KUALA LUMPUR, Nov 7 — Patients admitted to government hospitals run by the Health Ministry receive at least two to three doctor visits daily or more, depending on their condition, clinicians say.
Medical practitioners working in the Ministry of Health (MOH) explained how the government health service upholds patient need and clinical autonomy, contrasting this to blanket cost control measures by a third-party administrator (TPA) to restrict physician visits to one per day for admissions in private hospitals in Malaysia.
Dr Muhammad Yassin, an anaesthesiology Master trainee and Hartal Doktor Kontrak (HDK) spokesman, said warded patients in MOH hospitals are usually reviewed by doctors three times a day: morning (AM), afternoon or evening (PM), and night.
Specialist reviews for dengue patients are more frequent, like every four to six hours, as they can deteriorate very quickly.
“Obstetric patients in certain high-risk conditions like severe preeclampsia or massive postpartum haemorrhage also may need more frequent reviews,” Dr Muhammad told CodeBlue yesterday.
“Post-surgery patients like post neurosurgical, cardiothoracic, and vascular surgery also will need more than three reviews. For ICU (intensive care unit) patients, it’s more frequent – reviews can go up to every few hours, sometimes hourly reviews, depending on how critical the patients are.”
CodeBlue reported a November 1 guarantee letter (GL) by MediExpress (Malaysia) Sdn Bhd that imposed a blanket restriction on physician visits to a maximum of one per day for both surgical and non-surgical admissions, without specifying any exemptions.
A medical officer at an MOH hospital explained that most patients in general wards in government hospitals are reviewed at least twice a day.
If patients are acutely ill, they will be reviewed at least three times a day, for example patients who are in shock, severe sepsis, or severe exacerbation of asthma, among others.
“Other special conditions, such as dengue fever with warning signs in critical phase, will usually require blood-taking three to four times a day and to review the patients along with blood results three to four times a day,” the doctor in the MOH health service, who requested anonymity, told CodeBlue.
“This does not include extra reviews if the patient’s condition changes for the worse, or seeing the patient before (to see if the patient is fit for the upcoming operation) and after an operation (to see how the patient is doing after the operation, is there any bleeding, etc).
“Furthermore, when we do rounds in the morning, we will order investigations which we have to review later in the day when the results are out, for example a CT scan report and film.”
He explained that the types of patients reviewed by doctors only on a daily basis are “very stable” patients who are usually in step-down wards.
“An example is patients with an abscess which requires prolonged antibiotics, but are very stable and the infection is under control, hence the patient is there just to complete the entire duration of intravenous antibiotics,” said the MOH doctor.
“ICU and high-dependency ward patients usually will be reviewed at least three times a day.”
The medical officer added that specialists in government hospitals conduct patient reviews at least once a day; the rest are by MOs or house officers under the supervision of MOs.
“Specialists are kept in the loop if necessary. Acutely ill patients will usually be seen by specialists twice a day.”
Another senior medical officer similarly said public hospitals provide warded patients with unlimited doctor visits, unlike private hospitals that may face restrictions by payers like TPAs for insured patients.
“Ours no limit; we will review more often if the patient is more critical,” the government doctor told CodeBlue.
“If I see the patient is not critical, I’ll review once. If I see the patient and I think I need to review PM based on the severity, then I’ll review,” he said, adding that doctor visits can go up to four to five times a day in government hospitals.
The senior medical officer also said complex cases in MOH hospitals are sometimes referred to multiple specialties: “One same patient can be seen by a neurologist/ cardiologist/ nephrologist etc.”
Cardiothoracic Surgeons Stay With Patient The Entire Night In CICU
Dr Basheer Ahamed Abdul Kareem, a consultant cardiothoracic surgeon in the MOH who is former president of the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS), said doctor reviews for “very stable” patients in wards can be twice or thrice daily.
However, patients in the cardiac intensive care unit (CICU) following open heart surgery need to be reviewed “frequently”, with the frequency of doctor visits depending on the patient’s condition.
“For patients who are ill, bleeding, heart function not good, reviews may be every half hour – the doctor cannot go home,” Dr Basheer told CodeBlue based on his personal capacity.
