August 2013 THE INTERNIST Volume 1, Issue 2 College of Physicians Academy of Medicine

College of Physicians Council 2012/2014

President Prof Dato' Dr Aminuddin Message from the Editor’s Desk Ahmad

Immediate Past President Dear Members of the College of In the past 1 year as a council Prof Dato' Dr Khalid Yusoff member, amongst the issues most Physician, discussed seem to be about Vice President making the college more active Prof Dr Rosmawati On behalf of our president and the and also relevant to physicians in Mohamed college council I wish you all Malaysia. At present we have a total of 477 members and 107 greetings and Selamat Hari Raya fellows in the College of Honorary Secretary to all Muslim members! Physicians. If I were to think about Dr Goh Kim Yen It gives me great pleasure to have that, what would I see? Too few the opportunity to write to all my members? Too many inactive Honorary Treasurer esteemed fellow collegians on members? No, what I see is a significant pool of some of the Dr Chew Hon Nam some of my thoughts and greatest medical minds in the challenges as the editor of the Internist. I would like to thank our country and I would imagine that if and get to know one another Council Members President Prof Dato Dr. Aminuddin we could all somehow come better. Share your challenges and Dato' Dr Abdul Razak Ahmad for allowing me this together and share our thoughts dilemmas within your practice. Tell us about how rewarding it is Mutallif privilege in place of his President’s and experiences on medicine and healthcare in general we could to train juniors or perhaps the Dr Azmillah Rosman message. really create something exciting concerns you may have for the Dr Letchuman Ramanathan In this rapidly developing world we and vibrant. future of our young doctors. Dr Richard Lim Boon Leong live in today, communication is the Dr Mohd Noh Idris key to just about everything. It Being one of the youngest So I invite all members to feel free Dato' Dr S Nagappan provides information, updates, members of the council, some to use the Internist as a platform cynics may say that the for expressing your views about Prof Dr Roslina Manap brings people together, prepares enthusiasm will die off medicine in Malaysia and make Dr Tan Soek Siam us for the future and keeps us in touch with things that are relevant. eventually….however, it may also the college of physicians really Assoc Prof Dr Tengku When I started off as a newly be said that the future lies in a work for you. Saifudin elected council member and then good succession plan and new appointed as editor for the ideas that can energize and Thank you once again for the Internist, it was indeed a daunting revitalise. So I would like to opportunity to serve you as the Contents: task as I was fairly new to the challenge each and every member editor and I look forward to your college. Initially I wondered how I of the college, junior or senior to input. Editor’s Message would try to put the Internist put on your thinking caps and ask together and what form it would yourselves, “How can the college Warmest regards, Review of Medical take. My first few ideas were become more relevant and what Subspecialties in Malaysia overzealous perhaps as the format can I suggest to bring about Dr. Richard Lim seemed to mirror that of a medical change?” Send in your thoughts

Respiratory Medicine 6-7 journal. Later I realised that the and ideas, no matter if you think Infectious Diseases 8-9 newsletter should really be about the idea is bad or good, Let us just (If you would like to share communication. Communication start talking and sharing. We something with the Internist, College Activities 2013 for the members, about the would love to just hear more from please email to members and by the members. I all of you. There are many of you [email protected]) had therefore endeavoured to who are doing wonderful things Medicolegal course 2 gather more contributions about from your own individual platforms MRCP PACES 2-3 college activities from college be it as a consultant or head of New members 9 members. I am indeed pleased department of medicine training Upcoming events 10 that in this issue there are a fair younger physicians, a young number of contributions from physician teaching medical Psychiatry & Medicine members of the college and I thank officers how to pass the MRCP or all of you for your support and a senior consultant giving Pseudodementia 4-5 welcome further contributions. weekend talks and running CME workshops. Let’s share about it

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Medicolegal Course Kedah-Perlis 26th January 2013

