August 2013

Volume 1, Issue 2 THE INTERNIST

College of Physicians

Academy of Medicine

College of Physicians

Council 2012/2014

President

Prof Dato' Dr Aminuddin

Ahmad

Immediate Past President

Prof Dato' Dr Khalid Yusoff

Vice President

Prof Dr Rosmawati

Mohamed

Honorary Secretary

Dr Goh Kim Yen

Honorary Treasurer

Dr Chew Hon Nam

Council Members

Dato' Dr Abdul Razak

Mutallif

Dr Azmillah Rosman

Dr Letchuman Ramanathan

Dr Richard Lim Boon Leong

Dr Mohd Noh Idris

Dato' Dr S Nagappan

Prof Dr Roslina Manap

Dr Tan Soek Siam

Assoc Prof Dr Tengku

Saifudin

Contents: Editor’s Message Review of Medical Subspecialties in Malaysia Respiratory Medicine 6-7 Infectious Diseases 8-9 College Activities 2013 Medicolegal course 2 MRCP PACES 2-3 New members 9 Upcoming events 10 Psychiatry & Medicine Pseudodementia 4-5

Dear Members of the College of

Physician,

On behalf of our president and the college council I wish you all greetings and Selamat Hari Raya to all Muslim members! It gives me great pleasure to have the opportunity to write to all my esteemed fellow collegians on some of my thoughts and challenges as the editor of the Internist. I would like to thank our President Prof Dato Dr. Aminuddin Ahmad for allowing me this privilege in place of his President’s message. In this rapidly developing world we live in today, communication is the key to just about everything. It provides information, updates, brings people together, prepares us for the future and keeps us in touch with things that are relevant. When I started off as a newly elected council member and then appointed as editor for the Internist, it was indeed a daunting task as I was fairly new to the college. Initially I wondered how I would try to put the Internist together and what form it would take. My first few ideas were overzealous perhaps as the format seemed to mirror that of a medical journal. Later I realised that the newsletter should really be about communication. Communication for the members, about the members and by the members. I had therefore endeavoured to gather more contributions about college activities from college members. I am indeed pleased that in this issue there are a fair number of contributions from members of the college and I thank all of you for your support and welcome further contributions.

Message from the Editor’s Desk

In the past 1 year as a council member, amongst the issues most discussed seem to be about making the college more active and also relevant to physicians in Malaysia. At present we have a total of 477 members and 107 fellows in the College of Physicians. If I were to think about that, what would I see? Too few members? Too many inactive members? No, what I see is a significant pool of some of the greatest medical minds in the country and I would imagine that if we could all somehow come together and share our thoughts and experiences on medicine and healthcare in general we could really create something exciting and vibrant. Being one of the youngest members of the council, some cynics may say that the enthusiasm will die off eventually….however, it may also be said that the future lies in a good succession plan and new ideas that can energize and revitalise. So I would like to challenge each and every member of the college, junior or senior to put on your thinking caps and ask yourselves, “How can the college become more relevant and what can I suggest to bring about change?” Send in your thoughts and ideas, no matter if you think the idea is bad or good, Let us just start talking and sharing. We would love to just hear more from all of you. There are many of you who are doing wonderful things from your own individual platforms be it as a consultant or head of department of medicine training younger physicians, a young physician teaching medical officers how to pass the MRCP or a senior consultant giving weekend talks and running CME workshops. Let’s share about it

and get to know one another better. Share your challenges and dilemmas within your practice. Tell us about how rewarding it is to train juniors or perhaps the concerns you may have for the future of our young doctors. So I invite all members to feel free to use the Internist as a platform for expressing your views about medicine in Malaysia and make the college of physicians really work for you. Thank you once again for the opportunity to serve you as the editor and I look forward to your input.

Warmest regards,

Dr. Richard Lim

(If you would like to share something with the Internist, please email to theinternistcopm@gmail.com)

The INTERNIST Page 2 of 10

Medicolegal Course Kedah-Perlis 26th January 2013

This course was jointly organized by Hospital Sultanah Bahiyah Alor Star Medical Department and the College of Physicians Malaysia under Dato Dr. Muhammad Radzi B Abu Hassan who is the representative for Kedah/ Perlis. It was held as a half day course on the 26

th January

2013. The venue was the spacious auditorium of Hospital Sultanah Bahiyah Alor Star. We were privileged to have Dato Dr Zaki Morad B (Consultant Nephrologist) and Dato Dr ( Mr) Wan Khamizar (Colorectal surgeon ) as the speakers for this event. Both are highly respected clinicians

in their field besides having a wealth of experience in dealing with medicolegal issues. This gave them the edge when speaking on the topics presented during the course. The topics presented were : 1) Serious Professional

Misconduct : Meaning and Implications

2) Disciplinary Action by MMC : Why and the procedures Involved

3) Clinical risk management 4) Informed Consent This was followed by a question and answer session. The topics were enlightening and highly relevant to clinical practice. The course received good

response with over 300 registrants. The course participants included doctors from government tertiary hospitals, district hospitals and clinics in Kedah and Perlis. It was also attended by paramedical staff. We were also delighted with the participation of the AIMST University students and their lecturers and a number of private medical practitioners. Judging by requests from some participants to organize the course again at different locales, it can be concluded that it was a worthwhile and successful event.