“The worst case scenario – the surgeon needs to stay in the CICU and sleep there. Bear in mind, patients can have cardiac arrest anytime, necessitating emergency resuscitation and open chest procedures at any time, meaning the CICU also functions or is converted to a pseudo operating theatre anytime.”
The cardiothoracic surgeon stressed that all cardiac surgery patients post-operation have a risk of having their chest reopened anytime due to bleeding or other complications.
“Some big cases – aorta etc. – the chest may even be left open in the CICU while the patient gets better,” said Dr Basheer.
He added that he believes his private sector colleagues only charge for two visits, even if they manage their patients for an entire night in the CICU.
“The situation in the public sector may be better as surgeons work in teams, including registrars, anaesthetists etc., so the burden of monitoring may be shared,” said Dr Basheer.
On the other hand, surgeons in private hospitals are more like a “lone ranger”, forced to bear the sole burden of monitoring patients. Even if there’s some help from anaesthetists, “generally it’s intense and totally consultant-led,” said Dr Basheer.
However, Dr Basheer stressed that the workload in public hospitals is very high amid doctor shortages. The public sector, he said, also performs more highly complex cases.
The Value Of A Doctor’s ‘Hello, How Are You?’
CodeBlue’s Facebook post of the article on MediExpress’ restriction on doctor reviews generated a lively discussion in the comments section between doctors and people supporting insurance companies.
A woman, who claimed to be a nurse, alleged there were some “unscrupulous” doctors who visited patients twice or thrice a day, “just to say hello” without any clinical examination and charged their full consultation rates.
“Time for doctors to ask themselves- is it right for you to charge that much, when all you do is, go into patients room, say hello, ask how they are and maybe review the results of the investigation?”
In response, a plastic and reconstructive surgeon listed multiple findings that he could interpret from asking his patient a deceptively simple, “hello, how are you?”.
1. Able to respond- verbalising. Airway is patent. If his eyes is already opened thats a 4 on eye for GCS
2. Oriented response – that’s a 5 to verbal component to GCS. His cerebral perfusion is still intact.
3. We watch for limb movements while talking and score that too
4. His facial expressions. Pain score.
5. His response to the question. Decides our next course of action.
6. The pat on the back is reassurance and rapport that the physician is there for the patient. Builds trust and compliance to treatment.
7. ‘Maybe review investigations?’ We always review investigations. But that doesn’t happen in the room. It happens outside before or after the, ‘hello how are you.’
8. Not only investigations- we review the vital signs. We make sure medications are served.
9. We talk to the nurse to get their input and concerns.
10. Is his lying, sitting position optimal
“‘Hello, how are you?’ means a whole world to an experienced medical practitioner. You are paying for that experience and expertise,” said the surgeon in a post that received 91 likes.
A paediatrician participating in the comments section on CodeBlue’s page wrote that denying coverage for necessary reviews effectively discouraged doctors from proper follow-up, “putting patients’ safety at risk.”
Another doctor sarcastically posted: “Morning round stable, evening round code blue same patient. ‘Oh no, I am allowed to visit once per day, do you agree for another visit?’ Take consent while patient gasping air.”
Yet another paediatrician said she only charges two visits a day despite doing multiple rounds for ill patients. “This blanket rule is rubbish. Dengue cases can turn bad within hours.”
Deputy Finance Minister Lim Hui Ying told the Dewan Rakyat yesterday that insurers and takaful operators (ITOs) and TPAs had no power to “determine” patient care, but claimed that patients could simply pay out-of-pocket for treatment in private hospitals when hit with insurance denials.
In CodeBlue’s recent nationwide survey among 855 private specialists, 73 per cent said health insurance denials or delays forced their patients to switch to public hospitals.
In response to the poll, Bank Negara Malaysia warned ITOs and TPAs not to “direct” patient care, saying that ITOs assess medical claims based on accepted treatment protocols and clinical practice guidelines.
Yet, the latest directive from MediExpress limiting doctor reviews illustrates how insurance companies or payers fall short of the standard of care set by the MOH in at least one aspect of treatment.
