August 2013

Volume 1, Issue 2

THE INTERNIST
College of Physicians
Academy of Medicine

College of Physicians
Council 2012/2014

Message from the Editors Desk

President
Prof Dato' Dr Aminuddin
Ahmad
Immediate Past President
Prof Dato' Dr Khalid Yusoff
Vice President
Prof Dr Rosmawati
Mohamed

On behalf of our president and the

college council I wish you all
greetings and Selamat Hari Raya
to all Muslim members!

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:
Editors Message
Review of Medical
Subspecialties in Malaysia
Respiratory Medicine 6-7
Infectious Diseases 8-9
College Activities 2013

Medicolegal course
MRCP PACES
New members
Upcoming events

2
2-3
9
10

Psychiatry & Medicine

Pseudodementia

Dear Members of the College of

Physician,

4-5

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 Presidents
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.

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. Lets 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

Dato Dr. Zaki Morad

Dato Dr.(Mr) Wan Khamizar

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 26th 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)

2)

3)
4)

Serious Professional
Misconduct : Meaning and
Implications
Disciplinary Action by
MMC : Why and the
procedures Involved
Clinical risk management
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

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

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
Physicians 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.

Page 3 of 10

The INTERNIST

(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 theyll 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.

9.

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.
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.

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

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 dont have to
wait till the end.

2009
Dr Ang Chong Lip

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

2012
Dr Teng Kok Seng

______________________

2010
Dr Thong Kah Meng
2011
Dr Albert Iruthiaraj

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
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
doubts were being cast upon the claimed reversibility of
reversible dementia syndrome secondary to a primary
pseudodementia, based on longer follow-up periods in
psychiatric disorder. The concept has proved to be popular
outcome studies. Several subsequent studies found that if
clinically although it is not classified as a diagnosis in either
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
th
carried out by Ownby et al (2006) found that depression was
Since its origins in the 19 century, research interest in it has
associated with a doubling of the risk for subsequent
waxed and waned and opinions about its clinical utility have
been divided. Following the revival of the term pseudodementia dementia. Finally, Korczyn & Halperin (2009) rationalized
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. both in Alzheimers Disease (AD) and in depression result
It has frequently been dismissed as redundant while some
from vascular changes, supporting the concept of vascular
experts have urged its abandonment altogether. On the other
depression.
hand, some researchers had endeavoured to validate the
clinical utility of the term pseudodementia and met with
Small et al (1981) had proposed differentiating dementia
success.
from DPD as in table 1.
It is interesting to retrospectively examine how ideas related to
Rabins et al (1984) found that treatment of depression
initial observations have carved a path towards our current
improved MMSE scores with a rise to normal scores two
understanding and approach to this condition manifestation
years later in their depressed/demented group. Post (1965)
depressive pseudodementia. Despite many advances in the
and Burgeois et al (1970) found that ECT was especially
fast-developing field of neuropsychiatry, countless errors and
effective in this group, a consistent finding most recently
post-hoc changes makes this subtype worthy of special
echoed by Rapinesi et al (2013). In an article
consideration. However, we shall not neglect the impact of the
commemorating the 50th anniversary of Kilohs classic paper,
other phenomena that have also been described under the
Snowden (2011) points out that the concept of
broad heading of pseudodementia, namely hysterical
pseudodementia may be worth retaining even insofar as the
pseudodementia, Gansers syndrome and simulated dementia.
cognitive deficits in depressive pseudodementia may be at
Finally, differentiating this condition from bipolar illness and
least temporally reversed and true dementia postponed as a
schizophrenia is also worthy of mention.
result of active treatment.
1. Depressive Pseudodementia (DPD)
2. Gansers Syndrome
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.

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.

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 Gansers 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 Gansers 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
Nevertheless, Folstein & McHugh (1978) claimed both dementia from the associated confabulation and childish, playful
attitude. The change in consciousness, as well as the
and depression interact together and that the term
pseudodementia was a misnomer as cognitive deficits resolve conversion symptoms, was proof that this is a hysterical
syndrome and not just simple malingering. (cont pg. 5)
when the depression resolves. Thus they suggested the term

*Penang Adventist Hospital

premkumar@pah.com.my

** Penang Medical College

vincent@pmc.edu.my

Page 5 of 10
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.

