JILID 5 BIL 4 NOVEMBER 2003

JILID 5 BIL 4 NOVEMBER 2003
Newsletter of the Malaysian Society of Anaesthesiologists and the College of Anaesthesiologists,
Academy of Medicine of Malaysia

Table of Contents

• We are not short of activities...
• When can Anaesthetists say no to Surgery
• Conferral of Honorary Membership on Dato' Dr Lim Say Wan by the MSA
• History of Anaethesia - Help Needed Please
• Write In
• Calendar of Events
• Snapshots of the 15th ACA Surabaya
• Maintenance of Professional Standards (MOPS)

Click here to Download Berita Anestesiologi in PDF Format (5.68 MB)

We are not short of activities...
PROF Y K CHAN
President, Malaysian Society of Anaesthesiologists

In the last 2 months, members of the society were treated to such a vast array of activities that it was difficult for some of us to keep up, much less be present in all of them. There were activities to cater to our varying needs - the need to learn and update, the need to publicize and interact with the public, the need to socialize and of course the need to honor someone has done wonderful things for the society.

We started off celebrating Anaesthesia Day on 15 October 2003, one day in advance of the usual day (16 October) to allow the public to get insights into our daily lives and our roles in society. By rotation, the main part of the event was held in Johor Bahru under the able leadership of Datuk Dr Subrahmanyan Balan and Dr Tan Cheng Cheng.

Most of us were aware that whilst the Intensive care meeting was underway in Kuala Lumpur from the 17 to 19 of October, the Asean Congress of Anaesthesiologists was held in Surabaya from the 14 to the 19 October. The coincidence was due to the fact that we were forced by the SARS epidemic in May to reschedule our intensive care meeting and had limited alternative dates after that to hold the meeting in The Legend Hotel. This split the crowd a bit but it did make us realize that the Society has matured enough to be able to cope with more than one activity at the same time!

This was followed very soon after by the Asian Oceanic Society of Regional Anesthesia (AOSRA) and Pain Medicine in Bangkok where a fair number of us participated from the 5 to 8 November.

In both the Intensive care meeting and the AOSRA meeting, Datuk Dr Lim Say Wan was honoured for the immense contributions he has made not only to the Malaysian Society of Anaesthesiologists / College of Anaesthesiologists but to the Societies of Anaesthesiologists in the region and also the world.

For those who had missed the recent spate of events, there are more to come. In December, we are going to have a 2-day event on Respiratory Therapy in Kuala Lumpur. This promises to be a very special meeting as it is going to be a possible forerunner to the introduction of respiratory therapy as a speciality in the country.

The Society has seen it fit to come together again to discuss the issue of pain management and it will be our theme for our AGM meeting in late March 2004. So if you feel pain medicine has developed beyond your comprehension, do make time to come and spend the AGM weekend with us and get the latest developments from the experts.

A few very active members of the Society are already making plans to join in the activities of the World Congress which will be held in April next year in Paris. The Society promises to support all participants who are going to present papers in the World Congress. In anticipation of more of you wanting to take part and to know the rules behind the financial support from the Society, our far-sighted editor, Dr K P Ng, has included it in our previous bulletin!

The Society hopes more will come to the fore to join the rest who already realize the amount of gain to be had participating actively in the activities of the Society. There is a lot of potential in the Society - some lying dormant and waiting to be tapped, others are already in full display. We hope that by sharing with you closely, the activities that others in the Society have been involved with, in the recent two months you will be encouraged to give your all to the Society to allow it to realize its full potential. We are definitely not short of activities, we are sometimes short of participants!

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When can Anaesthetists say no to Surgery
by Dato' Dr K Inbasegaran

Introduction

The relationship between anaesthetists and surgeons represent a very interesting model of teamwork. Both need each other for their existence and the optimal output from each often results in good patient outcomes. This relationship in the operating room as well as in the intensive care has evolved over time. In the early days the surgeon was often the unchallenged captain of the ship as those administering the anaesthesia were of lower ranking staff such as medical assistants or nurses, or worse still, attendants. The establishment of anaesthesiology as a medical specialty with its own training and standards as well as obvious improvements in care changed all that and today we are acknowledged as independent specialists with an invaluable contribution to perioperative care. There is absolutely no doubt that most of our surgical colleagues recognize us as equals who do contribute significantly to their patients' outcome.

