping with similar moves by our neighbours in the region, namely Singapore, Thailand and Brunei.

We are aware of allegations that this move is a result of lobbying by the tobacco industry, but it should be pointed out that most electronic cigarettes are manufactured by tobacco companies. Furthermore, we welcome the statements by YB Khairy Jamaluddin (Minister for Youth and Sports) and Datuk Dr Lokman Hakim, Deputy Director-General for Public Health, that a ban of electronic cigarettes should be in tandem with a ban of tobacco.

We call upon Parliament, as the most august law-making body of the land, to take the above points into consideration and to take into account the following proposals:

I. restrictions be immediately put in place for the retail sales and public use of electronic cigarettes and vaping
II. a discussion in Parliament in the foreseeable future regarding the need to implement a ban for both electronic cigarettes and tobacco
III. introduction of retail licensing for tobacco products retailers
IV. ensure that restrictions and bans are enforced rigorously without fear or favour
V. ensure that a fixed proportion of taxes and excise duties raised from tobacco sales are used exclusively for tobacco control efforts
VI. continuous increase in tobacco taxes and electronic cigarettes alongside related paraphernalia
VII. support access to smoking cessation services, including subsiding the cost for treatment. We are aware that more than 50% of current smokers in Malaysia are keen to quit, and it is our duty to help them achieve abstinence

We reiterate the point that it is misleading to say that the effects of electronic cigarettes on our health and society is minimal. We must learn from the mistakes made during the public health efforts against tobacco, in which it took decades for the true costs of tobacco to society to be made public.

The health of Malaysians today and tomorrow is too precious a commodity to be gambled. We urge the Members of Parliament from across the political spectrum to set aside their differences and support the Ministry of Health’s efforts in prioritising the health of the rakyat above all else.

Issued by:
The Malaysian Thoracic Society (MTS) on behalf of the following medical
professional bodies and non-governmental organisations:
Academy of Medicine of Malaysia Addiction Medicine Association Malaysia (AMAM)
Asia Pacific Academic Consortium for Public Health Kuala Lumpur
College of Public Health Medicine
Consumer Association of Penang (CAP)
Faculty of Medicine, Universiti Mal
Faculty of Medicine, Universiti Kebangsaan Malaysia
Faculty of Medicine, Universiti Teknologi Mara
Family Medicine Specialists Association (FMSA)
Federation of Malaysian Consumers Association (FOMCA)
Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM)
Ikatan Pengamal Perubatan dan Kesihatan Muslim Malaysia (I-Medik)
Islamic Medical Association of Malaysia (IMAM)
Islamic Renaissance Front (IRF)
Lung Foundation of Malaysia (LFM)
Malaysian Academy of Pharmacy
Malaysian Adolescent Health Association (MAHA)
Malaysian Animal-Assisted Therapy for the Disabled and Elderly Association (PETPOSITIVE)
Malaysian Association for Bronchology and Interventional Pulmonology (MABIP)
Malaysian Association of Environmental Health
Malaysian College of Physicians
Malaysian Council for Tobacco Control (MCTC)
Malaysian Association of Dental Public Health (MADPH)
Malaysian Green Lung Association
Malaysian Gynaecological Cancer Society
Malaysian Medical Association (MMA)
Malaysian Paediatric Association (MPA)
Malaysian Pharmaceutical Society (MPS)
Malaysian Psychiatric Association (MPA)
Malaysian Thoracic Society (MTS)
Malaysian Women’s Action for Tobacco Control & Health (MyWATCH)
Medical Practitioners Coalition Association of Malaysia (MPCAM)
National Cancer Society Malaysia (NCSM)
Pemuda dan Wanita Ikatan Muslimin Malaysia (ISMA)
Penang Medical Practitioners’ Society
Persatuan Belia Islam Nasional
Persatuan Doktor Pakar Kesihatan Awam Malaysia
Persatuan Pakar Perubatan Islam Malaysia (PAKAR)
Persatuan Pengguna-Pengguna Pengangkutan Awam Malaysia (4PAM)
Pertubuhan Amal Perubatan Ibnu Sina Malaysia (PAPISMA)
Pertubuhan Doktor-Doktor Islam Malaysia (PERDIM)

Role of Family Medicine Specialists

By Dr Iskandar Firzada Osman

 

 

Question

Is there a difference between Medical Officers/GPs and a Family Medicine Specialist? If yes, what can a Family Medicine Specialist do that normal MOs or GPs can’t?