This course was jointly in their field besides having a response with over 300 organized by Hospital wealth of experience in dealing registrants. The course Sultanah Bahiyah Alor Star with medicolegal issues. This participants included doctors Medical Department and the gave them the edge when from government tertiary College of Physicians speaking on the topics hospitals, district hospitals and Malaysia under Dato Dr. presented during the course. clinics in Kedah and Perlis. It Muhammad Radzi B Abu The topics presented were : was also attended by Hassan who is the paramedical staff. We were Dato’ Dr. Zaki Morad representative for Kedah/ 1) Serious Professional also delighted with the Perlis. It was held as a half Misconduct : Meaning and participation of the AIMST day course on the 26th January Implications University students and their 2013. The venue was the 2) Disciplinary Action by lecturers and a number of spacious auditorium of MMC : Why and the private medical practitioners. Hospital Sultanah Bahiyah procedures Involved Alor Star. 3) Clinical risk management Judging by requests from 4) Informed Consent some participants to organize We were privileged to have the course again at different Dato Dr Zaki Morad B This was followed by a locales, it can be concluded (Consultant Nephrologist) and question and answer session. that it was a worthwhile and Dato Dr ( Mr) Wan Khamizar The topics were enlightening successful event. (Colorectal surgeon ) as the and highly relevant to clinical speakers for this event. Both practice. COP Kedah-Perlis are highly respected clinicians The course received good Dato’ Dr.(Mr) Wan Khamizar

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

Taiping Hospital has being organising MRCP of time keepers, surrogates etc they could get a mock exam since 2007. Initially, it was only a first hand view of the questions asked and mock exam for candidates from Taiping and Ipoh answers given. When it is held annually without with local examiners. Over the years, annual mock fail, it helps to attract medical officers to your unit. examination has grown to a stage where we take in 30 candidates for the mocks with up to 20 In the past 6 years, 11 people going through the observers. These candidates now come from all medical unit of Taiping Hospital have passed the over the country. Half of the examiners are the exam. For those who wish to start organising the actual MRCP examiners. For the past 2 years, we course, it is advisable to go through College of have also included teaching component for all Physician’s document on the core requirements of stations on day 1 of the two day course/mock the real exam. Our local MRCP examiners usually exam. So far we have maintained 2 examiners per will have a copy. We would like to highlight some station. This is to allow candidates to have the points which may be useful to you, that we have actual feel of the exam and to get the feedback learnt over the years: from 2 different examiners for the same station. Furthermore, one examiner will have more time to 1. The date setting is extremely important. write comments while the other is actively Setting it early is good but you may not be examining the candidates. However, you may still able to foresee other factors. Recently, we carry out the mock exam with one examiner per had our MRCP exam on the last week of station, having the advantage of lower cost. March. The trip back to KL after the exam For the benefit of medical units which have not yet was jammed. We did not foresee that the organised MRCP mock exam, we would ‘Cheng Beng ‘and ‘School holidays’ were encourage doing so because it has many ending on the same day. The year before, a advantages for the unit. Firstly, it prepares your youth festival was going on in Taiping at the own candidates for the exam. Because the date is same period. That festival lead to a major set early, it propels them to start getting ready. On blackout in the hotel for the examiners. We top of it, it encourages the younger medical officers to sit for part one. While they play the role had to ferry the examiners to alternative hotels in the wee hours of the night.

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(cont. from page 2)

2. On whether to have the mock exam on a weekday to the event. In the first year, the college did give or weekend depends on your local setting. In our RM 2000 up front for us to organise. Over the hospital, we always have it on the weekend years, we have had some savings and this has because of space constraints. We always inform been returned. our surgical colleagues’ months ahead as we use their Day Care centre. This is to avoid surgeries 11. There is usually little profit made from organising being scheduled on the event days. (On this point, this event and sometimes it could be a loss. we are very grateful to our examiners who are willing to come on weekends.) 12. Few days before the event, you need to train the surrogates (usually HOs) on how to act for 3. Call potential examiners months ahead. Senior stations 2, 4 and 5. At the same time you need to Dr. GR Letchumanan, consultants may have other commitments to train the time keepers. The hospital security Head of Department of attend to and planning ahead ensures their needs to be informed about allocating parking Medicine, Hospital Taiping participation. Always be prepared with reserve spots. Signs leading to the venue should be put examiners as there will be last minute withdrawals up. Certificates of participation and appreciation due to unpredictable circumstances. are usually printed by the College much earlier. Copies of calibration sheets, marks sheets and “Organising MRCP 4. Hotels have to be booked early for examiners’ case scenarios for the respective stations have to Mock exams has many accommodation. be made. benefits to the medical 5. Write to MMA for CME points. 13. One day before the event, the teams with their department. It prepares respective leaders should be in place for the 6. A few weeks before the actual event, you will have following: Transport of examiners; Transport of your own candidates, to keep in contact with the examiners. They have patients; Food and beverage; Registration + encourages younger to be informed of the stations they’ll be in. You will issuance of certificates; Time keeping; Payment need to send them the scenarios for them to look for patients and examiners; Movement of the MOs to sit for part one through and give their feedback. The candidates clinical aids; beds; tables; chairs; screens. A and when it is held should also be given the timetable and the list of rehearsal of the time keeping is done to ensure hotels. all understand their roles. annually without fail, it helps to attract medical 7. It is very necessary to involve other categories of 14. On the actual day, the biggest stress factor will staff (nursing and Assistant Medical Officers) to be whether the patients will arrive on time. You officers to your unit .” help you organise the event. They would be would need to identify patients from wards as needed as chaperones, to arrange food, register back up. The cooperation of the on call doctors is candidates, transport patients and to get clinical necessary to get suitable case. We usually keep The following doctors led in equipments. 1-2 back up patients per station. The time organising the mock exams keeping is very important and should be handled successfully in Hospital 8. It will be good idea to elect 1 Medical by someone who had gone through the exam Taiping over the last few Officer/specialist for each station to help you to before. years: get the patients. One way to make this task easier 2007 is to have a registry of cases with patients’ name, 15. There should someone assigned to welcome the Dr Leong Weng Sam contacts and their findings – something that would examiners and candidates and brief them on the be accumulated over the years. These doctors will latest schedule; availability of refreshments; the 2008 also be responsible for contacting the patients, way to the toilets etc. Dr Cheah Wee Kooi keeping in touch with them until the day of exam, ensure patients’ payment, and preparing the 16. During the mock exam, the candidates who are 2009 instructions for candidates for their respective not in a particular cycle will be waiting. You can Dr Ang Chong Lip