However, all of us have heard of, or personally experienced, surgeons wanting to operate on a particular case despite the anaesthetist's reluctance for a host of reasons. There are also the pushy surgeons who want things their own way, from determining time of surgery to the type of anaesthesia that should be given. I have heard of surgeons who, in total exasperation, have stated that the best anaesthetist in their view is one who keeps quiet and the patient quiet as well. I have also noticed in general, that often there are professional relationship problems, where on occasion, both the surgeon and the anaesthetist have an excellent bond between them and at other times, they may not even be on talking terms!

In this article, I wish to explore the circumstances in which the anaesthetist can actually say no' to surgery. This is a very complex and contentious issue as it covers several aspects such as duty of care, obligation to the institution, payment arrangements (so essential in private practice), and standards of practice and sometimes the cultural and religious values of the attending anaesthetist. We have to ensure that our patients do indeed get the best treatment as guided by best practice, and at the same time maintain high ethical standards. Our obligation to the institutions we practice in as well as to our surgical colleagues are important, but should never compromise our duty to our patients.

The non-optimized patient - Data from the National Perioperative Mortality Review (POMR), an ongoing audit in the Ministry of Health hospitals, show that in the surgically related causes of death, the most common is inadequate preparation or optimization of patients before surgery. Although the data is a little skewed towards emergency surgery, (emergency surgery consists of 60% to 70% of our public hospital surgical workload), this is applicable to elective surgery as well. In the National Confidential Enquiry of Perioperative Deaths or NCEPOD in the UK, it was also shown that poor optimization, particularly in the elderly, is a major factor contributing to avoidable deaths. In elective cases there is good evidence that adequate control of preoperative hypertension and diabetes, two very common co-morbidities in our population, reduces the incidence of postoperative adverse events, just as the adequate treatment of ischaemic heart disease does. I think it is important sometimes to educate our surgical colleagues that the preoperative optimization of medical problems does actually produce better patient outcomes. From the POMR audit, we have clearly been shown that many of the patients who were rushed into surgery without appropriate preoperative assessment and optimization, often succumbed postoperatively. How much of optimization is necessary for high-risk surgery is again subject to debate, there being some evidence that too much optimization may not make much difference in patient outcomes. There has to be some effective communication with surgeons, to convince them that postponement is in the best interests of the patient.

Personal, moral or religious convictions - In Malaysia abortion and termination of pregnancy are considered illegal, although the law allows it in situations where the pregnant women's health may be at risk in any way; a provision which lends itself to great laxity in interpretation. It is also recognized that these procedures are carried out widely in many private centers. The feelings of our obstetric colleagues are divided in this matter. Many feel that it is permissible, as it is better that these potentially hazardous procedures be done in safe conditions i.e. in medical centers under anesthesia, rather than have them done by unqualified backyard practitioners. However, it is also recognized that an anaesthetist, who has very strong moral or religious objection against abortions, has as much right to refuse to anaesthetize such a case as an obstetrician to refuse to carry out termination of pregnancy. There could be problems if the anaesthetist is a single operator in an institution. It would be best to inform the hospital before the anaesthetist takes up an appointment, of his or her reservations in carrying out anaesthesia for such procedures, so that the hospital or surgeon can make other arrangements.

Consent for surgery - Our current arrangements (in most cases) are such that the surgeon takes consent for surgery and anaesthesia, although the surgeon and anaesthetist are independent professionals, with each of them being responsible for different aspects of the patient's welfare. From a practical point of view, it is best that there be constant communication between surgeon and anaesthetist as to the various aspects of the consent, particularly when specific surgical or anaesthetic risks are involved. It is also vital that both parties adhere to proper ethical practices as well as the legal requirements in obtaining informed consent. The practice of obtaining a separate consent for anaesthesia, although practiced in some institutions is unnecessary, and places an additional administrative burden. Contrary to popular belief, it does not protect the anaesthetist in any way. There are some specific areas of consent, which may be of special interest to the anesthetist.