Answer:

Laws of Malaysia; Medical Act 1971 require ALL doctors, including MOs, GPs, Specialists and/or Consultants to be registered with the MMC before they are allowed to practice in Malaysia. MMC will look at the basic medical degree to determine whether the doctors are eligible or not for registration. The doctors can claim that he/she is a specialist and he/she can practice as a specialist but no authority in Malaysia can dispute his/her claim. Medical (Amendment) Bill 2012 requires ALL medical specialists who claim that he/she is a specialist and would like to practice in that particular specialty to be authenticated, credentialed and privileged and be registered with the MMC by the National Specialist Register (NSR). Family Medicine specialty is one of the medical specialties listed under the NSR. Thus, please ensure the Family Medicine Specialist (FMS) that your hospital plan to employ is registered with the NSR. Otherwise, he/she can only practice as a MO/GP. You can check his/her name in the NSR’s website: https://www.nsr.org.my/
Nothing a FMS does that the normal MOs or GPs can’t do, vice versa. However a FMS has been trained to sieve through first contact, early presentation, undifferentiated and sometimes with multiple and multitude clinical presentations to come about with a decent problem list taking into consideration not only the biological/physical aspects but the psychosocial domain as well. In order to keep up with the ever changing and dynamism of medicine and diseases, FMS need to constantly update and upgrade their knowledge and skills through continuous professional development which has been second nature to a FMS. It’s also a requirement to renew the specialty register in the NSR. Whereas most MOs and GPs rely on their experience and seldom update and upgrade their knowledge and skills. FMS is skilful in managing more complex and complicated medical and psychosocial illnesses, both acute and chronic, across all age group and systems, collaborating and becoming patient’s advocate if the patients need referral to hospital-based specialists or to secondary care. At the same time, FMS has been ingrained with knowledge and skills to provide comprehensive care; from wellness promotion, disease prevention, early detection, treatment, rehabilitation and palliative care. These are applicable across different age groups, gender, organ systems and healthcare settings.

Why Family Physicians Are Different From Other Doctors

By Shelly Reese

Article from Medscape : November 13, 2014

THE DILEMMA OF FAMILY PHYSICIANS

Many doctors have suggested that family physicians are struggling with an identity crisis. Is it true?

Family physicians are specialists who, paradoxically, specialize in being comprehensivists. They practice in a realm bookended by nurse practitioners (NPs) and physician assistants on one side, and specialists on the other. “The former claim to do what we do, and the latter claim to do it better,” lamented one family physician in a Family Practice Managementeditorial.[1] “Our clinical expertise, both cognitive and procedural, is being assailed.”

The fact that many employed family physicians face restrictions on the scope of care they can deliver exacerbates the identity problem. As Dr Daniel Sprogen, director of medical education at the University of Nevada School of Medicine, wrote, “If family physicians aren’t providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?”[2]

But the underlying cause of family physicians’ identity struggle may derive from the nature of the specialty itself. Although all physicians must contend with unprecedented regulatory, administrative, and technological changes, most specialists can rest assured that their practice remains anchored in the constancy of their special focus on one system or aspect of the human body.

For family physicians, whose practice is based on a philosophy of comprehensive care, rather than treatment of a distinct biological system or disease, even that constant is off the table.

How Has the Specialty Developed?

Almost since its inception in 1969, the specialty of family practice has been evolving. The description of what constitutes a family physician hasn’t changed: The primary care specialty defines itself by broad-based training and a philosophy of medicine that emphasizes relationships and meeting the needs of patients within the broader context of their families and communities. Because families and communities are in constant flux, family physicians’ role is likewise elastic, constantly evolving in light of shifting societal needs.

“The question of family medicine’s identity has really been a perpetual question since the founding of the specialty,” explains Dr Russell Kohl, chief medical officer of TransforMed, a nonprofit subsidiary of the American Academy of Family Physicians (AAFP) that is working to advance the patient-centered medical home model. “Family medicine is often defined by the needs of the community where it is practiced.”

For years, Dr Kohl practiced in rural Oklahoma, where community needs dictated that he deliver babies and perform colonoscopies. In contrast, he notes, friends with whom he trained went on to practice in inner-city communities where HIV/AIDS posed a major healthcare need. Because family physicians must respond to the needs of the communities they serve, defining their shared identity can result in “a bit of a philosophical argument when you get a group of us into a room,” he says.

Because patients themselves shape the doctor’s role by virtue of their needs, family physicians enjoy a rich and varied practice, says AAFP President Dr Robert Wergin. “A patient may come in with a sore throat and then start crying because she’s having trouble with her marriage or her kids are in trouble,” he says.

“Patients turn to you for help. You’re the one they want to count on because you’re the one with whom they have the relationship,” he says, noting with a chuckle that he’s had elderly patients inquire whether he will be the physician who will put in their new aortic valve.

Perhaps because family physicians are already practicing in such diverse settings and meeting such a broad array of shifting needs, the specialty is taking the reins and working to assert itself as a leader in charting the future of healthcare. In October at the AAFP Assembly in Washington, DC, the specialty kicked off its $20-million, 5-year Family Medicine for America’s Health: Future of Family Medicine 2.0 initiative.

