PRESIDENTIAL ADDRESS
Dr S T Arasu
(Delivered at the MMA Annual General Dinner at Penang on 13-4-74)

It is not often given to a General Practitioner to preside over the affairs of the Malaysian Medical Association, and as a General Practitioner myself, I deem it a signal honour to have been called upon to serve at the forefront among the eminent and worthy colleagues of my profession.

Definition of a General Practitioner
"The General Practitioner is a doctor who provides personal, primary and continuing medical care to individuals and families........ He accepts the responsibility for making an initial decision on every problem his patient may present to him, consulting with specialists when he thinks it appropriate to do so...... His diagnosis will be composed in physical, psychological and social terms. He will intervene educationally, preventively and therapeutically to promote his patient's health". This briefly outlines the modern concept of the General Practitioner or the Family Physician.

Not long ago, it was thought by some that, with increasing specialization in medicine, the General Practitioner would disappear from the medical scene altogether. But events have proved these pundits wrong. Indeed, as John Hunt says, there has been a renaissance of General Practice during the recent years.

The Need for the General Practitioner
It is because of, rather than in spite of, the ever-narrowing specialisms based on discrete organ systems in which the integrity (meaning the wholeness) of the individual tends to get lost that the need for a personal doctor has been felt. The patient needs the General Practitioner as his trusted guide in a maze of specialities and new forms of specialist treatment, many of them frightening and some of them dangerous.

In our country, about 40% of the doctors are in private practice which is predominantly General Practice. The government-run outpatient clinics treat about ten million patients in a year. It may not be an exaggeration to say that the General Practitioners of Malaysia treat an equal number, if not more. Therefore, although primary medical care has not achieved that degree of refinement here as obtained in a country like the U.K., the importance of the role of the General Practitioner in our present and future health services cannot be ignored or minimized. Any health scheme that fails to take into account the role of the General Practitioner services must, perforce, have a lacuna within it.

The Changing (Medical) Canvas and the Role of the General Practitioner
What is the role of the General Practitioner in our country? The kind of primary medical care service must be tailored as closely as possible to the health care needs of the community it is intended to serve. Our country is relatively a prosperous one and, thanks to the far-sighted policies of the government, we are increasingly becoming so; and Malaysia is on the threshold of industralization. Therefore, there may be similarities to draw from the experience in the more industrialised western communities. There, the pattern of illness, and hence the pattern of demand for medical care, has altered significantly int he past half-century. Essentially, the change has been that the major life-threatening infections are no longer a problem. Instead, the main hazard to health includes the survival of children with congenital or traumatic handicap; the chronic degenerative diseases such as coronary heart disease, chronic bronchitis and arthritic conditions in the middle years; and a prolongation of life so that chronic degenerative diseases in the elderly become multiple infirmities. All these conditions share one important characteristic, namely, that they cannot be cured but rather that their effects have to be lived with. One may treat a man who has had coronary thrombosis by admitting him to a coronary care unit and electrically starting his arrested heart; but, when he is discharged from hospital, he still has coronary heart disease which may substantially alter his lifestyle. If the pattern of illness alters in the way illustrated, then, it is the Primary Care Physicians, that is the General Practitioner, who will have to increasingly make his assessments in physical, behavioural and social terms. Such a pattern of illness postulates a medical care system in which the specialists and Primary Care Physicians must work alongside each other rather than in competition, since each is doing a different job.

True enough, we should in our country develop secondary medical care - that is cardiology, surgery and the like - at the district hospital level to deal with a specific problem. There is also a place for tertiary medical care, e.g. heart and kidney transplants, performed by super-specialists, perhaps at the national level. But, in developing these specialist fields, we cannot ignore the importance of Primary Medical Care - the concept of a "personal doctor" - for the first approach in episodes of illness of all kinds and for the continuity of care. And, while trying to raise the standard of hospital specialist care, we cannot afford not to raise the standard of Primary Medical Care pari passu.

Education Needs of the General Practitioner
The General Practitioner needs education, with the recognition that the Primary Care Physician of the future will need to be vocationally trained for the job, like the specialist in the other branches of medicine, rather than simply rely on his undergraduate teaching; and that eduation is a continuing process throughout one's professional career. What our General Practitioner could obtain so far, in the form of refresher courses, has been hospital-oriented medicine that may not be directly applicable to General Practice. The College of General Practitioners of Malaysia, I hope, will fill the gap by providing an educational programme that is relevant to General Practice.

Professional Standard and Medical Audit
The idea that doctors - not only General Practitioners, but also those in other specialties- shoudl have their competence to practise regularly tested (the so-called Medical Audit) is the burning issue in world medical circles. A satisfactory standard will only flow from a satisfactory educational framework, both at the undergraduate and postgraduate level.

The Handicap of the Malaysian General Practitioner
One of the handicaps with which our GP functions is that he does not have full and easy access to the diagnostic tools of modern medicine which are largely available at the government laboratories. Most of our patients can ill afford the investigations that may be necessary for the correct diagnosis of disease and its treatment. To be trained in the methods of modern medicine and then not to be able to use the simple tools of the trade is a severe disadvantage. It is a moot point whether in the interests of the sick, the government should not allow free and direct access to its laboratory and radiological facilities.