Jehovah's Witnesses - This is a religious order, which forbids the transfusion of blood into believers, usually homologous but in some instances autologous blood as well. They pose a special challenge for anaesthetists in the event the patient requires transfusion during surgery. There are pockets of individuals belonging to this religious order in Malaysia although thankfully not many. I have had personal experience with a couple of these cases in Penang Hospital where I was working in the early eighties. There have been many legal precedents on this in the UK and elsewhere, but none in Malaysia. For elective procedures it is deemed that the patient has the absolute right to refuse blood transfusion and transfusing blood against the patient's wishes can be constituted as battery or assault although it may be life saving and be done in good faith. Although the patient's convictions may be completely at odds with the doctor, and may even be seen as irrational, the rights of patients and their autonomy are viewed to be of greater importance by the courts. In the eyes of the law the adult patient of sound mind has the absolute right to refuse any treatment including surgery that is proposed by a doctor. In the case of the Jehovah's Witnesses the patient may consent to surgery but certainly not for blood transfusion. The anaesthetist has just as much right to refuse to anaesthetize such a case if he or she feels that blood transfusion may become a necessity at sometime during the procedure. There are precedents in the case of a child, where doctors can override the wishes of the parents. Under the Child Act, doctors are obliged to always act in the best interest of the child even if the parents object to a procedure, particularly if it is life saving. If needed, a court can intervene for the doctors, although it is rarely necessary. Although there are precedents in the UK (for court intervention) I do not know if such precedents have been set here before.

Age of consent - Legally for medical and surgical procedures there is no age of consent, although age of consent exists for others under the Penal code, eg. children below 10 cannot be charged for crime, a girl under 16 cannot give consent for sexual relations and a boy under 14 cannot be charged for rape. The age for which a minor can give consent for surgery is still not defined although in the UK a mature minor can give consent for surgery. Here we tend to be a little conservative and in public hospitals we have arbitralily set the age of consent as 16 years. This is an important point in the event we have to anaesthetize a critically ill child for a life saving procedure and the parents are not available to give consent. For the mentally competent adult, consent is necessary for all procedures including emergencies. For the adult who is unable to give consent, eg. the unconscious patient, the doctors can proceed in the best interests of the patient, provided the patient has not indicated earlier that he or she does not want surgery. Courts will not accept a consent that is obtained from a surrogate eg. a spouse or sibling, but I have seen such consent being accepted by surgeons who are unaware of the risks involved.

Futile surgery - One of the lessons learnt from our Perioperative Mortality audits (both the POMR as well as the NCEPOD) is that there were instances where heroic or futile surgery was carried out on very ill patients whose outcome almost always ended in death. This is a rather difficult situation and the surgeon is often pushed to give a chance to the patient and the anaesthetist in turn pressurized to anaesthetize a patient who in his opinion will certainly not survive post operatively. As an extension, surgeons may even go ahead with a radical procedure in a severely compromised patient resulting in mortalities. Compounding this is the fact that in our public hospitals many of these cases are emergencies, which are operated on after hours when more experienced staff are not available to make rational decisions. This has been a recurring problem and as one of my senior surgical colleagues has pointed out, the surgeon is considered to have come of age when he or she can decide when not to operate. There are no guidelines for anaesthetists, except to discuss this with their more senior surgeons in the department when faced with such a situation. The decision not to operate and to also inform the patient or his relatives of that decision unfortunately lies with surgeons, and there may be a tendency (not uncommon in my experience) to blame the anaesthetists for not co-operating. On the other end of the scale there are instances where surgeons are not keen to operate but decide to ask the anaesthetist to assess the case in the hope they will not want to go ahead! These kinds of decisions often result in a waste of valuable resources in the operating room and intensive care. Decisions involved in allocation and use of resources should be considered under the ethical principle of justice. Resource allocation decisions should not be made on preconceived judgements on morbidity, mortality or age but involves a detailed evaluation of individual patient's needs and how these fit in the totality of the needs of other patients and available resources.

In conclusion, the debate as to whether the anaesthetist is entitled as an independent clinician to decide whether to anaesthetize a particular case will go on for a while. We have to be aware of our rights within ethical, legal and certain practice standards of our profession. We have to be prepared to discuss with our surgical colleagues and in certain instances, the management of our institutions, why, in some specific situations, we may not prepared to do what we are trained to do, always acting in the best interests of the patient.

References
Perioperative Mortality Review. A two Year Report (July 1994 - June 1996) Ministry of Health Malaysia, Published 1998

Campling EA, Devlin HB, Hoile RW, Lunn JN. The Report of the National Confidential Enquiry into perioperative Deaths (NCEPOD) 1992/93.