The initiative picks up where a 2004 program, which introduced the concept of the patient-centered medical home, left off and seeks “to transform the family medicine specialty to ensure that we can meet the nation’s healthcare needs and ultimately, improve the health of every American.”

WILL FAMILY PHYSICIANS GAIN MORE PRESTIGE AND CLOUT?

Funded by eight family medicine organizations, the initiative emphasizes the central role of family physicians in helping the nation achieve the triple aim of better health, quality, and value in healthcare. “Where we are trying to go as a nation is at the core of what family medicine has been all along,” Dr Wergin told physicians gathered for the AAFP Assembly. “Family medicine’s time is now.”

That attitude, the movement toward patient-centered medical homes, and the new emphasis on coordination of care is causing a fundamental shift in healthcare, says Kurt Mosely, vice president of strategic alliances for Merritt Hawkins, an Irving, Texas-based physician recruiting firm. For years, family physicians complained that they felt like second-class citizens relative to their specialist peers, he says. “Specialists have always kind of ruled the roost, but the leadership of medicine in America is moving back down to the grassroots level. The best leaders are the ones who know how to get things done, and family physicians are in that role.”

Mosely likens the family physician to the point guard on a basketball team. “They’re the player that brings the ball down the court. They’ve got the complete picture of the field and can see where handoffs should happen.”

That broad perspective is one of the reasons why accountable care organizations, hospital systems, retail clinics, corporations, insurers, and myriad other organizations have made family physicians the most highly recruited specialists for the past 8 years, according to Merritt Hawkins. What’s more, they’re often being sought for high-level positions, such as chief medical officer and chief executive officer, Mosely says.

According to Mosely, the demand stems from several factors, including a shortage of family physicians and recognition that their broad training makes them well suited to emerging team-based care models. But family physicians are also sought because they are revenue generators. In a 2013 survey, Merritt Hawkins tracked the amount of net inpatient and outpatient revenue physicians from 18 different specialties generated for their affiliated hospitals.[3] Physicians across the specialties generated an average of $1.47 million per year. Family physicians generated $2.07 million.

Gradually Gaining Ground

Growing recognition of the importance of family physicians and their unique role in the health system is likewise corresponding to several other subtle but positive developments.

In 2014, medical school graduates matching to family medicine residencies grew for the fifth consecutive year. This year, 1416 US medical school graduates matched to family medicine residency training, according to the AAFP. That represents a 31% increase since 2009.

Compensation is likewise increasing. Family physicians responding to Medscape’s 2014 Physician Compensation Survey reported earnings of just $176,000, a 1% increase over the previous year. Merritt Hawkins reports that in the past 5 years, family physicians have seen their base income—excluding production bonuses and other incentives—increase by 13.7%; in contrast, many specialists have experienced an overall decline in compensation during this same period.

IS SATISFACTION GROWING AMONG FAMILY PHYSICIANS?

Whether or not the gradual increase in pay and the growing sense of centrality to the system is translating to greater satisfaction among family physicians, however, depends on whom you ask.

In a 2014 Merritt Hawkins survey of more than 20,000 physicians conducted on behalf of the Physicians Foundation, 50.3% of family physicians described their morale and feelings about the current state of the medical profession as “very” or “somewhat positive.”[4] The overall share may seem low, but it vastly exceeds the number of specialists (40.7%) who expressed the same optimism and is slightly higher than the overall rate for primary care physicians as a whole, a category that includes pediatricians and physicians practicing general internal medicine.

What’s more, it marks a dramatic improvement compared with the same survey conducted in 2012, when only 36.5% of primary care physicians said expressed similar optimism about the state of the medical profession.

Family physicians responding to Medscape’s survey were far less optimistic. Although they were among the most likely physicians to say they would again choose medicine as a career, only 32% said they would choose family medicine as a specialty if they had the decision to make again.

Do Family Physicians Still Face Barriers to Progress?

Although family physicians face an array of frustrations, including competition from advance practice nurses and restrictions on the scope of care their employers allow them to provide, by far the biggest barrier to progress is a financial one. Emerging delivery models promoted by the Affordable Care Act emphasize the need to reward primary care physicians for coordinating care, implementing preventive care, and reaching quality goals, but these new compensation models are largely experimental and are not yet making their financial impact felt.

“If somebody came up with a compensation formula that considered patient malady improvement, patient maintenance, patient satisfaction, administrative and governance responsibility, community outreach, peer review, chart maintenance, timely communications, and an individual’s performance in meeting departmental objectives while still meeting a target of a certain number of patients a day, they’d win the Nobel Prize for medicine,” says Mosely.

Not surprisingly, shifting to a comprehensive primary care payment system is one of the key strategic objectives outlined by Family Medicine 2.0, along with ensuring a strong primary care workforce, advancing the use of technology, and furthering the evolution of the patient-centered medical home model.