stations. arrange teaching sessions for them but will need 2010 more teachers. Alternatively, as done in other Dr Thong Kah Meng 9. We usually have one CME event during lunch units, you can squeeze in a short feedback after break organised by a pharmaceutical company. each cycle so that the candidates don’t have to 2011 The reason for this is to bring the cost down. wait till the end. Dr Albert Iruthiaraj

10. Over the last 5 years, we have organised the 17. We have always added social events like dinners 2012 Dr Teng Kok Seng mocks under the College of Physician (Malaysia). / trips around our historical town of Taiping for

Hence all accounting matters are handled by the the examiners. We are indebted to them for 2013 college. The college issues the certificate of supporting us Dr Goh Kee San/ Dr Lai Ee attendance and participation which adds prestige Ling ______

The INTERNIST Page 4 of 10 The Pseudodementia Dilemma *Dr. Prem Kumar Chandrasekaran, ** Dr. Vincent Russell

Introduction ‘dementia syndrome of depression’. This brings us to the question, “Could depression then be a reaction to cognitive Pseudodementia refers to a condition resembling organic impairment in dementia?” Reifler et al (1982) felt that was so dementia to which underlying physical disease makes little or no but only in mild and early cases of dementia. By the 1980s, contribution. It describes a clinical picture characterised by a reversible dementia syndrome secondary to a primary doubts were being cast upon the claimed reversibility of psychiatric disorder. The concept has proved to be popular pseudodementia, based on longer follow-up periods in clinically although it is not classified as a diagnosis in either outcome studies. Several subsequent studies found that if DSM-IV(TR) or ICD-10. Pseudodementia is clearly not a single followed for long enough periods, many patients whose nosological entity as was once thought but rather a syndrome of cognitive deficits had initially appeared to have been relative clinical consistency, reflecting multiple and diverse reversed by psychiatric treatments went on to fulfill underlying psychiatric aetiologies. diagnostic criteria for dementia. A more recent meta-analysis