R. G. Rowlands and A. Beaumont
Is pre-optimization of patients undergoing major surgery justified?
Br. J. Anaesth. 2000; 84: 681 - 682

Linda Beecham. GMC advises doctors on seeking consent. BMJ 1999;318(7183):553

Applebaum P.S. and Grisso T.(1988) Assessing patient capacities for consent to treatment; NEJM; 319:1635-1638

Ethical Issues in Anaesthesia - Edited by M. Vickers, Wendy Scott and Heather Draper; Butterworth Heinemann Publishers; 1994

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Conferral of Honorary Membership on Dato' Dr Lim Say Wan by the MSA
Dato' Dr Lim Say Wan was conferred the Honorary Membership of the Malaysian Society of Anaesthesiologists on the 17 October 2003 during the Official Opening Ceremony of the National Conference On Intensive Care held from the 17 - 19 October 2003 at the Legend Hotel, Kuala Lumpur. The Honorary Membership was presented to Dato' Dr Lim by Dato' Chua Jui Meng, after the citation, which was prepared and read by Dato' Dr K Inbasegaran, Chairman of the Malaysian Society of Anaesthesiologists
Citation by
Dato Dr K Inbasegaran

Yang Berhormat, Dato' Chua Jui Meng, Menteri Kesihatan Malaysia, the President-Elect of the MSA and Organising Chairperson of the National Intensive Care meeting, Dr Ng Siew Hian, distinguished guests and fellow colleagues and friends. It is my privilege to present to you today, for conferment of the Honorary Membership of the MSA one of the most accomplished individuals in medicine in this country, Dato' Dr Lim Say Wan. The Honorary membership of the MSA is presented to any individual who, in the opinion of the Executive Committee, has contributed greatly to the advancement of Anaesthesiology and to the development of medicine in general. Very few are accorded this honour and up to date only 5 individuals have been conferred the Honorary membership in the 40 years history of this Society.

Dato' Dr Lim was born on the 7 of June 1939 in Penang, and studied in the Wellesley Primary School and later in Penang Free School from 1945 to 1957. He was an excellent student and sportsman, and in those early years was the school captain for badminton as well as Malaysian Schools National single and doubles champion in 1956 and 1957. In addition he also played football for the school. In 1957 he was awarded a state scholarship to study medicine in the University of Malaya, which at that time was in Singapore, the Medical Faculty then known as King Edward Hall or KE Hall. His love for and excellence in sports continued throughout his undergraduate days in spite of the heavy medical curriculum. He was the University singles badminton champion for 4 years in a row from 1957 to 1961 and represented Singapore as well. At one time he was even selected for the Thomas Cup team trials in 1959, which was no mean achievement. Later during his working life, he went on from badminton to golf, a sport he very much enjoys even till today.

He passed his MBBS in 1963 and went on to do his housemanship in Penang Hospital and then served as a medical officer in Terengganu, Province Wellesley and later in Kuala Lumpur from 1664 to 1966. In 1966 he was awarded a Colombo Plan Scholarship to train in anaesthesia in Liverpool, United Kingdom. He went on to obtain both his English and Irish Fellowships in Anaesthesia within 9 months after arrival, which was a record achievement by any Malaysian. This was only the beginning of the many firsts he achieved throughout his career and his life. He returned to Malaysia in 1968 and worked in the University Hospital Kuala Lumpur for a couple of years before going into private practice, first in the Chinese Maternity Hospital and later in Pantai Medical Center where he commenced practice from 1974 to date.

Throughout his career in medicine as well as his daily life, Dato' Dr Lim's objective was only one - to serve his patients, his colleagues in medical practice, as well as his fellow human beings. He has probably held more offices in both local and international medical bodies (as well as in other organisations), than anyone else I know, and in the process has set some records in the annals of medicine in this country. He was one of the early Presidents of this society and also served as chairman. His involvement with anaesthesiology went outside our shores and he served as chairman of the Australian and Asian Regional Section of the World Federation of Societies of Anaesthesiologists or WFSA from 1982 to 1986, the first anaesthesiologist from any Asean country to do so. His involvement in the international arena of medical politics took him to the main committee of the WFSA, and there he served, starting from 1976 as council member, then rising to chairman of the Executive Committee, General Secretary and finally President of the WFSA from 1992 to 1996, which was a crowning achievement for anybody, let alone a Malaysian. He was the second Asian to be accorded this honour, and coming from a country with so few anaesthesiologists, this was indeed a proud moment for us all. It was the equivalent of a Malaysian being elected as the Secretary
General of the United Nations.