COP Kedah-Perlis

Taiping Hospital has being organising MRCP mock exam since 2007. Initially, it was only a mock exam for candidates from Taiping and Ipoh with local examiners. Over the years, annual mock examination has grown to a stage where we take in 30 candidates for the mocks with up to 20 observers. These candidates now come from all over the country. Half of the examiners are the actual MRCP examiners. For the past 2 years, we have also included teaching component for all stations on day 1 of the two day course/mock exam. So far we have maintained 2 examiners per station. This is to allow candidates to have the actual feel of the exam and to get the feedback from 2 different examiners for the same station. Furthermore, one examiner will have more time to write comments while the other is actively examining the candidates. However, you may still carry out the mock exam with one examiner per station, having the advantage of lower cost. For the benefit of medical units which have not yet organised MRCP mock exam, we would encourage doing so because it has many advantages for the unit. Firstly, it prepares your own candidates for the exam. Because the date is set early, it propels them to start getting ready. On top of it, it encourages the younger medical officers to sit for part one. While they play the role

of time keepers, surrogates etc they could get a first hand view of the questions asked and answers given. When it is held annually without fail, it helps to attract medical officers to your unit. In the past 6 years, 11 people going through the medical unit of Taiping Hospital have passed the exam. For those who wish to start organising the course, it is advisable to go through College of Physician’s document on the core requirements of the real exam. Our local MRCP examiners usually will have a copy. We would like to highlight some points which may be useful to you, that we have learnt over the years: 1. The date setting is extremely important.

Setting it early is good but you may not be

able to foresee other factors. Recently, we

had our MRCP exam on the last week of

March. The trip back to KL after the exam

was jammed. We did not foresee that the

‘Cheng Beng ‘and ‘School holidays’ were

ending on the same day. The year before, a

youth festival was going on in Taiping at the

same period. That festival lead to a major

blackout in the hotel for the examiners. We

had to ferry the examiners to alternative

hotels in the wee hours of the night.

Dato’ Dr.(Mr) Wan Khamizar

Dato’ Dr. Zaki Morad

MRCP PACES MOCK EXAM:

The Taiping Hospital Experience 2007-2013 Dr Cheah Wee Kooi, Dr Albert Iruthiaraj, Dr Teng Kok Seng, Dr Goh Kee San, Dr Lai Ee Ling, Dr G R Letchuman, Hospital Taiping

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(cont. from page 2)

2. On whether to have the mock exam on a weekday

or weekend depends on your local setting. In our

hospital, we always have it on the weekend

because of space constraints. We always inform

our surgical colleagues’ months ahead as we use

their Day Care centre. This is to avoid surgeries

being scheduled on the event days. (On this point,

we are very grateful to our examiners who are

willing to come on weekends.)

3. Call potential examiners months ahead. Senior

consultants may have other commitments to

attend to and planning ahead ensures their

participation. Always be prepared with reserve

examiners as there will be last minute withdrawals

due to unpredictable circumstances.

4. Hotels have to be booked early for examiners’

accommodation.

5. Write to MMA for CME points.

6. A few weeks before the actual event, you will have

to keep in contact with the examiners. They have

to be informed of the stations they’ll be in. You will

need to send them the scenarios for them to look

through and give their feedback. The candidates

should also be given the timetable and the list of

hotels.

7. It is very necessary to involve other categories of

staff (nursing and Assistant Medical Officers) to

help you organise the event. They would be

needed as chaperones, to arrange food, register

candidates, transport patients and to get clinical

equipments.

8. It will be good idea to elect 1 Medical

Officer/specialist for each station to help you to

get the patients. One way to make this task easier

is to have a registry of cases with patients’ name,

contacts and their findings – something that would

be accumulated over the years. These doctors will

also be responsible for contacting the patients,

keeping in touch with them until the day of exam,

ensure patients’ payment, and preparing the

instructions for candidates for their respective

stations.

9. We usually have one CME event during lunch

break organised by a pharmaceutical company.

The reason for this is to bring the cost down.

10. Over the last 5 years, we have organised the

mocks under the College of Physician (Malaysia).

Hence all accounting matters are handled by the

college. The college issues the certificate of

attendance and participation which adds prestige

to the event. In the first year, the college did give

RM 2000 up front for us to organise. Over the

years, we have had some savings and this has

been returned.

11. There is usually little profit made from organising

this event and sometimes it could be a loss.

12. Few days before the event, you need to train the

surrogates (usually HOs) on how to act for

stations 2, 4 and 5. At the same time you need to

train the time keepers. The hospital security

needs to be informed about allocating parking

spots. Signs leading to the venue should be put

up. Certificates of participation and appreciation

are usually printed by the College much earlier.