The initiative “is not about reshaping the specialty,” says Dr Glen Stream, who chairs the collaborative. It’s about being willing “to continually reevaluate not just the scientific part of healthcare, but also the process by which we deliver it.”

Marcus Welby isn’t dead, he says. He’s evolving to meet the changing needs of the times.

Latest in Family Medicine/Primary Care

Source: Medscape Business of Medicine © WebMD, LLC

Cite this article: Why Family Physicians Are Different From Other Doctors Medscape. Nov. 13, 2014

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The World Best’s Health Care include Malaysia

worldMove over Canada.

A recent report finds France, Uruguay and Malaysia rank as the top three countries that provide the best and most affordable healthcare in the world.

Read: Help clients dissect the healthcare sector

France comes in first, finds InternationalLiving.com’s annual Global Retirement Index. This is because many French healthcare professionals in major cities speak English, and France has both public and private-sector healthcare. The public healthcare system is available to those who pay, or used to pay, into France’s Social Security system. This system offers excellent benefits, paying the bulk of the cost for a range of medical services that includes doctor’s visits, hospital stays and prescription medications.

Read: Canadians don’t get public vs. private healthcare

The private healthcare industry in Uruguay, which comes in second, consists of a number of independently operated healthcare organizations. They vary in size from a single clinic to networks of hospitals and clinics.

“The most popular private healthcare option in Uruguay is a ‘hospital plan,’ whereby you make monthly payments directly to an individual hospital or network that provides your care; everything from routine check ups to major surgery. The cost is extremely low compared to private healthcare options in the U.S.,” says David Hammond, InternationalLiving.com’s Uruguay correspondent.

In addition to hospital plans, there are private health insurance companies, including Blue Cross and Blue Shield of Uruguay, that provide a broad range of insurance plans.

Read: U.S. healthcare debate confuses Canadians

Malaysia placed third. It has gained fame as a medical-tourism destination as its healthcare is among the best and cheapest in the world. Medical expertise here is equal to or better than what it is in most Western countries.

“At this time, foreigners cannot access the public healthcare system here, but the low cost of healthcare and the range of health insurance options, means that paying for healthcare is no hardship,” says InternationalLiving.com’s Asia correspondent, Keith Hockton.

“Healthcare costs are so low that you can pay out of pocket for many standard procedures. A regular doctor’s visit costs $16 and a dental check-up costs $9,” he adds.

The Way Forward of Family Medicine in Malaysia

Sri WahyuBy: Dr Sri Wahyu Taher

It has been more than 10 years since the inception of the Family Medicine specialty. Since then the specialty has expanded enormously yet there is still room for further improvement. Family Medicine is a diverse specialty thus encroaching on wide areas of medicine pertaining to primary care. Over the years many FMS have received training in various areas of interests either overseas or locally namely in various areas such as Non Communicable Disease, Substance Abuse, Community Psychiatry, Community Paediatrics and others. The concept of ‘from womb to tomb’ provision of care has provided a wide opportunity for expansion. Its relevance has becoming increasingly significant since disease emergence has made a complicated turn in our society. Primary care is now the focus of disease control more so when intervention and promotion play vital roles in disease prevention. The concept of ‘prevention is better than cure’ i is certainly true in primary care and is spread across the board.

Clearly there are other areas where FMSs could have an impact in, i.e. by building up areas of interests. The fraternity must continuously seek and venture into areas that may seem to be less important but in actual fact are practical and needed. Areas like Travel Medicine, Rehabilitation, Aesthetic Medicine, E-Medicine and Complementary Medicine may sound irrelevant towards promoting a healthy society nevertheless these are the areas that is now growing in popularity in other developed countries. Therefore FMS should keep on striving and venturing into these relatively new areas for career development and opportunities in empowering our society into becoming healthier individuals. These advancements must not overshadow the existing areas of interests and the primary role of FMSs as a Primary Care Physician in delivering a holistic and comprehensive care for the society as a whole.

Being a specialist should not deter FMSs from becoming a leader with visionary aims of the future. A good leadership steered by credible FMSs with wide experience is needed in this current situation where primary care is continuously challenged. Leadership is not bestowed on individual naturally. It has to be instilled very early in the career. Personality and open mindedness is part of a good leadership. The training to become a leader has to start during the gazettement period if not during the specialty training itself. Therefore university trainers and lecturers are responsible in leadership training during the Master of Family Medicine Programme. Senior FMSs who are responsible in gazetting the junior FMS must direct and lead the young FMS into become leaders in the fraternity. Health clinics need good leaders to navigate the organization and all clinical programs. FMS are in the position to fulfil the need of a good conscientious leader in building up the health clinics into a centre of excellence in all aspect of care in the community. FMS have to be in the forefront of a health clinic in making the organization a competent and comprehensive centre in line with the needs of the community and the aspiration of the stake holders. FMS must always look forward and face up difficulties even though sometimes it may seem to be hopeless. A leader should not be deterred by the obstacles and must continuously be positive in facing these challenges for the betterment of the fraternity and the people we serve.