He has also served in various offices in medicine outside the field of anaesthesiology. He was involved in the activities of the Malaysian Medical Association from 1963, and served in various capacities at National level, finally culminating as President in 1982 - the second anaesthesiologist to be President of MMA. He joined the Academy of Medicine of Malaysia in 1970 and then served as council member for a record time of 29 years from 1974 to 2003. From 1984 to 1990 he was Master of the Academy of Medicine of Malaysia, again the first anaesthesiologist to do so. He is the first anaesthesiologist as well as the 3rd Malaysian in the Western Pacific region to become President of the Confederation of Medical Associations in Asia and Oceania (CMAAO) from 1983 to 1985. He is also the first Malaysian doctor to be conferred Honorary Fellowship of the Royal Australasian College of Physicians in 1988, and the Honorary Fellowship of the American College of Physicians in 1989. From the WFSA records, no other anaesthesiologist has ever received Honorary Fellowship from these bodies.

I have known Dato' Dr Lim for quite a while, since I joined the society in the early years and later in the Academy of Medicine of Malaysia, where we served in the same council. He has several outstanding qualities in him. He was a very impressive speaker and could articulate his thoughts extremely well - I sometimes think he would have done very well in politics. Secondly, he has a phenomenal memory for people's names, dates and places, and on meeting someone can immediately recall his or her name and in many instances their spouses' names as well. This gave him an excellent ability to connect well with people he met all over his travels and work in various international bodies. Thirdly, he was able to immediately solve problems without delay, thanks to the deep knowledge of the constituitions of the various bodies he held office in. I remember clearly, during the World Congress of Anaesthesiologists in Sydney 2000, when the general assembly of delegates was not complete due to the absence of delegates from several countries. Dato' Lim who was chairing the General Assembly as President did not dither. He managed a find a clause in the constitution that allowed him to call the meeting to order and convinced the main office bearers that this could be done instead of postponing the assembly. His capacity to serve was not limited to medical organisations alone. He is the founding President of the Kuala Lumpur Branch of the Lions club and was the President of the Royal Lake Club in 1990. His continuing interest in sports saw him as Chairman of the Squash Racquets Association in Kuala Lumpur. With so many activities it was indeed a wonder that he found time to do clinical work in private practice. He must have been a master in time management. Sometime ago, I asked him about his numerous activities, and he replied that he always sees it as a great opportunity to serve his fellow beings in any way he can; his is a record of selfless service, not only to the medical community, but also well beyond that. He has a tremendous love for life and for people, and appears to be a man who is driven to get the best out of each day.

Dato' Lim is blessed with a wonderful family. He is married to Jeannie a graduate in Zoology, who has been working in banking for a while and is now in the securities industry. They have 3 sons, all of whom are accomplished individuals. The eldest, Julian, who is a lawyer by training, works in the securities industry. Their second son, Justin, is a senior registrar in Orthopedics in the UK and the youngest, Johann, has a Masters in Computer Engineering from the Imperial College of London, and is currently employed in the IT industry in Malaysia.

About 2 years ago, Dato' Dr Lim was very unfortunately struck with a serious illness and here he showed his tremendous fighting spirit and courage. His tenacity and indomitable will as well as the tremendous support from his family and friends gave him the strength to overcome his illness and to be with us today. We will continue to pray for his health and well being in the coming years and look forward to seeing him often at our meetings. Yang Berhormat and Madam President, I now present to you a man for all seasons, Dato' Dr Lim Say Wan, for conferment of Honorary Membership of the Malaysian Society of Anaesthesiologists.

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History of Anaethesia - Help Needed Please

Some of you may be aware that the MSA has been trying to document the history of anaesthesia in Malaysia in the form of a book for some time now. Several years ago, Professor Patrick Tan Siow Koon, of the University Malaya Medical Centre, took on this
project single handedly, but eventually found the going tough due to the enormity of the task. The MSA has recently tried to inject new life into this endeavour by enlisting the talents and investigative abilities of Dato' Dr K Inbasegaran and Dr Joseph Manavalan to see this book to completion before it too, becomes a piece of history.