Copies of calibration sheets, marks sheets and

case scenarios for the respective stations have to

be made.

13. One day before the event, the teams with their

respective leaders should be in place for the

following: Transport of examiners; Transport of

patients; Food and beverage; Registration +

issuance of certificates; Time keeping; Payment

for patients and examiners; Movement of the

clinical aids; beds; tables; chairs; screens. A

rehearsal of the time keeping is done to ensure

all understand their roles.

14. On the actual day, the biggest stress factor will

be whether the patients will arrive on time. You

would need to identify patients from wards as

back up. The cooperation of the on call doctors is

necessary to get suitable case. We usually keep

1-2 back up patients per station. The time

keeping is very important and should be handled

by someone who had gone through the exam

before.

15. There should someone assigned to welcome the

examiners and candidates and brief them on the

latest schedule; availability of refreshments; the

way to the toilets etc.

16. During the mock exam, the candidates who are

not in a particular cycle will be waiting. You can

arrange teaching sessions for them but will need

more teachers. Alternatively, as done in other

units, you can squeeze in a short feedback after

each cycle so that the candidates don’t have to

wait till the end.

17. We have always added social events like dinners

/ trips around our historical town of Taiping for

the examiners. We are indebted to them for

supporting us

______________________

Dr. GR Letchumanan, Head of Department of

Medicine, Hospital Taiping

“Organising MRCP Mock exams has many benefits to the medical department. It prepares your own candidates, encourages younger MOs to sit for part one and when it is held annually without fail, it helps to attract medical

officers to your unit .”

The following doctors led in organising the mock exams successfully in Hospital Taiping over the last few years: 2007 Dr Leong Weng Sam 2008 Dr Cheah Wee Kooi 2009 Dr Ang Chong Lip 2010 Dr Thong Kah Meng 2011 Dr Albert Iruthiaraj 2012 Dr Teng Kok Seng 2013 Dr Goh Kee San/ Dr Lai Ee Ling

The INTERNIST Page 4 of 10

The Pseudodementia Dilemma *Dr. Prem Kumar Chandrasekaran, ** Dr. Vincent Russell

Introduction Pseudodementia refers to a condition resembling organic dementia to which underlying physical disease makes little or no contribution. It describes a clinical picture characterised by a reversible dementia syndrome secondary to a primary psychiatric disorder. The concept has proved to be popular clinically although it is not classified as a diagnosis in either DSM-IV(TR) or ICD-10. Pseudodementia is clearly not a single nosological entity as was once thought but rather a syndrome of relative clinical consistency, reflecting multiple and diverse underlying psychiatric aetiologies. Since its origins in the 19

th century, research interest in it has

waxed and waned and opinions about its clinical utility have been divided. Following the revival of the term ‘pseudodementia’ in the 1960s, there have been further controversies surrounding its use of the term, ranging from affirmations that it is a distinct entity to speculations that it represents a harbinger of dementia. It has frequently been dismissed as redundant while some experts have urged its abandonment altogether. On the other hand, some researchers had endeavoured to validate the clinical utility of the term ‘pseudodementia’ and met with success. It is interesting to retrospectively examine how ideas related to initial observations have carved a path towards our current understanding and approach to this condition manifestation – depressive pseudodementia. Despite many advances in the fast-developing field of neuropsychiatry, countless errors and post-hoc changes makes this subtype worthy of special consideration. However, we shall not neglect the impact of the other phenomena that have also been described under the broad heading of pseudodementia, namely hysterical pseudodementia, Ganser’s syndrome and simulated dementia. Finally, differentiating this condition from bipolar illness and schizophrenia is also worthy of mention.

1. Depressive Pseudodementia (DPD)

Some patients with depression do not exhibit hallmarks

symptoms of depression. Some signs and symptoms like

psychomotor retardation, anhedonia, laboured thinking, slipshod

behavior, failing to register events, faulty orientation and loss of

recent memory should alert clinician to possibility of this

category of pseudodementia. The 1961 publication by Kiloh

entitled “Pseudo-dementia” revived this concept from a

previously obscure and ambiguous position somewhere

between hysteria and malingering. He described the above set

of symptoms with additionally self-neglect and loss of weight

while Post (1965) added those symptoms to observations of

tremulous elderly patients with shuffling gait. Kiloh urged that

the possibility of depression be considered before diagnosing all

cases of dementia and his paper had a major impact, leading to

a surge of interest in what came to be referred to as DPD in the

period between the 1960s and 1980s. Several more follow-up

studies supported his argument for examining all patients for

potentially reversible causes of apparent dementia.