There are other problems that vex our GP. I wish to refer to the restriction by the government of the General Practitioner's privilege to medical certification to two days. To compel the General Practitioner to submit his patient to a government medical officer, who may be many years junior in knowledge and experience, for endorsement of the GP's certificate is to question the honesty or the clinical competence of the General Practitioner; it is nothing short of downright humiliation; guilty until declared innocent - and who is the judge?

It is perhaps a reflection of the stage of our development and moral standards that, while in the more developed countries, the GP would prefer to delegate the function of medical certification to his nurses, social workers and even lay person of appropriate standing, we in this country should be striving against bureaucracy to retain this function. It is a fact that in the U.K. even self-certification is allowed in many cases for a period of up to three days; it is also a fact that the midwife there certifies pregnancy for welfare benefits whereas, with us here, some of the over-zealous Directors of Education will not accept the certificate issued by the GP.

Absenteeism is a problem common to many societies. The doctor may find himself pressed to accommodate his professional values, his concept of health, disease and sick-role, and his criteria of what constitutes illness, to the demands of his patients and their employers.

The MMA believes that all doctors should be placed on a panel with freedom to unrestricted, but justifiable, certification. When abuse of this privilege on the part of a doctor is proved, then he, and he alone, should be penalised by exclusion from the panel altogether.

The Needs of the Society
In our society, like in any other developing society, an expectant public is emerging - "expectant of a fuller life with all the benefits and comforts associated with modern living, and particularly high amongst these greater expectations is the desire to achieve and maintain health during a long and useful life".

"The Charter of the World Health Organization states that health - a state of physical, mental and social well-being - should be regarded as a human and civic right".

But good medical care can be expensive and out of reach of the ordinary pocket. With the majority of our people being "have-nots", it is our duty to find ways and means of relieving the poor of the financial barrier to good medical care of their choice. For this reason, and because it is necessary to make the best use of available resources through planning, there must be increasing government involvement in the provision of medical services for our community. If a national organization of health service, would appear to solve our problem then we should not hesitate to explore the possibilities; and, if it is found to be suitable and related to our national characteristics and background, we should implement such a scheme. The Social Security Organisation (SOCSO) would appear to be a logical fore-runner to a nationally organised health service. I concede that this is an issue fraught with far-reaching implications and requires a careful study.

A few years ago, the MMA called upon the government to appoint a Commission of Health to study and plan the future needs of our health services. This proposal did not then receive the serious consideration that it deserved. The Garlick-Webb Assignment that was later appointed fell short of one's expectations because its terms of reference did not include General Practice which, as I pointed out earlier, 40% of our doctors practise.

Now that we have a sympathetic Minister for Health in the person of Tan Sri Lee Siok Yew, who is alive to the problems of both the public and the medical profession, I call upon the Honourable Minister and his Ministry to invite an expert in General Practice to study the present state and the future needs of the General Practice in Malaysia and to suggests ways and means as to how best our General Practice services may be improved and, if found necessary, integrated in a national scheme and utilized to the best interests of the nation. The Royal College of General Practitioners, the world's leading institution of its kind, is prepared to offer its services and expertise if so requested.

The GP's Attitude
The successful General Practitioner may be wary of a national health service and may not be keen to associate himself lock, stock and barrel with a government service. He has no cause for concern. It may be possible to devise such a framework within which he could retain his independence, only contracting his services to a national health organisation under terms and conditions that would have to be mutually satisfactory.

What the GP should do?
The development of an efficient medical care service will involve the proper housing and equipping of the doctor's clinic, supported by what is an appropriate clerical and para-medical nursing team, and organised in such a way that this functional unit performs smoothly. The future General Practitioner may not work in isolation but in groups so that skills may be shared and there could be continuity of service to the population. He may also have to function as a member of a health team comprising of the General Practitioner himself, the District Nurse, the District Midwife and the Health Education Nurse or their equivalents. For this, he will have to closely associate himself with the overall health services of the nation.

The Third Medical School
Given the shortage of doctors in the country, and the present necessity to recruit foreign doctors, the MMA welcomes the proposal of the Honourable Minister for Health, Tan Sri Lee Siok Yew, to establish a third medical school as timely and far-sighted. With its growing importance as the metropolis of North malaysia, with the Universiti Sains Malaysia and its School of Biological Sciences and School of Pharmaceutical Sciences as the nucleus - where the teaching already exists of many of the basic medical disciplines such as Physiology and Biophysics, Microbiology, Biochemistry, Parasitology, Histology, Pharmacology, Pharmaceutical Chemistry and Pharmacy - and with its well established hospital, Pulau Pinang would appear to be the logical choice as the site of the Third Medical School. This medical school could set a lead in this part of the world by establishing, among others, a Department of General Practice.

Doctors and Dispensing
Frequently, there is controversy in the press relating to medical matters. The latest issue was on who should dispense medicine - the doctor or the pharmacist? To claim that prescribing medicine to the sick by the doctor is a colonial trait is too frivolous to deserve comment.

With modern technique of factory-produced packed medicine, dispensing is no longer the complicated process that once it was and does not now call for expertise.

In changing the present system, I cannot see the advantage to the sick; in fact, any change will result in considerable inconvenience to the patient, having to seek a pharmacist after consulting a doctor. And, certainly he will have to foot a higher medical bill, having to pay for two separate services.

With all our goodwill towards the pharmacists, we doctors, surely, cannot relegate our responsibilities for our patients or surrender our right to dispense.