FMS as a renowned leader in the community providing clinical care must be prepared to be involved in research, scientific paper writing and most importantly to act as an advocator in policy making. Not many FMS are interested in writing or doing research.  However, these are some of the characteristics of a good leader of an organization. FMS have to be the primary provider of scientific evidence pertaining to primary care and interests in research must be a catalyst to new development. There are so many researches that a FMS can take up. It can also be collaboration with the counterparts in the secondary and tertiary centres. FMS must be bold enough to be the initiator in all research especially issues or hypothesis involving the community. In this way, FMS will always be seen as a specialist that has a lot of ideas, resourceful and in the frontier of new findings amidst the negative allegations spread around by other fraternity. FMS has every opportunity to do research because the family medicine discipline opens to a broad and diverse area of research. Primary care is a broad discipline and it enables FMS to lead research in all aspect of care because it is a comprehensive and holistic specialty.

Apart from research, FMS could also contribute as a writer. Writing can be in many forms. FMS can contribute in a scientific write up pertaining to a specific subject or findings like in a scientific research. FMS can also write in a scientific section as a contributor in a stated chapter of a particular issue in a publication. FMS can contribute as a writer in any of the chapter in a given subject, protocol or policies publish by Ministry Of Health. One of the examples is an invitation to become one of the writers in CPG Development Committee. It is really a great honour for the Family Medicine fraternity as FMS get invited to contribute in any of the Clinical Practice Guideline development by the Health Technology Assessment. In the past FMS has contributed in the development of various MOH CPGs and it is a pride of the fraternity. This achievement must continue and FMS must strive to achieve further success in order to uphold its reputation. However for other FMS who do not have the opportunity to write in a scientific paper they can also make a reputation in public writings example in magazines, newspaper or any articles that provide clinical and relevant information to the public so that they are guided to make healthy life choices. It may seem a small and less important contribution but in actual fact an essential provision of information coming from a credible and reliable writer especially if it touches the heart of the people and help them to lead a healthy life style thus disease prevention in the future.

FMS as a primary care physician must play a role in integrating primary care providers in MOH and private sector. There is a lot to share with the primary care doctors in the private sector. Family Medicine fraternity has been a bench mark in primary care services in Malaysia. Primary care providers in the MOH complement services provided by the private doctors in primary care. Likewise primary care doctors in private sector are to reflect on the present provision of care given by the FMS to improve their own service provision. However the relationship has to be strengthened in order to lift up the primary care services in Malaysia to a level of international recognition. Additionally, the strength will prepare the fraternity for future challenges in reaction to advancement.

FMS play a very important role in giving feedback and input to the Family Medicine training centres in universities and other agencies namely the AFPM. This responsibility is entrusted to the FMS because the training background gave us the experience and exposure to deliver services that meet the needs of the community in a holistic manner. Inputs from the FMS are important to improve the training curriculum and prepare Family Medicine trainees before passing the examination.  Curriculum must be in line with the demands of contemporary primary care provision of MOH. The universities have to ensure quality and competency in their candidates and feedback from FMS are needed to guide them to form a curriculum that is relevant and significantly adequate to face continued escalating demands.

In addition to the above discussion, involvement in NGO activities is an area FMS must aspire. FMS are in the best position to contribute and play a role in leading the NGO’s activities because we are specialists in the community and there are many NGOs that help the community in various ways. FMS are diverse specialists with multi skilled characteristics thus capable of steering the NGO. For example, involvement in NGO that fights for the right of abused individuals, people living with HIV, diabetes advocator and hospice care are just a few examples FMS can make an impact in helping out groups of society that has been given less attention and priority. This philanthropic relationship and involvement will definitely benefit the organization especially in planning for their community services.

FMS role and responsibilities

norsiahBy Dr Norsiah Ali

Health clinics in Malaysia provide both curative and preventive roles to patient and surrounding community. Being a specialist posted in health clinic, FMS must equip themselves with various skill and knowledge in order

i. To function as clinical leader,

ii. To provide specialize care that is accessible to patient and community,

iii. To act as effective gatekeeper,

iv. To function as the resource specialist in coverage area,

v. To provide holistic care,

vi. To develop good liaison with specialist in secondary care,

vii. To improvise health care in the community,

viii. To act as patient’s advocate,

ix. To guide Medical Officer and supporting staffs on clinical areas

x. To conduct research in order to improve patient care

1. Function as a clinical leader

A clinical leader is a person who leads the clinical decision and clinical works in his/her coverage area. In order to carry this role, a FMS must:

· Be knowledgeable in all aspect of clinical conditions that commonly encountered at primary care level. This role can be achieved by self-audit, getting updates, attending Continuous Medical Education (CME) sessions including via on line, adopting lifelong learning concept and discussion with other specialist counterparts.