Since its origins in the 19th century, research interest in it has carried out by Ownby et al (2006) found that depression was waxed and waned and opinions about its clinical utility have associated with a doubling of the risk for subsequent “ Pseudodementia been divided. Following the revival of the term ‘pseudodementia’ dementia. Finally, Korczyn & Halperin (2009) rationalized refers to a condition in the 1960s, there have been further controversies surrounding that since depression and dementia are both common in old its use of the term, ranging from affirmations that it is a distinct age and frequently occur together, white matter changes entity to speculations that it represents a harbinger of dementia. resembling organic both in Alzheimer’s Disease (AD) and in depression result It has frequently been dismissed as redundant while some dementia to which experts have urged its abandonment altogether. On the other from vascular changes, supporting the concept of ‘vascular hand, some researchers had endeavoured to validate the depression’. underlying physical clinical utility of the term ‘pseudodementia’ and met with success. Small et al (1981) had proposed differentiating dementia disease makes little from DPD as in table 1. or no contribution. It is interesting to retrospectively examine how ideas related to initial observations have carved a path towards our current Rabins et al (1984) found that treatment of depression It describes a understanding and approach to this condition manifestation – improved MMSE scores with a rise to normal scores two depressive pseudodementia. Despite many advances in the years later in their ‘depressed/demented’ group. Post (1965) clinical picture fast-developing field of neuropsychiatry, countless errors and and Burgeois et al (1970) found that ECT was especially characterised by a post-hoc changes makes this subtype worthy of special effective in this group, a consistent finding most recently consideration. However, we shall not neglect the impact of the echoed by Rapinesi et al (2013). In an article reversible dementia other phenomena that have also been described under the commemorating the 50th anniversary of Kiloh’s classic paper, broad heading of pseudodementia, namely hysterical Snowden (2011) points out that the concept of syndrome secondary pseudodementia, Ganser’s syndrome and simulated dementia. pseudodementia may be worth retaining even insofar as the Finally, differentiating this condition from bipolar illness and cognitive deficits in depressive pseudodementia may be at to a primary schizophrenia is also worthy of mention. least temporally reversed and true dementia postponed as a psychiatric result of active treatment. 1. Depressive Pseudodementia (DPD) disorder.” 2. Ganser’s Syndrome Some patients with depression do not exhibit hallmarks symptoms of depression. Some signs and symptoms like This was first described by Ganser in 1897. Frequently, the focus is on the classic symptoms of or psychomotor retardation, anhedonia, laboured thinking, slipshod ‘vorbeireden’ approximate answers or answering past the point, which behavior, failing to register events, faulty orientation and loss of Scott (1965) described as Ganser’s symptom and which is recent memory should alert clinician to possibility of this commoner than the syndrome itself. However, this has led to category of pseudodementia. The 1961 publication by Kiloh other features being overlooked, for example prominent entitled “Pseudo-dementia” revived this concept from a hallucinatory experiences (pseudohallucinations), hysterical previously obscure and ambiguous position somewhere stigmata and fluctuating disturbance in consciousness. between hysteria and malingering. He described the above set Resolution is abrupt with complete and sometimes, residual of symptoms with additionally self-neglect and loss of weight amnesia (‘hysterical twilight state’) for the brief duration of the illness, which Ganser (1898) himself believed was central while Post (1965) added those symptoms to observations of to the presentation. tremulous elderly patients with shuffling gait. Kiloh urged that the possibility of depression be considered before diagnosing all The apparent dementia that accompanies approximate cases of dementia and his paper had a major impact, leading to answers in Ganser’s syndrome is usually incomplete, a surge of interest in what came to be referred to as DPD in the inconsistent and self-contradictory. These patients are able period between the 1960s and 1980s. Several more follow-up to adapt to demands of daily life which those with organic dementia cannot. Motor behavior ranges from dazed stupor studies supported his argument for examining all patients for to histrionic outbursts of excitement. Mood ranges from potentially reversible causes of apparent dementia. apathetic indifference to anxious bewilderment. Whitlock (1967) called it the ‘buffonery syndrome of schizophrenia’ Nevertheless, Folstein & McHugh (1978) claimed both dementia from the associated confabulation and childish, playful and depression interact together and that the term attitude. The change in consciousness, as well as the ‘pseudodementia’ was a misnomer as cognitive deficits resolve conversion symptoms, was proof that this is a hysterical when the depression resolves. Thus they suggested the term syndrome and not just simple malingering. (cont pg. 5)

*Penang Adventist Hospital [email protected] ** Penang Medical College [email protected]