Nevertheless, Folstein & McHugh (1978) claimed both dementia

and depression interact together and that the term

‘pseudodementia’ was a misnomer as cognitive deficits resolve

when the depression resolves. Thus they suggested the term

‘dementia syndrome of depression’. This brings us to the

question, “Could depression then be a reaction to cognitive

impairment in dementia?” Reifler et al (1982) felt that was so

but only in mild and early cases of dementia. By the 1980s,

doubts were being cast upon the claimed reversibility of

pseudodementia, based on longer follow-up periods in

outcome studies. Several subsequent studies found that if

followed for long enough periods, many patients whose

cognitive deficits had initially appeared to have been

reversed by psychiatric treatments went on to fulfill

diagnostic criteria for dementia. A more recent meta-analysis

carried out by Ownby et al (2006) found that depression was

associated with a doubling of the risk for subsequent

dementia. Finally, Korczyn & Halperin (2009) rationalized

that since depression and dementia are both common in old

age and frequently occur together, white matter changes

both in Alzheimer’s Disease (AD) and in depression result

from vascular changes, supporting the concept of ‘vascular

depression’.

Small et al (1981) had proposed differentiating dementia from DPD as in table 1. Rabins et al (1984) found that treatment of depression improved MMSE scores with a rise to normal scores two years later in their ‘depressed/demented’ group. Post (1965) and Burgeois et al (1970) found that ECT was especially effective in this group, a consistent finding most recently echoed by Rapinesi et al (2013). In an article commemorating the 50

th anniversary of Kiloh’s classic paper,

Snowden (2011) points out that the concept of pseudodementia may be worth retaining even insofar as the cognitive deficits in depressive pseudodementia may be at least temporally reversed and true dementia postponed as a result of active treatment.

2. Ganser’s Syndrome

This was first described by Ganser in 1897. Frequently, the focus is on the classic symptoms of ‘vorbeireden’ or approximate answers or answering past the point, which Scott (1965) described as Ganser’s symptom and which is commoner than the syndrome itself. However, this has led to other features being overlooked, for example prominent hallucinatory experiences (pseudohallucinations), hysterical stigmata and fluctuating disturbance in consciousness. Resolution is abrupt with complete and sometimes, residual amnesia (‘hysterical twilight state’) for the brief duration of the illness, which Ganser (1898) himself believed was central to the presentation. The apparent dementia that accompanies approximate answers in Ganser’s syndrome is usually incomplete, inconsistent and self-contradictory. These patients are able to adapt to demands of daily life which those with organic dementia cannot. Motor behavior ranges from dazed stupor to histrionic outbursts of excitement. Mood ranges from apathetic indifference to anxious bewilderment. Whitlock (1967) called it the ‘buffonery syndrome of schizophrenia’ from the associated confabulation and childish, playful attitude. The change in consciousness, as well as the conversion symptoms, was proof that this is a hysterical syndrome and not just simple malingering. (cont pg. 5)

*Penang Adventist Hospital premkumar@pah.com.my ** Penang Medical College vincent@pmc.edu.my

“ Pseudodementia refers to a condition resembling organic dementia to which underlying physical disease makes little or no contribution.

It describes a clinical picture

characterised by a reversible dementia syndrome secondary

to a primary psychiatric disorder.”

The INTERNIST Page 5 of 10

Table 1: Differentiating dementia from DPD (Small et al 1981)

The change in consciousness, as well as the conversion symptoms, was proof that this is a hysterical syndrome and not just simple malingering .Thus it has been grouped under dissociative disorders in the DSM-IV (as well as in the TR version) and under other dissociative (conversion) disorders in ICD-10. Ganser’s syndrome can occur during the course of a depressive illness, head injury, early dementia, alcoholism and other toxic states and purely as a response to emotional trauma. It is felt that organic and psychogenic factors operate together here. The concept of gain had led to the term ‘prison psychosis’ and although malingering can be suspected, of note is that patients do not provide spontaneous absurd remarks, merely answers to questions they were asked.

3. Hysterical Pseudodementia

Mechanisms of hysterical dissociation may operate to some degree in pseudodementia. Conversion pseudodementia in older people is felt to be caused by a catastrophic reaction to cumulative loss in later life in individuals with predisposing borderline and narcissistic traits. Hepple (2004), reminiscing Wernicke’s 1906 original conceptualization, refocused attention on the possible psychological basis on patients with pseudodementia. He contended that the syndrome is more common in women from a higher socio-economic background with past psychiatric histories dominated by depressive symptoms. The core features are apparent cognitive impairment, regression and increasing physical dependency. Other symptoms could include the classical sensory loss, paralysis and ‘belle indifferance’ of conversion. There can be fatuous cheerfulness or sullen apathy and in severe cases, hysterical puerilism, infantilism and amnesia. There appeared to be no response, in Hepple’s case series, to various treatments for depression. The prognosis was considered poor. Treatment using psychotherapeutic approaches may limit the progression of the syndrome if recognised at an early stage. The role of abreaction and sleep deprivation was described by Patrick & Hommels (1990), who conversely found that confusion was exacerbated with those modalities in patients having organic dementia. 4. Simulated Dementia