· Be skilful in clinical areas. This role can be achieved by upgrading knowledge and conducting clinical procedures that can be carried out in primary care level. In order to do this, FMSs may need to refresh /sharpen clinical skill by attending refresher courses, doing attachments and the most important thing is keep on conducting the procedures to avoid losing their clinical skills. Keep on learning and invent on new thing in order to enrich your clinical capability.

· Be a clinical champion in your coverage area. In order to acquire this, an FMS, apart from being knowledgeable and skilful, he/she must function and appear as a respected clinician who can treat various conditions that can be managed as outpatient by specialist in secondary care (unless certain procedures that are not feasible at primary care level). This standard must be set by every FMS in order to appear at par with specialist in secondary care and to differentiate them from medical officers working in primary care. FMS must be able to make decision on critical clinical matters. By portraying this important role, other primary care providers may feel handicap to function without existence of FMS guidance.

2. Capability to provide specialize care that is accessible to patient and community.

One of the reasons for putting a specialist in health clinic is to ensure that specialised care is accessible to patient and community. This is in conjunction with the aim of providing care near to home. In order to do this, a FMS must be able to ensure specialize care can be received by as many as possible in the community. This role can be conducted by managing patients that are referred to them and conducting clinical round to guide medical officers on proper patient care. Apart from taking care of patients in the clinic, it is also important to ensure similar patient care can be provided to other nearby clinics without FMS by consultation visit and phone consultation.

3. Function as effective gatekeeper

Traditionally the primary care doctor serves as a gatekeeper, regulating whether or when specialty consultation and treatment are needed. If a referral is made, it is to specialist who has a contract with, or is a member of that particular organization. Pre negotiated discounts and fewer overall referrals lead to savings. After the treatments are finished, there is continuity of care as the patient continues to be followed by his or her primary care doctor (Lloyd M, Managed Care Magazine April 1996).

However, the problem with the gatekeeper model is that it is designed to limit, rather than to truly integrate, patient care. The lack of integration results in delayed or inappropriate referrals. It causes inappropriate tests or procedures to be done prior to, or instead of, referrals. This in turn, leads to progression of disease, and worse and more expansive outcomes.

In Malaysia, the gatekeeper role is not the same as practised in other countries. FMS is expected to provide integrated patient care and only refer when there is a clear indication. Patients are expected to be managed at primary care level unless it is beyond the FMS’s capability. It is crucial for FMS to ensure medical officers refer patient to secondary care appropriately by providing consultation between FMS and medical officers and clear referral guidelines, continuous guidance and clinical audit. Effective gatekeeper role and co-ordinator of care will ensure that patients get better care. The provider morale will also improve and in the long run there will be cost savings.

4. Function as the resource specialist in coverage area

FMS is expected to be contactable for clinical consultation either via direct consultation, telephone, SMS or email. FMS must acquire the skill of giving relevant advice and education using different strategies including safe practice approach and. identifying danger signs

FMS is also expected to conduct or organize regular CME sessions especially with medical officers not just in a particular clinic but also in a wider coverage area within the district. FMS must be able to identify current clinical problem in his/her particular coverage area and this include handling a disease outbreak where the Public Health Physician may be taking charge of preventive / control measures for community in general and FMS need to identify disease, give proper treatment and provide safe and preventive advice. So, FMS must place himself/herself in the frontline in terms of clinical care as well as to be the resource in preparing documents such as guidelines and standard operating procedures. By heading the clinical session with other medical officers through CME sessions, FMS will be the key clinical person in certain coverage area. It is important that an FMS must be clinically competent and knowledgeable in all clinical areas at the primary care level.

5. To provide holistic care

A FMS is expected to provide care “from womb to tomb” and should be able to provide at least initial management for complaints related to various systems. Many clinical problems should be able to be settled at the primary care level. The care is not just directly to the patient but also indirectly to his or her family members, relatives and community who may have influence on patient’s illness. These tasks if conducted well will portray the beauty and uniqueness of Family Medicine Specialty and clearly reflect the capability and complexity of tasks conducted by FMSs.

In order to be able to carry these challenging tasks, a FMS must be brave to manage certain conditions at the primary care level and explore new things within the scope of patient care. Seeking updates, going for attachments and liaising with specialists in secondary care are among the strategies that can be taken. Apart from giving benefit to patients, it will uplift the values of primary care services in this country. FMSs must not be rigid in their scope of work. Enriching the primary care services that is needed by surrounding community must always be looked positively and regarded as an honour rather than regarded as unnecessarily increasing the existing workload. Willingness of FMS to function according to patients’ and communities’ needs will reflect being responsible and sensitive to existing needs.

