With regards to the letter Doctors must put patients first, allowances second , it should be said that the universality of the medical profession's duty to put the patient first is ideally noble and continues to be echoed from time to time, even in Malaysia.

Such a duty is nicely set out in the UK General Medical Council's Good Medical Practice Guidelines amongst the many others available.

What continues to concern me, as a practising doctor who has tasted both the government and private sectors in Malaysia, are the following issues.

1) The confusion caused by the proliferation of knowledge, especially from the Internet. In any K-economy, the buzz phrase is 'knowledge is power'. But this simplistic thought can be challenged as false knowledge cannot be powerful but harmful.

Medicine has over the centuries been practised as a science and an art. Even when scientifically sound, it may be poor art when a patient is subjected to an intervention which lead to an adverse outcome.

Whilst it is a doctor's responsibility to keep up to date with a huge, evolving knowledge base, it would be an impossibility for a person to have specialised knowledge in every field. The challenge of when to concede will continue to be a thorn in every practitioner's flesh.

2) The sheer volume of available, and often conflicting, information also generates discordant expectations. Relatives may have different expectations from doctors and from the patients themselves. Common ground may occasionally not be found. So whose wishes should be ultimately respected?

When I was practising in Kuala Lumpur, I saw a patient with advanced cancer whose condition could be only controlled and palliated with cytotoxic chemotherapy. The pros and cons were explained to him in an impartial setting and he later chose to receive the treatment for the relief of his suffering.

Out of the blue, a long lost son appeared and ordered the immediate cessation of this treatment. It turned out that the patient had a vast fortune. Whose interests was to be served? It appeared that money talked but the problem here was that it did not talk as the patient was very vulnerable to the son's ministrations.

3) Some doctors may be experts in giving all sorts of advice to their patients despite not having kept up with the latest global literature. Last year, in a large Australian city, I met a very senior and well-respected Malaysian-based specialist and in our brief conversation, I inquired about how the practice of evidence-based medicine was progressing in my country of origin.

He was adamant that the practice of medicine in Malaysia continues to be 'opinion-based medicine' and that it takes the dominant role. Those who know the difference between this and evidence-based medicine would be totally shocked by this remark.

I am not surprised that in Malaysia, the opinions of powerful doctors are still strongly respected despite the absence of evidence. Emotion-based medicine perhaps?

4) The legal challenge. With the growth of the private medical sector and with an increasingly litigious society, medicine is rapidly becoming a dangerous occupation. For the slightest disagreement, people will send a solicitor's notice in the false belief that a doctor, not wanting trouble, will settle discreetly.

The notion is that if one 'catch a doctor out', it could lead to a handsome outcome and this has led to a new subculture of ambulance-chasers. Thankfully, Malaysia is still behind many developed countries in this but it appears to be catching up as evidenced by medical indemnity insurance premiums escalating and more cases being presented for expert consultation.

If the regulatory authorities do not seriously consider addressing this, it may get out of hand.

I agree with Dr Chong that Malaysia has come a very long way in terms of the standard of care in both the private and public medical sectors. But challenges still remain and more changes will be inevitable.

The most thorny is the seeming inequality in how doctors are treated in the public and private sectors. Those who remain in public service after the compulsory period often do so for security and comfort rather than for altruistic reasons. But there are, of course, doctors who are truly there to serve. I do agree with the younger doctors about the generally poor conditions of their workplaces, even today.

Government doctors are still subject to the same antiquated regulations as before. Reforms within the public health system, including health insurance, may lead to a new order where doctors may not actually be civil servants and be reclassified under a special wing of the civil service. They will then serve in both government and private hospitals to benefit both the rich and the poor.

But with all these complexities, dare I revisit the question: 'Should doctors act in the best interests of their patients in Malaysia at this present time?' My answer would be: 'Generally yes, but not all the time as they may not be following the right evidence-based decision but that of a hidden third party instead'.

Nonetheless, I remain also very concerned about the Private Healthcare and Facilities Act and its impact on the autonomy of medical practitioners in the future.

This, read together with the proposal for a now very certain national health insurance scheme , suggests that doctors will, in the near future, be quasi-puppets of a government-introduced, parliament-legitimised privatised consortia of health industry giants which is probably owned and run by the crony machinery of the Barisan Nasional - just like almost anything else in the country at present.