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The change in consciousness, as well as the conversion Final remarks symptoms, was proof that this is a hysterical syndrome and not just simple malingering .Thus it has been grouped under Pseudodementia would seem to represent a term which is dissociative disorders in the DSM-IV (as well as in the TR impossible to adopt uncritically but which equally should not be version) and under other dissociative (conversion) disorders in discarded completely as a potentially useful theoretical and clinical ICD-10. construct. The likelihood is that it will continue to pose a dilemma to present day clinicians, researchers and medical educators. Ganser’s syndrome can occur during the course of a depressive Notwithstanding the considerable evidence that most patients with illness, head injury, early dementia, alcoholism and other toxic pseudodementia have a latent tendency to progress to dementia, states and purely as a response to emotional trauma. It is felt our own conclusions are that there is merit in retaining the concept that organic and psychogenic factors operate together here. as a descriptive term, particularly in relation to the phenomenon of The concept of gain had led to the term ‘prison psychosis’ and depressive pseudodementia. although malingering can be suspected, of note is that patients Depression remains as a common, treatable condition that is all do not provide spontaneous absurd remarks, merely answers to too often underdiagnosed and untreated. This is more likely when it questions they were asked. presents with co-morbid medical conditions in older patients. Recent studies have drawn attention to the fact that depression 3. Hysterical Pseudodementia may be inappropriately labeled as ‘understandable’ in such patients – both by patients and clinicians. The reality is that most older Mechanisms of hysterical dissociation may operate to some people, even those with major medical co-morbidity, are not degree in pseudodementia. Conversion pseudodementia in clinically depressed and when they are, depression should never be older people is felt to be caused by a catastrophic reaction to ignored as they do require and respond to treatment. If we add the cumulative loss in later life in individuals with predisposing cognitive impairment to the clinical picture in these patients, it borderline and narcissistic traits. Hepple (2004), reminiscing increases the risk of ‘normalising’ their depressive symptoms and Wernicke’s 1906 original conceptualization, refocused attention missing treatment opportunities that could greatly improve the on the possible psychological basis on patients with medical outcome and quality of life. pseudodementia. He contended that the syndrome is more References common in women from a higher socio-economic background 1. Kiloh LG. Pseudo-dementia. Acta Psychiatrica Scandinavia 1961; 37; 336-51. with past psychiatric histories dominated by depressive Lishman WA: Organic psychiatry - the psychological consequences of cerebral disorder symptoms. (3rd edition). Blackwell Science, 1998. 2. Ownby RL et al. Depression and risk of alzheimer’s diseasae: systematic review, meta- The core features are apparent cognitive impairment, analysis and meta-regression analysis. Archives of General Psychiatry 2006, 63: 530-8. regression and increasing physical dependency. Other 3. Rapinesi et al. Depressive pseudodementia in the elderly: effectiveness of symptoms could include the classical sensory loss, paralysis 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 and ‘belle indifferance’ of conversion. There can be fatuous paper. Australasian Psychiatry 2011; 0: 391-7. 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 Table 1: Differentiating dementia from DPD (Small et al 1981) depression. The prognosis was considered poor.

Treatment using psychotherapeutic approaches may limit the Characteristics Dementia DPD progression of the syndrome if recognised at an early stage. The role of abreaction and sleep deprivation was described by History Patrick & Hommels (1990), who conversely found that confusion Precise Onset Unusual Usual was exacerbated with those modalities in patients having Duration of symptoms Long Short organic dementia. Rapid symptom progression Unusual Usual Complaints of cognitive loss Variable (minimized in later Emphasised 4. Simulated Dementia stages) Description of cognitive loss Vague Detailed In this subtype, memory loss appears to be an isolated main Family awareness of Variable (usual in later Usual symptom. There could also be mutism and lack of cooperation. dysfunction and severity stages) Anderson et al (1989) found that it was not possible to convincingly feign dementia – with repeated efforts, fatigue sets Loss of social skills Late Early in and a ‘pull on reality’ would be experienced. Psychopathology history Uncommon Common Hunt (1973) used the MMPI to distinguish a malingerer from Examination one with organic dementia as the series of questions were Memory loss for recent vs. Greater About equal designed to weed out inconsistencies and a malingerer would remote events get anxious and upset when slips were pointed out, as Uncommon Common observed by Kraupl-Taylor (1966). Specific memory loss (‘patchy’ deficits) A point in differentiating those simulating dementia is that they Attention and concentration Often poor Often good would appear to be more ‘superficial’ than patients with Ganser’s syndrome. There will be an increase in conscious ‘Don’t know’ answers Uncommon Common malingering and the course of the disorder is longer and ‘Near miss’ answers Variable (common in later Uncommon relapsing. There will also be an absence of melancholia present stages) in DPD. Performance on tasks of Consistent Variable similar difficulty Other Considerations Emotional reaction to Variable Great distress Sometimes, functional disorders have dementia-like symptoms symptoms (unconcerned/shallow in later and in hypomania, distractibility and random answers can mimic stages) disorientation and failing memory; playfulness could lead to false replies. Carney (1983) observed that manic overactivity Affect Labile, blunted or depressed Depressed can be mistaken for agitation. In schizophrenia, poverty of ideas, emotional blunting and an unkempt state may suggest Efforts in task performance Great Small dementia. Confusing the clinical picture is the presence of late Efforts to cope with Maximal Minimal paraphrenia (Roth, 1981) and demonstration of the presence of dysfunction mild cognitive disorder and enlargement of ventricles (Naquib & Levy, 1987).