In view of the wide scope of work, one strategy that a FMS can adopt is by delegating and empowering medical officers to carry out certain tasks. Medical officers should be regarded as valuable partners in patient care. FMS can identify potential medical officers especially the senior ones and train them to carry out certain specific tasks. For instance, appoint one medical officer each to be responsible for Non Communicable Diseases, Communicable Diseases, Mental Health, Maternal & Child Health, School Health, Adolescent Health, Elderly Services, Children with Special Needs and Home Care Nursing. In a bigger clinic setting with many medical officers, more than one medical officer can be appointed to take care of certain programs. For instance, under Non Communicable Diseases, one medical officer can be appointed for diabetes, hypertension & cardiovascular activities and another medical officer to take care of Quit Smoking Services. For Communicable Diseases, one medical officer can be appointed to be responsible for Tuberculosis, HIV/STI & harm reduction against HIV/AIDS and emerging diseases. However in a smaller clinic setting, the task can also be shared with assistant medical officers and staff nurses. Usually the Medical Officer in-charged (MOIC) will run all administrative activities such as general administrative measures of the clinic, MS ISO and Panel Penasihat Kesihatan etc.

Empowering, delegating and giving some freedom to make decisions will make the medical officers feel trusted, important and shared authority in patient care. Making the medical officers feel responsible and to be answerable to certain condition also can improve their self-esteem and attract more medical officers to stay longer and be productive at primary care setting. Hopefully, in the long run, they will be interested to take up Family Medicine programme. FMS must not be irresponsible and let things to be fully taken care by medical officers! FMS still holds the responsibility of clinical care and should be answerable to any problems or shortfalls in his/her coverage areas.

6. To develop good liaison with specialists in secondary care

Good liaison with specialists in secondary care is very important. Apart from getting clinical updates, good liaison will give better perception towards FMS’s credibility. Liaison could be in the form of seeking opinion regarding patient care, conducting shared care and following up patient’s progress after referral to secondary care. Communicating with specialists in secondary care will not just give one way benefit but should be regarded as an opportunity for specialist in secondary care to be updated on the various progress and new things in patient care that occur in health clinics and primary care services. It will give a clear picture of various tasks and roles conducted by FMS.

FMSs need to develop rapport with specialists in secondary care by introducing themselves at any opportunity such as while attending CME sessions conducted in hospitals or by Malaysian Medical Association, attending meetings for specialists organized by the state health departments and during telephone consultations.

In order to obtain good perception from other specialists or working colleagues, FMS may need to develop certain soft skills. Actions that can be taken include:

· Speaking confidently and fluently

· When giving an opinion, always consider the two parties’ interests and phrase your sentence so that you can speak concisely, appear experienced and matured in giving opinion

· Always try to speak up when you are in a meeting (officially or unofficially) with other specialists so that your presence is felt and appreciated.

· Always feel and act as a clinical representative from primary care who can rationalize the services, defend or rectify any shortfalls and weaknesses with an open mind without appearing too defensive.

· Polish your English so that you are able to talk fluently.

7. To improvise health care in the community

The scope of work for FMS is not just limited to clinic setting but also to the wellness of community under health clinic’s coverage area. It is essential for FMS to understand the health status of his/her surrounding community, disease burden and potential disease threats. Among examples: to know the number of people living with diabetes, hypertension, asthma, mental illness, HIV, tuberculosis etc in the community. FMS can also contribute to plan community interventions such as cardiovascular screening, diabetes intervention, early identification of danger signs among sick children and antenatal mother, mental wellbeing and harm reduction measures against HIV/AIDS etc.

FMS can collaborate with local Public Health Specialists or medical officers. There might be some overlapping task between FMS and Public Health Specialists. It should be perceived as shared responsibility to the community and both parties could work together to achieve one common goal. FMS must be sensitive with disease trend in the community by looking at the notification on disease surveillance. The paramedical staffs usually plot the trend while FMS is responsible to monitor.
8. To act as patient’s advocate

FMS is expected to be an advocator for their patients’ health and wellbeing. This will strengthen FMSs’ credibility through patients’ perspective. It gives authority in terms of clinical aspect and a clear reflection of a clinician role in the community. FMS can create linkages between various patients’ need and local existing resources that can provide help especially in psychosocial aspects. In term of improving clinical aspects, FMS may justify for new drugs, clinical instrument or better clinic infrastructure in order to improve care to patients; through certain platforms such as attending meetings within department / state level or through related local Non-Government Organization. Some examples are Breast Feeding Support Group, National Association of Diabetes (NADI), harm reduction/ HIV related support group, support group for patients with mental illness and support group for children with special needs etc.

To guide medical officers and supporting staffs on clinical areas

FMS is responsible to make sure that medical officers and other supporting staffs see and treat patients properly. FMS must not just sit in their own consultation room and only limit patients seen by them. It is the responsibility for FMS to develop rapport with medical officers and other supporting staffs so that good clinical networking can be established.

