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September 2013 Volume 06 Issue 09

President's Column

 Newborn Screening for Congenital Hypothyroidism:

Page No.


Dear all,

 Ethics of Confidentiality


It is a pleasure and a privilege to write to each and every

 SLMA Pre Congress Workshop on Sports Medicine.


 Story: My Wife Doesn't Work !


one of you, again. There are some further activities that we have arranged which will take place right up to the end of our tenure. One such initiative is to try and initiate a sustainable programme of recording and providing some of the Continuous Professional Development activities of the SLMA through a web-based platform. We are currently in negotiation with other stakeholders who already have the infrastructure in place for this endeavour. If we are successful in these efforts, it would be possible to provide the facility of following our CPD activities at the convenience of members even from remote areas without having to attend the activities at the SLMA. I am sure that this will be helpful to all members and especially for those in far-flung areas of the country. We will be involved with the following meetings during the dates indicated :1. Collaborative Meeting with the Jaffna Clinical Society 10 – 12 October 2013 2. Foundations Session in partnership with the Anuradhapura Clinical Society 23 – 25 October 2013 3. Collaborative Meeting with The Batticaloa Clinical Society 6 – 8 November 2013 4. Collaborative Meeting with The Matara Clinical Society 20 – 21 November 2013 5. SLMA – INASP – CMJ Research Workshop 28 November 2013 6. Collaborative Meeting with the Avissawella Clinical Society 13 December 2013 The Medical Dance would be on the 7th December 2013 at Waters Edge. We hope as many people as possible will grace the occasion and take part in the merry making. The Annual General Meeting of the SLMA would be on Saturday the 14th of December 2013 and the Induction Ceremony of the President of the SLMA for 2014 would be on

 Quality of Healthcare research findings led to lively discussion


 Jawatte Lunatic Asylum


 Joint clinical meeting of SLMA with the Monargala Clinical Society.  SEMINAR ON CAREER GUIDANCE FOR JUNIOR MEDICAL OFFICERS - 2013

GlaxoSmithKline Pharmaceuticals. MCSL Financial Service Limited Future Automobiles (pvt) ltd. Commercial Bank of Ceylon PLC | Sri Lanka A.Baurs & Co. (Pvt.)Ltd. Nation Lanka Finance PLC Pan Asia Banking Corporation PLC George Steuart Health. Tokyo Cement Company (Lanka) Plc. Seylan Bank PLC LOLC PLC Hongkong and Shanghai Banking Corporation Limited Astron Ltd. State Pharmaceuticals Corporation of Sri Lanka Asiri Surgical Hospital. Emerchemie NB (Ceylon) Ltd. GlaxoSmithKline Pharmaceuticals.

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September, 2013

Newborn Screening for Congenital Hypothyroidism: From Southern Province to Sri Lanka: Challenges and Opportunities Dr. Manjula Hettiarachchi Senior Lecturer in Nuclear Medicine Nuclear Medicine Unit Faculty of Medicine University of Ruhuna Galle


he newborn screening for congenital hypothyroidism was established in Southern Province of Sri Lanka with the assistance from Family Health Bureau (FHB) of Ministry of Health (circular 2-90/2010) and National Research Council (NRC) of Sri Lanka (NRC grant 08/08) from September 2010 onwards under Prof Sujeewa Amarasena’s guidance. This achievement is from some pioneering research work carried out in Nuclear Medicine Units (NMU) of the Peradeniya (1) and Galle (2, 3). Later the District General Hospital of Moneragala and Base Hospital, Bibila joined this project on the enthusiasm of the consultant Paediatricians of these institutes. At present all neonates born in the Southern province and these 2 hospitals are screened with a heel prick sample of blood collected on to Year 2010 –Sep to Dec

No screened

The next step is to have a national Recalled

Confirmed CH












2013 –Jan to June








a filter paper like in other countries. The NMU Galle has now performed more than 113000 tests (using primary TSH followed by serum TSH /fT4 confirmation) since the commencement of the program and identified 73 cases of CH since then. Coverage is at 98.0% and the recall rate is 0.7%. Further, the incidence of CH varied between 1: 1500 (in 2012) to 1:1750 (in 2011) live births.


We have employed Radioimmunoassay (RIA) and enzyme-linked immunoassay (ELISA) techniques during first 2 years. Then we negotiated a donation of DELFIA Newborn analysis System (fluoroimmunoassay) from Perkin Elmer, Finland (worth USD 55,000) to enhance our working capacity. Use of nonradioactive labels and improved sensitivity with the potential for better separation between normal and abnormal TSH concentrations remarkably improved our recall rates in this year. With the ability of handling more than 1000 samples per day with 3 different analytical methods make sure sufficient backup facility/ capacity development for a wider coverage. Even, a breakdown of a machine will not result in the breakdown of the service. Therefore, the NRC (NRC 11-160) and the FHB has pushed us to expand the coverage. Therefore, entire Kalutara & Ratnapura districts are also incorporated to the existing program since August 2013.