The past and present members of the MSA exco all see the merit in this attempt because we owe a lot to our predecessors for what we are today. We are unwavering in our determination to chronicle our development and achievements in the past millennium, to be accomplished preferably within this millennium. With this in mind, we are appealing to any member of our society with any links with the past (documents or photos of events or people, etc) to come forward and share their bit of history to be recorded and preserved for ever. Considering our relatively short history, (when was the first anaesthetic administered in Malaya? - you'll have to read the book to find out&) it may not seem too monumental a job, but our labouring authors are severely limited in resourses as well as time (they have families and regular jobs too) and need, as well as deserve, any help that they can get. Besides accelerating the process, your contribution will result in a more complete and meaningful record. So, if you know someone who, or something which, you think is interesting or noteworthy (preferably with documentation), please allow us to record it and enrich our history.

The authors can be reached through the MSA by email, snail mail, telephone or fax. Just leave your contact number with Ms Kong at the Academy House, and the relevant people will get back to you. This is not a waste of time. There is much to be learned from history. Without history, there is no present and there can be no future.

EDITOR

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Write In
LETTERS TO THE EDITOR - 19 Jalan Folly Barat,
50480 Kuala Lumpur, Malaysia
Email: acadmed@po.jaring.my, acadmed@streamyx.com,
drkpng@hotmail.com All letters must be accompanied by
full name and contact address. A pseudonym may be included.

ANAESTHETIST'S DILEMMA

What is the view of the fraternity, especially the academy, regarding anaesthesiologists who run two operating theatres simultaneously. This means that there will be 2 or even 3 patients undergoing operations under anaesthesia and looked after by a single sole anaesthetist. I have learnt that such a practice is rampant even in large private hospitals. Are there practice guidelines regarding such a serious matter? Do insurance companies condone such a practice? Are the rights of the patient being violated in this instance?

On a separate issue, I have given anaesthesia for a 4 year old child to remove a foreign body in the nose. This turned out to be a simple 5 minute job for the surgeon. He charged about RM 250 as it was done at night. I had to intubate the child as the surgeon indicated that it might take time and be difficult. Also I wanted to be safe. Does it mean that I can only charge RM 80, that being one third the surgeons fee? This amount barely covers a consultation, let alone the fact that it was an emergency procedure. Therefore the one third rule should not apply here. Yet insurance companies dictate that this is so. I think that as members of a distinct and separate professional body, we should fight for our own fee schedule just as the surgeons do.

I work in a private hospital. I can tell you that the practice here is a lot diff e rent than that in the government service. It is often difficult to strictly follow guidelines when financial considerations are imposed by the management and pressures imposed by the surgeons dictate protocol. I think that we have to stand together and try to introduce into our anaesthetic practice proper ethics and moral considerations. The safety of patients should be paramount.

Thanks

APPREHENSIVE ANAESTHESIOLOGIST

Dear Apprehsive Anaesthesiologist, Thank you for bringing up these two issues which I believe are pertinent to all practicing anaesthetists whether in the private or government sector.

In response to your first question, the issue involves patient safety and this, I believe is the 1st commandment in medical practice, ie First of all do no harm'. However the concept of what actually constitutes doing harm is a matter of great debate. The position of the MSA is clearly documented in their 1997 publication of the Recommendations for Standards of Monitoring During Anaesthesia and Recovery', Section 1 Paragraph 3 which states: Professional care of the patient during anaesthesia requires the continuous presence of the anaesthesiologist throughout the anaesthetic. The presence of a skilled assistant is no substitute for the anaesthesiologist. This, however, is only a recommendation and no legislation exists to enforce most facets of medical practice, the question of right or wrong usually being decided by consensus of our peers.

Coincidentally, the problem of shortage of anaesthetists in the Government hospitals was brought up by Dr Tan Cheng Cheng of the Sultanah Aminah Hospital in the front page of the New Straits Times, 7 October, in conjunction with the National Anaesthesia Day organised in JB this year. Her statement that anaesthesiology specialists in her hospital were sometimes assigned to four operating theatres simultaneously stimulated immediate feedback and clarification from Prof Dr Chan Yoo Kuen in her capacity as President of the MSA (NST, 17 October). In her letter. Prof Chan stressed that although not all anaesthesia in Government Hospitals were performed personally by specialists, all patients were being individually looked after by medical officers undergoing training in anaesthesiology, under supervision of the specialist. She went on to comment about the steps being taken to recitfy the situation and mentioned that the lack of anaesthetists may be the limiting factor in the number of operations that can be done each day - implying that presence of an anaesthetist, or a doctor with anaesthesiology training under specialist supervision, was mandatory for the conduct of surgery under anaesthesia, in the Government sector.