In this subtype, memory loss appears to be an isolated main symptom. There could also be mutism and lack of cooperation. Anderson et al (1989) found that it was not possible to convincingly feign dementia – with repeated efforts, fatigue sets in and a ‘pull on reality’ would be experienced. Hunt (1973) used the MMPI to distinguish a malingerer from one with organic dementia as the series of questions were designed to weed out inconsistencies and a malingerer would get anxious and upset when slips were pointed out, as observed by Kraupl-Taylor (1966). A point in differentiating those simulating dementia is that they would appear to be more ‘superficial’ than patients with Ganser’s syndrome. There will be an increase in conscious malingering and the course of the disorder is longer and relapsing. There will also be an absence of melancholia present in DPD. Other Considerations Sometimes, functional disorders have dementia-like symptoms and in hypomania, distractibility and random answers can mimic disorientation and failing memory; playfulness could lead to false replies. Carney (1983) observed that manic overactivity can be mistaken for agitation. In schizophrenia, poverty of ideas, emotional blunting and an unkempt state may suggest dementia. Confusing the clinical picture is the presence of late paraphrenia (Roth, 1981) and demonstration of the presence of mild cognitive disorder and enlargement of ventricles (Naquib & Levy, 1987).

Final remarks Pseudodementia would seem to represent a term which is impossible to adopt uncritically but which equally should not be discarded completely as a potentially useful theoretical and clinical construct. The likelihood is that it will continue to pose a dilemma to present day clinicians, researchers and medical educators. Notwithstanding the considerable evidence that most patients with pseudodementia have a latent tendency to progress to dementia, our own conclusions are that there is merit in retaining the concept as a descriptive term, particularly in relation to the phenomenon of depressive pseudodementia. Depression remains as a common, treatable condition that is all too often underdiagnosed and untreated. This is more likely when it presents with co-morbid medical conditions in older patients. Recent studies have drawn attention to the fact that depression may be inappropriately labeled as ‘understandable’ in such patients – both by patients and clinicians. The reality is that most older people, even those with major medical co-morbidity, are not clinically depressed and when they are, depression should never be ignored as they do require and respond to treatment. If we add the cognitive impairment to the clinical picture in these patients, it increases the risk of ‘normalising’ their depressive symptoms and missing treatment opportunities that could greatly improve the medical outcome and quality of life. References 1. Kiloh LG. Pseudo-dementia. Acta Psychiatrica Scandinavia 1961; 37; 336-51. Lishman WA: Organic psychiatry - the psychological consequences of cerebral disorder (3

rd edition). Blackwell Science, 1998.

2. Ownby RL et al. Depression and risk of alzheimer’s diseasae: systematic review, meta-analysis and meta-regression analysis. Archives of General Psychiatry 2006, 63: 530-8. 3. Rapinesi et al. Depressive pseudodementia in the elderly: effectiveness of electroconvulsive therapy. International Journal of Geriatric Psychiatry 2013; 28: 433-40. 4. Snowdon J. Pseudodementia, a term for its time: the impact of Leslie Kiloh’s 1961 paper. Australasian Psychiatry 2011; 0: 391-7.

Characteristics Dementia DPD

History

Precise Onset Unusual Usual

Duration of symptoms Long Short

Rapid symptom progression Unusual Usual

Complaints of cognitive loss Variable (minimized in later stages)

Emphasised

Description of cognitive loss Vague Detailed

Family awareness of dysfunction and severity

Variable (usual in later stages)

Usual

Loss of social skills Late Early

Psychopathology history Uncommon Common

Examination

Memory loss for recent vs. remote events

Greater About equal

Specific memory loss (‘patchy’ deficits)

Uncommon Common

Attention and concentration Often poor Often good

‘Don’t know’ answers Uncommon Common

‘Near miss’ answers Variable (common in later stages)

Uncommon

Performance on tasks of similar difficulty

Consistent Variable

Emotional reaction to symptoms

Variable (unconcerned/shallow in later stages)

Great distress

Affect Labile, blunted or depressed Depressed

Efforts in task performance Great Small

Efforts to cope with dysfunction

Maximal Minimal

The INTERNIST Page 6 of 10 .

State Private MOH University Total

Johor 2 1 3

Kedah 1 3 1 5

Melaka 1 1

Kelantan 1 2 3

Negeri

Sembilan

1 1

Pahang 4 4

Perak 3 2 5

Perlis 0

Penang 6 3 1 10

Sabah 1 1

Sarawak 2 2

Selangor 10 1 4 15

WP (KL) 15 5 7 27

Terengganu 2 2

Total 42 22 17 79

Introduction

Respiratory Medicine involves the care of patients with all forms of respiratory disease. The scope is interesting and wide and the conditions treated are diverse: some are very common and some rare. Respiratory Medicine physicians are specially trained in diseases of the chest such as asthma, tuberculosis, chronic obstructive pulmonary disease (COPD), lung cancer, respiratory infections, sleep apnoea and interstitial lung disease. This branch of internal medicine is also referred to as Pulmonology and Chest Medicine. There are close links between the specialty and radiology, infectious disease specialists and thoracic surgery.