A new medical officer who is posted to health clinic under FMS coverage should do clinical attachment with FMS and other senior medical officers for at least two weeks in order to understand their functions at primary care setting and services that are provided. Medical officers should take turns to do the clinical presentation during CME session while FMS supervise and provide clinical input. This will make medical officers update their clinical knowledge. The CME can be in the form of discussing about clinical matters, clinical practice guidelines or even journal clubs. FMS can create an email mailing list with the medical officers and supporting staffs in order to improve communication and distribute information. When conducting clinical audit, it should be to guide them rather than to find faults. FMS must portray good leadership and example. Through this strategy, FMS can be seen as a mentor / clinical sifu and working environment can be more pleasant.
9. To conduct research in order to improve patient care

Doing research is an evidence-based practice to explore or find answers for certain clinical doubt. It also shows FMS is concerned about the clinical outcomes of patients under their care. This reflects high standard and quality patient care. Involvement in research also makes work life more interesting as one explores new processes, interventions and outcomes.

Even though research can be an important element, as clinician, the time allocated for this function should be around 5-10% of FMS main duties. It will be good if FMS can allocate 1 to 2 afternoon sessions in a month for research in related activities. Doing research in a team is a smart way of doing many things with time and human resource constraints. The information obtained via research must be shared with others by making presentation in conferences or publishing in medical journal. This will also give good image to FMS and its fraternity.

In conclusion, FMSs play very important curative and preventive role in the Malaysian primary care setting. It is the responsibility of FMSs to carry themselves well, to portray excellent image and function to ensure good reflection to the fraternity. Good emotional quotients, soft skill, responsible, responsive and clinically competent are among important values that FMS must have.

History of Family Medicine in Malaysia

e coverBy: Dr Zaiton Ahmad & Prof Kwa Siew Kim

Family Medicine is gaining more attention and importance both as a medical speciality and service provider. The uniqueness of this speciality is that it transcends all disciplines and is not delineated by the patients’ age, sex or nature of their complaints. The government policy on “equity and accessibility” has also made this area of expertise more in demand.   This awareness is also due to the need of a holistic and integrated approach to patients’ care especially in the community. The public especially in the community now demand higher quality of care at the primary care level.

In Malaysia, Family Medicine is relatively new to the Malaysian health system. It started in the late 1980s when there was a need to change and expand the paradigm in primary care. Hence there was a need for specialised medical care at the primary care level. The training of Family Medicine involves all aspects of clinical care, preventive health care, managerial skills and continuing education. It has now been recognised as a specialty in its own right in the developed countries. Realising the country’s needs, the public universities have initiated the FMS through its Masters programme.

UM had started the Master of Family Medicine Programme in the year 1989 with two candidates. The next batch of FMS graduated from UKM and UM in 1997, making a total of ten FMSs in the MOH. The three universities i.e. UKM, UM with Universiti Sains Malaysia (USM) held their first conjoint examination in 2002. The number of contact hours for this attachment in most universities is at same par with the other disciplines such as Surgery, Obstetrics and Gynaecology, Paediatrics and Internal Medicine.  Since then more than 250 FMSs have graduated from the three universities. More than three quarters of the FMS is working with the MOH while the others are in the both public and private universities as well as in private practice.

Currently less than 15% of all the health clinics have FMSs. This is   less in number than what the three public universities (UKM, UM, USM) could produce. Other universities e.g. Universiti Technology MARA (UiTM) just started their own program  while University Putra Malaysia (UPM) and International Islamic University Malaysia (IIUM) will start their own Masters of Family Medicine programme in order to increase the number of graduates. This is in line with the MOH’s target to allocate FMS in all the health clinics throughout Malaysia. Since the presence of FMS in the country, the scope and services offered in public primary care clinics has been augmented. As a consequence, the FMS felt there was a need for them to be represented as in other specialties. With the founding of the association, members of the organization will also have financial standing; issues related to the speciality will also be addressed appropriately.

Hence, the establishment of the FMSA was initiated during the FMSA Conference in Cinta Sayang Resort Kedah in year 2000. A protem committee was formed headed by Dr Zaiton Ahmad. Subsequently Dr Khairi Mohd Taib was nominated as the first FMSA president in 2003.Since then, FMSA has gained strength in terms of membership not only from graduates of Family Medicine but also from the MRCGP and FRACGP.

As gate keepers in the health system, the Family Medicine speciality has various challenges both currently and in the future. These challenges are due to the changing socio-economic factors, lifestyles and disease patterns. Issues on ageing population, communicable and non-communicable diseases as well as mental health are among the current concerns.

In conclusion, the public expects doctors to be professional, have good communication skills and to be caring and compassionate.  Since primary care is the most accessible and utilized form of medical and health care, FMSs have an important and leading role in maintaining the health of individuals, their families and the population.