I have no idea how the fee structure of anaesthetists evolved and would be very interested to know if this one third the surgeon's fee' applies to all anaesthetic fees in private practice. Perhaps some members in the know could enlighten the rest of us.

EDITOR

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Calendar of Events

SNAPSHOTS OF THE 15TH ACA SURABAYA

The President fulfilling her duty	All dressed up for the ASEAN nite
The Malaysian Contingent	Anaesthetists turned entertainers
Practising the Dikir Barat &&&??	Yes, the shopping was good too

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Snapshots of the 15th ACA Surabaya

The President fulfilling her duty	All dressed up for the ASEAN nite
The Malaysian Contingent	Anaesthetists turned entertainers
Practising the Dikir Barat &&&??	Yes, the shopping was good too

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Maintenance of Professional Standards (MOPS)

Dear Colleagues,

In this issue of the Berita you will find a document which has been formulated by the College to ensure that all our members are maintaining some form of continuing self education. This is an essential step as we move towards the credentialing of specialists as well as the creation of a specialist register. At the moment the Academy's specialist register is open to all qualified specialists, and no compulsory requirement is needed for those specialists, whose names appear in the register, to show some form of continued professional education. A National Credentialing Committee is currently being set up for the purpose of credentialing all specialists and sub specialists, which will probably require that specialists fulfill their respective MOPS criteria in order to remain in the register. Thus, we have moved forward by taking the initiative to set up our own standards, which we feel is the minimum required to keep abreast and update ourselves of developments in our very dynamic specialty.

This is nothing new and several countries including Australia and Singapore have made participation in the MOPS compulsory for all their specialists. In Malaysia, we have the MMA's CME points system which is voluntary but quite generic and focuses exclusively on CME activities. It does not cover adequately areas which today are deemed essential for specialist practice e.g. audit and quality assurance activities and teaching or research. We have designed a form that is tailored for anaesthetic practice, which will suit us better than any generic form which may be proposed later. The proposed form covers several areas involving maintenance of professional standards including CME activities, quality assurance activities and audit as well as teaching, research, etc. It has been designed in such a way to enable doctors across a spectrum of practice from Universities to public hospitals to private practice, to fulfill the requirements. The intention of this is not to encumber you or make your professional practice difficult but rather to stimulate members of the college to involve themselves actively in maintenance of professional standards, which we feel is essential to assure the community we serve that our anaesthesiologists are not only highly skilled but up-to date as well.

This exercise will commence on a voluntary basis with the intention of implementing it across the board once the planned specialist register becomes formalized. We therefore urge you to read and digest this proposal and give us your feedback before it is sent to and approved by the Academy of Medicine of Malaysia at the end of the year. You can send your comments to the secretary of the college or email me at inba@hkl.gov.my. Please participate. You will eventually have to get involved - better on our own terms than others.

DATO' DR K INBASEGARAN

MAINTENANCE OF PROFESSIONAL STANDARDS (MOPS)
COLLEGE OF ANAESTHESIOGISTS, AAM
Credit Point Allocation: Anaesthesiology
Total minimum requirements of 80 credit points per year. For all activities listed

Points if credited, will depend on the educational value of the particular activity. Approval from the QA/MOPS Officer should be sought, preferably in advance.

GENERAL NOTES

1. A minimum of 80 points should be achieved by all practitioners and this includes activities in sections 1, 2 and 3.
2. For section 1 the participant should indicate that he or she is doing active clinical work and only 10 points will be given for this.
3. For major meetings (item 2.2) and workshops (sec. 5) some form of proof must be given for e.g. a attendance certificate.
4. For self directed learning activities no verification will be needed.
5. For all QA activities in section 3 the head of department or the director of the hospital can certify that the practitioner is involved in QA activities as listed.
6. All completed forms are to be returned to the MOPS secretariat, College of Anaesthesiologists, Academy of Medicine of Malaysia.
7. Participation for the start will be voluntary.

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