Historically, at the time of Malaysia’s independence, the few pioneer respiratory physicians were concerned mainly with combating tuberculosis, the number one cause of death during the 1940s and 1950s. With the advent of the National Tuberculosis Control Programme in 1960 there was an initial rapid decline in the incidence of tuberculosis followed by a plateau.

Review of Respiratory Medicine in Malaysia M. Abdul Razak, LN Hooi, CK Liam

The National Tuberculosis Centre in Kuala Lumpur

functioned as the headquarters of the National Tuberculosis Control Programme and the state general hospitals with their chest clinics functioned as the state directorates.

In the 1980s and 1990s the scope of respiratory medicine services expanded to include diseases "other than tuberculosis, and in 1996 the National Tuberculosis Centre was renamed Institute of Respiratory Medicine.

The specialist society for Respiratory Medicine, Malaysian Thoracic Society, was formed in 1986.

Current status of the specialty The table below shows the estimated number of working respiratory physicians in Malaysia. The sources of data are the specialist census of Ministry of Health, National Specialist Register and Malaysian Thoracic Society membership database. There is a relative concentration of respiratory physicians in Wilayah Persekutuan Kuala Lumpur and Selangor and a noticeable shortage in the East Malaysian states of Sabah and Sarawak as well as in smaller states such as Perlis, Melaka and Negeri Sembilan.

Training Structure Respiratory physicians are physicians who after their first medical degree (MBBS or equivalent) complete training in internal medicine, followed by at least three additional years of subspecialty fellowship training. After satisfactorily completing subspecialty training in Respiratory Medicine, the physician must pass a formal exit examination before being certified as a respiratory physician. Components of the training include out-patient clinic posting, in-patient care, intensive care exposure (at least for 3 months), flexible bronchoscopic procedures, other specialised respiratory procedures, lectures, tutorials, seminars and clinical meetings, research, teaching, tuberculosis control and pulmonary rehabilitation. The exit assessment includes a viva voce comprising acute respiratory emergencies, respiratory procedures, controversial issues in management of respiratory diseases and interpretation of data / slides / chest radiographs / CT scan images, as well as documentary review of the training log book, free paper presentations at scientific meeting(s) / publications and confidential report(s) by the trainer(s).

(Continued on page 4)

“The scope of respiratory medicine is interesting and wide and the conditions treated are diverse. …There are close links to radiology, infectious disease and thoracic surgery. ”

The INTERNIST Page 7 of 10

… continued Specialist register criteria A doctor can apply to be credentialed as a Respiratory Physician if he/she fulfils ALL the following requirements:

1. A basic medical degree registrable with the Malaysian Medical Council.

2. A recognised postgraduate qualification in Internal Medicine such as Master of Medicine from UM, UKM and USM, MRCP, FRACP or an equivalent qualification registrable with the National Specialist Register.

3. Satisfactorily completed the duration of formal training in Respiratory Medicine as stipulated by the Specialty Subcommittee (SSC) of Respiratory Medicine.

Needs & Vision

The respiratory fraternity aims to increase

access to specialist respiratory care services,

as well as improve quality of care in

Respiratory Medicine. Respiratory physicians

have been at the forefront in the development

“In the meantime, the old enemy, tuberculosis has reared its head once again with a rise in cases to over 22,000 in 2012. ” “…respiratory physicians must reassert a leadership role and be at the forefront once again in tuberculosis control.”

of clinical practice guidelines (CPG) on the

management of respiratory diseases including

asthma, COPD, tuberculosis and pulmonary

arterial hypertension and should continue to

develop benchmarks for the common

respiratory illnesses.

Some respiratory units already provide

highly specialised services, such as for lung

transplant and sleep-related medical

problems.

There has been a recent surge of interest in

Interventional Pulmonology leading to a flurry

of educational and training activities in this

area. In the meantime, the old enemy,

tuberculosis, has reared its head once again

with a rise in the number of cases to over

22,000 in 2012. Amongst all the activity to

achieve progress in more sophisticated

services, respiratory physicians must reassert

a leadership role and be at the forefront once

again in tuberculosis control.