The INTERNIST
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.
Gansers 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
may be inappropriately labeled as understandable in such patients
3. Hysterical Pseudodementia
both by patients and clinicians. The reality is that most older
people, even those with major medical co-morbidity, are not
Mechanisms of hysterical dissociation may operate to some
clinically depressed and when they are, depression should never be
degree in pseudodementia. Conversion pseudodementia in
ignored as they do require and respond to treatment. If we add the
older people is felt to be caused by a catastrophic reaction to
cognitive impairment to the clinical picture in these patients, it
cumulative loss in later life in individuals with predisposing
increases the risk of normalising their depressive symptoms and
borderline and narcissistic traits. Hepple (2004), reminiscing
Wernickes 1906 original conceptualization, refocused attention missing treatment opportunities that could greatly improve the
medical outcome and quality of life.
on the possible psychological basis on patients with
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
(3rd edition). Blackwell Science, 1998.
symptoms.
2. Ownby RL et al. Depression and risk of alzheimers diseasae: systematic review, metaThe 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
electroconvulsive therapy. International Journal of Geriatric Psychiatry 2013; 28: 433-40.
symptoms could include the classical sensory loss, paralysis
4. Snowdon J. Pseudodementia, a term for its time: the impact of Leslie Kilohs 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
Table 1: Differentiating dementia from DPD (Small et al 1981)
response, in Hepples case series, to various treatments for
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.
History
The role of abreaction and sleep deprivation was described by
Precise Onset
Unusual
Usual
Patrick & Hommels (1990), who conversely found that confusion
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
Loss of social skills
Late
Early
convincingly feign dementia with repeated efforts, fatigue sets
Psychopathology history
Uncommon
Common
in and a pull on reality would be experienced.
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
Specific memory loss (patchy Uncommon
Common
observed by Kraupl-Taylor (1966).
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
Dont know answers
Uncommon
Common
Gansers syndrome. There will be an increase in conscious
Near miss answers
malingering and the course of the disorder is longer and
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
Affect
Labile, blunted or depressed
Depressed
false replies. Carney (1983) observed that manic overactivity
can be mistaken for agitation. In schizophrenia, poverty of
Efforts in task performance
Great
Small
ideas, emotional blunting and an unkempt state may suggest
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).

The INTERNIST

Page 6 of 10

Review of Respiratory Medicine in Malaysia

M. Abdul Razak, LN Hooi, CK Liam

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.

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.

Historically, at the time of Malaysias

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.

State

Private

MOH

Johor

Kedah

Melaka

Kelantan

Negeri
Sembilan

3
1

4
5

Perlis
Penang

4
3

Total

Pahang
Perak

University

0
6

10

Sabah

Sarawak

Selangor

10

15

WP (KL)

15

27

Terengganu
Total

2
42

22

2
17

79

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)

Page 7 of 10

The INTERNIST

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

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.

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.

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

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

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 noncommunicable 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
bodys natural defences or bring
about a state of
immunosuppression and the
general thrust toward
specialization.
ID is a relatively new subspeciality in Malaysia. It started
out in the early 1990s 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 1990s, 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.