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. Review of Respiratory Medicine in Malaysia

M. Abdul Razak, LN Hooi, CK Liam

Introduction The National Tuberculosis Centre in Kuala Lumpur functioned as the headquarters of the National Respiratory Medicine involves the care of patients Tuberculosis Control Programme and the state with all forms of respiratory disease. The scope is general hospitals with their chest clinics functioned interesting and wide and the conditions treated are as the state directorates. diverse: some are very common and some rare. In the 1980s and 1990s the scope of respiratory Respiratory Medicine physicians are specially medicine services expanded to include diseases trained in diseases of the chest such as asthma, "other than tuberculosis, and in 1996 the National tuberculosis, chronic obstructive pulmonary disease Tuberculosis Centre was renamed Institute of (COPD), lung cancer, respiratory infections, sleep Respiratory Medicine. apnoea and interstitial lung disease. This branch of internal medicine is also referred to as Pulmonology The specialist society for Respiratory Medicine, and Chest Medicine. There are close links between Malaysian Thoracic Society, was formed in 1986. the specialty and radiology, infectious disease specialists and thoracic surgery. Current status of the specialty Historically, at the time of Malaysia’s independence, the few pioneer respiratory The table below shows the estimated number of “The scope of physicians were concerned mainly with combating working respiratory physicians in Malaysia. The tuberculosis, the number one cause of death during sources of data are the specialist census of Ministry respiratory the 1940s and 1950s. With the advent of the of Health, National Specialist Register and National Tuberculosis Control Programme in 1960 Malaysian Thoracic Society membership database. medicine is there was an initial rapid decline in the incidence of interesting and tuberculosis followed by a plateau. There is a relative concentration of respiratory physicians in Wilayah Persekutuan Kuala Lumpur wide and the and Selangor and a noticeable shortage in the East Malaysian states of Sabah and Sarawak as well as conditions in smaller states such as Perlis, Melaka and Negeri Sembilan. State Private MOH University Total treated are Training Structure diverse. Johor 2 1 3

Respiratory physicians are physicians who after …There are Kedah 1 3 1 5 their first medical degree (MBBS or equivalent) close links to complete training in internal medicine, followed by at Melaka 1 1 radiology, least three additional years of subspecialty fellowship training. After satisfactorily completing Kelantan 1 2 3 infectious subspecialty training in Respiratory Medicine, the physician must pass a formal exit examination Negeri 1 1 disease and before being certified as a respiratory physician. Sembilan Components of the training include out-patient thoracic clinic posting, in-patient care, intensive care Pahang 4 4 surgery. ” exposure (at least for 3 months), flexible bronchoscopic procedures, other specialised Perak 3 2 5 respiratory procedures, lectures, tutorials, seminars and clinical meetings, research, teaching, Perlis 0 tuberculosis control and pulmonary rehabilitation.

Penang 6 3 1 10 The exit assessment includes a viva voce comprising acute respiratory emergencies, Sabah 1 1 respiratory procedures, controversial issues in management of respiratory diseases and Sarawak 2 2 interpretation of data / slides / chest radiographs / CT scan images, as well as documentary review of Selangor 10 1 4 15 the training log book, free paper presentations at WP (KL) 15 5 7 27 scientific meeting(s) / publications and confidential report(s) by the trainer(s). Terengganu 2 2 (Continued on page 4) Total 42 22 17 79

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… continued

Specialist register criteria of clinical practice guidelines (CPG) on the management of respiratory diseases including A doctor can apply to be credentialed as a asthma, COPD, tuberculosis and pulmonary Respiratory Physician if he/she fulfils ALL the following requirements: arterial hypertension and should continue to 1. A basic medical degree develop benchmarks for the common registrable with the Malaysian Medical respiratory illnesses. Council. 2. A recognised postgraduate Some respiratory units already provide qualification in Internal Medicine such as Master of Medicine from UM, UKM and USM, highly specialised services, such as for lung MRCP, FRACP or an equivalent qualification transplant and sleep-related medical registrable with the National Specialist problems. Register. 3. Satisfactorily completed the There has been a recent surge of interest in duration of formal training in Respiratory Medicine as stipulated by the Specialty Interventional Pulmonology leading to a flurry “In the meantime, the old enemy, Subcommittee (SSC) of Respiratory of educational and training activities in this Medicine. area. In the meantime, the old enemy, tuberculosis has reared its head tuberculosis, has reared its head once again Needs & Vision once again with a rise in cases to with a rise in the number of cases to over over 22,000 in 2012. ” The respiratory fraternity aims to increase 22,000 in 2012. Amongst all the activity to achieve progress in more sophisticated access to specialist respiratory care services, as well as improve quality of care in services, respiratory physicians must reassert “…respiratory physicians must