Pusat Tibi Negara then (Lt) and Institut Perubatan Respiratori today (Rt)

The INTERNIST Page 8 of 10

Introduction Throughout the history of medicine, the treatment and prevention of infections have always been closely linked to mainstream medical practice, thus it can be argued that every physician in the past was an infectious disease (ID) physician. However the mortality and morbidity of infectious diseases slowly started to wane with the advent of antibiotics, vaccinations and improved hygiene and health awareness. Health care resources and most doctors then gradually turned their attentions to non-communicable diseases. The field of infectious disease has however undergone resurgence in the last few decades. Factors that contribute to this include the appearance of newly recognized infectious disease syndromes; emergence of novel and reemergence of older microbes, some exhibiting resistance against previous treatment; advances in microbiology, immunology and epidemiology; the advent of more effective therapeutic and preventive agents; newer medical interventions that breach the body’s natural defences or bring about a state of immunosuppression and the general thrust toward specialization. ID is a relatively new sub-speciality in Malaysia. It started out in the early 1990’s in Hospital Kuala Lumpur with Dr Christopher Lee managing patients with HIV. HIV then was a new disease which then spelled certain mortality and one that provoked strong sentiments even among the medical fraternity. It became clear that adequate HIV care would require doctors to be specifically trained in this field to handle the complexities of the illness. As the era of highly active anti-retroviral therapy (HAART) begin to dawn by the late 1990’s, the challenge of treating HIV became more demanding albeit much more rewarding. It was during this time that ID started attracting more doctors into its fold.

Review of Infectious Diseases Subspecialty in Malaysia Dato’ Dr. Christopher Lee , Dr. Benedict Sim

“HIV care, with close to 100,000 people

known to be infected in our country, still

remains the bread and butter of the ID doctor

in Malaysia. Apart from the clinical care,

ID physicians are involved in managing

the often complex psycho-social aspects of

patients living with HIV and helping their families cope with the

stigma of being infected or affected by

HIV”

Scope With the growing number of specialists, the scope of ID increased tremendously over the next few years. HIV care however, with close to 100,000 people known to be infected in our country, still remains the bread and butter of the ID doctor in Malaysia. Apart from the clinical care, ID physicians are involved in managing the often complex psycho-social aspects of patients living with HIV and helping their families cope with the stigma of being infected or affected by HIV. To do this effectively, we work closely with paramedics, pharmacists, non-governmental organisations, pharmaceutical industries and other government agencies to facilitate improve access to care and treatment. Our work also brings us into the area of addiction medicine where we promote risk reduction and preventive measures to reduce the spread of HIV. Apart from HIV, another exciting part of ID is being called upon to lend expertise in diagnosing patients across a range of clinical presentations beyond the scope of a general physician. These are categorized into whether the suspected infection is localised or systemic, nosocomial or healthcare associated, gathering epidemiological clues from the patient, considering the patients underlying immune status, the possibility of other medical conditions mimicking infections and the pros and cons of specific therapeutic trails. The ID doctor would need to juggle the range of diagnostic tests available to him being aware of the limitations and costs of tests involved and would need to work closely with microbiologists, pathologists and radiologists to achieve this end. The next broad area of coverage in ID is managing and preventing nosocomial infections, usually involving multi-resistant organisms. This aspect of our work cuts across different specialities in a hospital

as these infections are among patients needing intensive care, post surgery, post prostheses and device implantations and in the immune-compromised and immunosuppressed hosts. The ID community often leads the fight against antimicrobial resistance in the hospitals and community. Thus we are tasked with initiating, advising and implementing antimicrobial stewardship and control programs in both hospitals as well as in the community to minimize the impact and magnitude of inappropriate antimicrobial usage. The other key aspect of reducing the spread of antimicrobial resistance is proper infection control practices especially in hospitals and in particular areas with critically ill patients. Often leading infection control committees together with microbiologists and infection control practitioners, ID are involved in producing and implementing guidelines for hand hygiene adherence, isolation precautions, transmission based precautions and guidelines on antibiotic treatment and prophylaxis. Treating tropical diseases like dengue, meliodosis, lepto-spirosis, malaria and other emerging or re-emerging diseases form another aspect of ID that is exciting and challenging. The field also has its fair share of rare and “exotic” diseases that sporadically arise. The threat and the emergence of epidemics and pandemics of influenza and other respiratory viruses constantly keep us on our toes. Thus, working in ID allows us the opportunity to work closely with public health physicians, state and national health administrators and epidemiologists. Currently we also jointly managed infections like TB, sexually transmitted infections and viral hepatitis with other subspecialties.

The INTERNIST Page 9 of 10

In the area of preventive medicine for infections, advocacy with vaccine interest groups is also part of the brief of an ID physician. Another area that is developing in ID is the field of travel medicine and infections in the returning traveller. Finally, the scope of ID also includes work on prevention and management of needle stick injuries in hospitals, in particular, providing counselling and if needed, post exposure prophylaxis for health care workers exposed to contaminated sharps during work. ID is a rapidly expanding field in medicine with many emerging and re-emerging infections and newer understanding of infections and novel modes of therapy. Thus we are closely linked to clinical research and advocacy. Teaching is an integral part of our job and we reach out to multiple layers of doctors (medical student level to subspecialty care), paramedics, pharmacists, public health personnel and even patient groups. Current status The current number of ID physicians in the country number 19 that are fully trained; 3 still in training and around 10 in private practice and universities (some fully trained, others still in training). Training structure Eligibility for training:

I. A recognized basic medical degree

recognized by Malaysian Medical

Council

II. Must have been gazetted as a clinical

specialist in the Ministry of Health

(MOH) of Malaysia

The College of Physicians of Malaysia warmly welcomes the following new members and

congratulates our most recent fellows:

Fellowship

Datuk Dr. Muhammad Radzi bin Abu Hassan

Membership

Dr. Ahmad Izuanuddin bin Ismail Dr. Rafiza bt Shaharudin

Dr. Bahariah bt Khalid Dr. Ruzita bt Jamaluddin

Dr. Chiew Kean Shyong Dr. Shivanan Thiagarajah

Dr Giri Shan Rajahram Dr. Sazzli Shahlan bin Kasim

Dr. Hafizah bt Zainuddin Dr. Ooi Boon Han

Dr. Ho Khek Choong Dr Tie Siew Teck

Dr. Kiew Kuang Kiat

Dr. Leong Chong Men

Dr Mazlin bt Mohd Baseri

Dr. Ngiu Chai Soon

New Membership and Fellowship to COPM

OR Appointed as a clinical specialist in a uni-versity department of Medicine recognized by Ministry of Higher Education (MOE) . OR Any other equivalent medical postgraduate degree recognized by Malaysian Medical Speciality Board on case by case basis.

Training and Supervision:

i. Completion of minimum of three (3)

years of training of which 9 -12 months of

training is preferably done in a

recognised overseas infectious disease

centre.

ii. Trainee is expected to spend a minimum

of 12 weeks (full- time) or 24 weeks

(part-time) doing lab work and infection

control activities.

Needs and vision As listed above, the field of ID is very vast, spans across many disciplines and is ever enlarging in its scope and influence. Our vision in Ministry of Health is to have at least one ID physician in every hospital with specialists, at least two for every state hospital and more for regional centres like Klang Valley, Penang, Johor, Kota Bahru, KK, Kuching. Thus there is still ample room for ID to grow in our country.

“The threat and the emergence of epidemics and

pandemics of influenza and other respiratory

viruses constantly keep us on our toes. Thus, working

in ID allows us the opportunity to work closely

with public health physicians, state and

national health administrators and epidemiologists.”

Call for

articles

Johor Dr. Hooi Lai Seong Head, Department of Medicine & Haemodialysis Unit, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, 80100 Johor Bahru, Johor Kedah/Perlis Dato’ Dr Muhammad Radzi Abu Hassan Department of Medicine Hospital Sultanah Bahiyah Alor Setar, Kedah Kelantan Dato’ Dr. Rosemi Salleh Department of Medicine Hospital Raja Perempuan Zainab II Kota Bharu Kelantan

Date Event Venue

13-15.9.13 COPM Annual Scientific Meeting UiTM Campus, Sungai Buloh

14.9.13 COPM strategic planning meeting UiTM Campus, Sungai Buloh

21.9.13 Medical Update – Johor state branch M Suites Hotel, Johor Bahru

30.10.13 Hot Topics in Medicine – Kelantan state

branch

Perdana Hotel, Kota Bharu

Nov 2013 Saturday teach in – Neurology Academy of Medicine, Kuala Lumpur

Dec 2013 Saturday teach in – Emergency Med Academy of Medicine, Kuala Lumpur

Upcoming College of Physicians Events

The Internist invites

all members to

contribute articles

on current

updates,

interesting events

and educational

materials on

clinical medicine.

Please send all

articles to:

theinternistcopm@

gmail.com

College of Physicians, State Representatives

UPDATE ON INFECTIOUS DISEASES

Dengue update

Sexually transmitted diseases – old

disease in the new era

Common skin infections in the

primary care clinic

Febrile neutropenia – issues and

management

HIV – approach to management

MRSA infection – prevention and

therapy

Rheumatic fever – A disease in the

past?

Mellioidosis – an emerging problem

Emerging viral infections

Meningococcal meningitis

Infective endocarditis update

Tuberculosis – pitfalls and

challenges

Travel medicine – what we need to

know

MDR-TB

Septic Arthritis – update on

management

Negeri Sembilan Dr. Yong Kam Leng C/o Yong’s Specialist Clinic 8 Jalan Tuanku Munawir 70000 Seremban Negri Sembilan Perak Dr. GR Letchumanan c/o Department of Medicine Hospital Taiping Taiping Perak Penang Dato’ Dr. Chong Keat Fong c/o Island Hospital 308 Macalister Road 10450 Penang Pahang Dr. Yew Kuan Leong

Terengganu Dr. Norhaya Mohd Razali Physicians Clinic Department of Medicine Hospital Kuala Terengganu Jalan Sultan Mahmud 20000 Kuala Terengganu Terengganu Sabah Datuk Dr. Jayaram Menon c/o Department of Medicine Hospital Queen Elizabeth Kota Kinabalu Sabah Sarawak Dr. Bryan Tie Siew Teck Department of Medicine Hospital Umum Sarawak Jalan Tun Ahmad Zaidi Adruce 93586 Kuching Sarawak

13th – 15th September

2013

Register online at:

www.acadmed.org.my