Scope

as these infections are among

patients needing intensive care,
post surgery, post prostheses
With the growing number of
and device implantations and in
specialists, the scope of ID
increased tremendously over the the immune-compromised and
immunosuppressed hosts.
next few years. HIV care
however, with close to 100,000
The ID community often leads
people known to be infected in
the fight against antimicrobial
our country, still remains the
bread and butter of the ID doctor resistance in the hospitals and
community. Thus we are tasked
in Malaysia. Apart from the
with initiating, advising and
clinical care, ID physicians are
implementing antimicrobial
involved in managing the often
stewardship and control
complex psycho-social aspects
programs in both hospitals as
of patients living with HIV and
well as in the community to
helping their families cope with
minimize the impact and
the stigma of being infected or
magnitude of inappropriate
affected by HIV. To do this
effectively, we work closely with antimicrobial usage.
paramedics, pharmacists, nonThe other key aspect of
governmental organisations,
reducing the spread of
pharmaceutical industries and
antimicrobial resistance is proper
other government agencies to
facilitate improve access to care infection control practices
especially in hospitals and in
and treatment. Our work also
particular areas with critically ill
brings us into the area of
patients. Often leading infection
addiction medicine where we
control committees together with
promote risk reduction and
microbiologists and infection
preventive measures to reduce
control practitioners, ID are
the spread of HIV.
involved in producing and
implementing guidelines for hand
Apart from HIV, another
exciting part of ID is being called hygiene adherence, isolation
precautions, transmission based
upon to lend expertise in
precautions and guidelines on
diagnosing patients across a
antibiotic treatment and
range of clinical presentations
prophylaxis.
beyond the scope of a general
physician. These are categorized
Treating tropical diseases like
into whether the suspected
infection is localised or systemic, dengue, meliodosis, leptospirosis, malaria and other
nosocomial or healthcare
emerging or re-emerging
associated, gathering
diseases form another aspect of
epidemiological clues from the
patient, considering the patients ID that is exciting and
challenging. The field also has its
underlying immune status, the
fair share of rare and exotic
possibility of other medical
diseases that sporadically arise.
conditions mimicking infections
and the pros and cons of specific The threat and the emergence of
therapeutic trails. The ID doctor epidemics and pandemics of
influenza and other respiratory
would need to juggle the range
viruses constantly keep us on
of diagnostic tests available to
our toes. Thus, working in ID
him being aware of the
allows us the opportunity to work
limitations and costs of tests
involved and would need to work closely with public health
physicians, state and national
closely with microbiologists,
health administrators and
pathologists and radiologists to
epidemiologists. Currently we
achieve this end.
also jointly managed infections
like TB, sexually transmitted
The next broad area of
coverage in ID is managing and infections and viral hepatitis with
other subspecialties.
preventing nosocomial
infections, usually involving
multi-resistant organisms. This
aspect of our work cuts across
different specialities in a hospital

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.

The INTERNIST
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.

ii.
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.

II.

A recognized basic medical degree

recognized by Malaysian Medical
Council
Must have been gazetted as a clinical
specialist in the Ministry of Health
(MOH) of Malaysia

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.
Trainee is expected to spend a minimum
of 12 weeks (full- time) or 24 weeks
(part-time) doing lab work and infection
control activities.

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.

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.

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. Bahariah bt Khalid
Dr. Chiew Kean Shyong
Dr Giri Shan Rajahram
Dr. Hafizah bt Zainuddin
Dr. Ho Khek Choong
Dr. Kiew Kuang Kiat
Dr. Leong Chong Men
Dr Mazlin bt Mohd Baseri
Dr. Ngiu Chai Soon

Dr. Rafiza bt Shaharudin

Dr. Ruzita bt Jamaluddin
Dr. Shivanan Thiagarajah
Dr. Sazzli Shahlan bin Kasim
Dr. Ooi Boon Han
Dr Tie Siew Teck

Upcoming College of Physicians Events

Call for
articles
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

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

College of Physicians, State Representatives

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

Negeri Sembilan
Dr. Yong Kam Leng
C/o Yongs Specialist Clinic
8 Jalan Tuanku Munawir
70000 Seremban
Negri Sembilan
Perak
Dr. GR Letchumanan
c/o Department of Medicine
Hospital Taiping
Taiping
Perak

Penang
Kelantan
Dato Dr. Chong Keat Fong
Dato Dr. Rosemi Salleh
c/o Island Hospital
Department of Medicine
308 Macalister Road
Hospital Raja Perempuan Zainab II 10450 Penang
Kota Bharu
Pahang
Kelantan
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

UPDATE ON INFECTIOUS DISEASES

13th 15th September

2013

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

Register online at:

www.acadmed.org.my