Respiratory Medicine. Respiratory physicians a leadership role and be at the forefront once again in tuberculosis control. reassert a leadership role and be have been at the forefront in the development 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 Review of Infectious Diseases Subspecialty in Malaysia

Dato’ Dr. Christopher Lee , Dr. Benedict Sim

Introduction Scope as these infections are among patients needing intensive care, Throughout the history of With the growing number of post surgery, post prostheses medicine, the treatment and specialists, the scope of ID and device implantations and in prevention of infections have increased tremendously over the the immune-compromised and always been closely linked to next few years. HIV care immunosuppressed hosts. mainstream medical practice, however, with close to 100,000 thus it can be argued that every people known to be infected in The ID community often leads physician in the past was an our country, still remains the the fight against antimicrobial infectious disease (ID) physician. bread and butter of the ID doctor resistance in the hospitals and However the mortality and in Malaysia. Apart from the community. Thus we are tasked morbidity of infectious diseases clinical care, ID physicians are with initiating, advising and slowly started to wane with the involved in managing the often implementing antimicrobial advent of antibiotics, complex psycho-social aspects stewardship and control “HIV care, with close vaccinations and improved of patients living with HIV and programs in both hospitals as hygiene and health awareness. helping their families cope with well as in the community to to 100,000 people Health care resources and most the stigma of being infected or minimize the impact and doctors then gradually turned affected by HIV. To do this magnitude of inappropriate known to be infected in their attentions to non- effectively, we work closely with antimicrobial usage. communicable diseases. The paramedics, pharmacists, non- our country, still field of infectious disease has governmental organisations, The other key aspect of however undergone resurgence pharmaceutical industries and reducing the spread of remains the bread and in the last few decades. Factors other government agencies to antimicrobial resistance is proper butter of the ID doctor that contribute to this include the facilitate improve access to care infection control practices appearance of newly recognized and treatment. Our work also especially in hospitals and in in Malaysia. Apart infectious disease syndromes; brings us into the area of particular areas with critically ill from the clinical care, emergence of novel and addiction medicine where we patients. Often leading infection reemergence of older microbes, promote risk reduction and control committees together with ID physicians are some exhibiting resistance preventive measures to reduce microbiologists and infection against previous treatment; the spread of HIV. control practitioners, ID are involved in managing advances in microbiology, involved in producing and immunology and epidemiology; Apart from HIV, another implementing guidelines for hand the often complex the advent of more effective exciting part of ID is being called hygiene adherence, isolation therapeutic and preventive upon to lend expertise in precautions, transmission based psycho-social aspects of agents; newer medical diagnosing patients across a precautions and guidelines on patients living with interventions that breach the range of clinical presentations antibiotic treatment and body’s natural defences or bring beyond the scope of a general prophylaxis. HIV and helping their about a state of physician. These are categorized immunosuppression and the into whether the suspected Treating tropical diseases like families cope with the general thrust toward infection is localised or systemic, dengue, meliodosis, lepto- specialization. nosocomial or healthcare spirosis, malaria and other stigma of being associated, gathering emerging or re-emerging infected or affected by ID is a relatively new sub- epidemiological clues from the diseases form another aspect of speciality in Malaysia. It started patient, considering the patients ID that is exciting and HIV” out in the early 1990’s in Hospital underlying immune status, the challenging. The field also has its Kuala Lumpur with Dr possibility of other medical fair share of rare and “exotic” Christopher Lee managing conditions mimicking infections diseases that sporadically arise. patients with HIV. HIV then was and the pros and cons of specific The threat and the emergence of a new disease which then therapeutic trails. The ID doctor epidemics and pandemics of spelled certain mortality and one would need to juggle the range influenza and other respiratory that provoked strong sentiments of diagnostic tests available to viruses constantly keep us on even among the medical him being aware of the our toes. Thus, working in ID fraternity. It became clear that limitations and costs of tests allows us the opportunity to work adequate HIV care would require involved and would need to work closely with public health doctors to be specifically trained closely with microbiologists, physicians, state and national in this field to handle the pathologists and radiologists to health administrators and complexities of the illness. As the achieve this end. epidemiologists. Currently we era of highly active anti-retroviral also jointly managed infections therapy (HAART) begin to dawn The next broad area of like TB, sexually transmitted by the late 1990’s, the challenge coverage in ID is managing and infections and viral hepatitis with of treating HIV became more preventing nosocomial other subspecialties. demanding albeit much more infections, usually involving rewarding. It was during this time multi-resistant organisms. This that ID started attracting more aspect of our work cuts across doctors into its fold. different specialities in a hospital

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In the area of preventive medicine for infections, OR advocacy with vaccine interest groups is also part “The threat and the of the brief of an ID physician. Another area that Appointed as a clinical specialist in a uni-versity is developing in ID is the field of travel medicine department of Medicine recognized by Ministry of emergence of epidemics and and infections in the returning traveller. Higher Education (MOE) . Finally, the scope of ID also includes work on pandemics of influenza prevention and management of needle stick OR and other respiratory injuries in hospitals, in particular, providing counselling and if needed, post exposure Any other equivalent medical postgraduate degree viruses constantly keep us prophylaxis for health care workers exposed to recognized by Malaysian Medical on our toes. Thus, working contaminated sharps during work. Speciality Board on case by case basis. ID is a rapidly expanding field in medicine with in ID allows us the many emerging and re-emerging infections and Training and Supervision: newer understanding of infections and novel opportunity to work closely modes of therapy. Thus we are closely linked to i. Completion of minimum of three (3) clinical research and advocacy. Teaching is an years of training of which 9 -12 months of with public health integral part of our job and we reach out to training is preferably done in a multiple layers of doctors (medical student level to physicians, state and subspecialty care), paramedics, pharmacists, recognised overseas infectious disease national health public health personnel and even patient groups. centre. ii. Trainee is expected to spend a minimum administrators and

Current status of 12 weeks (full- time) or 24 weeks epidemiologists.” (part-time) doing lab work and infection The current number of ID physicians in the control activities. 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 Needs and vision training). As listed above, the field of ID is very vast, spans Training structure across many disciplines and is ever enlarging in its scope and influence. Our vision in Ministry of Eligibility for training: 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 I. A recognized basic medical degree Valley, Penang, Johor, Kota Bahru, KK, Kuching. recognized by Malaysian Medical Thus there is still ample room for ID to grow in our Council country. II. Must have been gazetted as a clinical specialist in the Ministry of Health (MOH) of Malaysia

New Membership and Fellowship to COPM

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

Upcoming College of Physicians Events Date Event Venue

Call for 13-15.9.13 COPM Annual Scientific Meeting UiTM Campus, Sungai Buloh 14.9.13 COPM strategic planning meeting UiTM Campus, Sungai Buloh

articles 21.9.13 Medical Update – Johor state branch M Suites Hotel, Johor Bahru 30.10.13 Hot Topics in Medicine – Kelantan state Perdana Hotel, Kota Bharu The Internist invites branch

all members to Nov 2013 Saturday teach in – Neurology Academy of Medicine, Kuala Lumpur contribute articles Dec 2013 Saturday teach in – Emergency Med Academy of Medicine, Kuala Lumpur on current updates, College of Physicians, State Representatives interesting events Johor Negeri Sembilan Terengganu Dr. Hooi Lai Seong Dr. Yong Kam Leng Dr. Norhaya Mohd Razali and educational Head, Department of Medicine & C/o Yong’s Specialist Clinic Physicians Clinic materials on Haemodialysis Unit, 8 Jalan Tuanku Munawir Department of Medicine Hospital Sultanah Aminah, 70000 Seremban Hospital Kuala Terengganu clinical medicine. Jalan Persiaran Abu Bakar Sultan, Negri Sembilan Jalan Sultan Mahmud 80100 Johor Bahru, Johor 20000 Kuala Terengganu Perak Terengganu Please send all Kedah/Perlis Dr. GR Letchumanan Dato’ Dr Muhammad Radzi Abu c/o Department of Medicine articles to: Hassan Hospital Taiping Sabah Department of Medicine Taiping Datuk Dr. Jayaram Menon theinternistcopm@ Hospital Sultanah Bahiyah Perak c/o Department of Medicine Alor Setar, Kedah Hospital Queen Elizabeth gmail.com Penang Kota Kinabalu Kelantan Dato’ Dr. Chong Keat Fong Sabah Dato’ Dr. Rosemi Salleh c/o Island Hospital Department of Medicine 308 Macalister Road Sarawak Hospital Raja Perempuan Zainab II 10450 Penang Dr. Bryan Tie Siew Teck Kota Bharu Department of Medicine Kelantan Pahang Hospital Umum Sarawak Dr. Yew Kuan Leong Jalan Tun Ahmad Zaidi Adruce 93586 Kuching Sarawak

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 13th – 15th September past? 2013  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

Register online at:

www.acadmed.org.my