project. The Ministry of Health has now accepted Screening for CH as a policy and assisted us to implement this service. However, establishment of national screening program will be dependent on funding. Adequate funding will not be available to start this in our country for another decade, while children suffer. Offering this service on payment to build a private – public partnership may be

efficient and more successful than attempting to do this in the public health service. That would be definitely quicker. Cost could be reduced if the collection, dispatch of specimen and communication is by the public health service and the laboratory tests are done by us. Then people can pay for the test at a lower rate. Further, the Sri Lanka College of Pediatricians (SLCP) have made a position statement where it advises all doctors and pediatricians to offer screening to all the babies when they come for routine checks. Currently many pediatricians are advising parents to get this test done. However, only serum TSH/fT4 is available in the private sector and one has to pay minimum of Rs. 2000.00 to get it done. However, the logistics of arranging free screening to the entire country will take time. Therefore, the NMU is offering this test to newborns at a price of Rs. 300.00 per test on filter paper blood spot. This offer is to all other districts not currently covered in the program. The filter paper attached request form and envelope addressed to NMU will be provided. The samples can be posted in ordinary post and results will also be posted to the patient by post for screening negative cases. Screening positive cases will be informed over the telephone to the mother /father, pediatricians for urgent retesting. It is also possible for mother /father or anybody to use the website (http:// to find the results using the BHT of the patient. The initial announcement is done last months and the response rate is so high and not only hospitals in Colombo but also from other areas including Northern Province has already inquired and implemented the program. Contd. on page 22


September, 2013

Ethics of Confidentiality:

How (not) to tell Whom, What, Where, When and Why By Naazima Kamardeen

Introduction: The doctor-patient relationship has always been viewed as one entailing a high degree of confidentiality, due to the sensitive nature of the information shared. It is also expected that the maintenance of confidentiality will promote better health in the nation, thus achieving an important socioeconomic goal for a nation. However, this relationship is not completely immune from interference. The law may demand that the medical care giver reveal information that is vital for the state to know. Other social and political considerations may dictate that confidentiality be breached. This paper considers the importance of confidentiality in medical ethics, and attempts to compare and contrast the legal versus ethical aspects of confidentiality, and examine the Sri Lankan law and practice in this area. Following this, suggestions and recommendations have been advanced for how the medical profession in Sri Lanka should approach the handling of confidential information. The various healthcare settings available in Sri Lanka were considered separately, for clarity of understanding. Confidentiality and medical ethics: The role of confidentiality as an integral part of the doctor’s code of conduct is considered an undisputable fact. Having its roots in the Hipocratic Oath , the duty of confidentiality is now ingrained in medical ethics. However, the requirement of The older version contains the words “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” (Translation from the Greek by Ludwig Edelstein. From The


confidentiality is not merely a decorative or fanciful notion; it is strongly believed that confidentiality will improve the health of a nation, by encouraging those afflicted to seek remedies, without fear of disclosure. Dicta in the British cases of W. v Egdell and X.v Y also confirm this view. In Egdell, the court was of the opinion that medical confidentiality is central to good healthcare. In X v Y, the court held that

only; the state, in contrast, has a duty toward all. Hence, a doctor may be required to breach confidentiality, where the law demands it. In such an instance, the breach would be legal, but it may be unethical. As there is a line (however fine) between these two concepts, it is important to consider the situations under which confidentiality may be breached.

‘In the long run, preservation of confidentiality is the only way of securing public health… future individual patients will not come forward if doctors are going to squeal on them. Consequently, confidentiality is vital to secure public as well as private health, for unless those infected come forward they cannot be counselled…’


Legal versus ethical aspects of confidentiality: While medical ethics places much importance on the maintenance of confidentiality, the legal system of a country treats confidential information slightly differently. As the upper guardian and custodian of the people, the state is under a duty to protect its entire populace. Hence, it is in the interests of the state to have access to all information that would potentially impact on its duty to protect and care for, its people. If such information is in the custody of any person, the state has the right to demand that such information be revealed to it. The doctor has a duty towards the patient

Legally justifiable breaches of confiThe clearest example of a justifiable breach is where the law demands it; in such a situation, there would be no legal liability on the doctor. Various statutes in Sri Lanka mandate disclosure of information. The only problem seems to be keeping up with the numerous laws that deal with the topic. The other instance is where the patient authorizes the disclosure of the information. If there is informed consent, then there is no liability on the doctor. Other breaches of confidentiality: There are several other instances where a doctor might be required to breach confidentiality. A doctor may reveal information about a patient if s/he believes that it is in the patient’s best interests to do so. In such a situation that doctor should inform the patient and try to obtain informed consent. A doctor may also breach confidentiality if the doctor believes that it is in society’s interests to have such information revealed. Contd. on page 4

Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943). A newer version, modifies this to “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know”. This was written in 1964 by Louis Lasagna, Academic Dean of the School

of Medicine at Tufts University, and is said to be used in many medical schools today. Available at, accessed on 1st July 2103 2

[1990] 1 All E.R, 835


[1988] 2 All E.R 648



September, 2013 Contd. from page 3

Ethics of ...


In these cases, it is the doctor who has to decide which is the more significant risk – the patient losing faith in the doctor anddiscontinuing medical care or treatment, or society being in danger due to the failure to disclose a potentially harmful condition or disease.

of evidence of certain crimes. There is a less clear area where it may be within the doctor’s discretion to decide whether or not to inform the authorities, where s/he is not quite sure if a crime has been committed or not. In such cases, there will be a balancing of interests by the doctor.

Legal parameters on the disclosure

Settings for doctor-patient interac-

of information:

tions in Sri Lanka:

As Sri Lanka does not have a law that deals specifically with data protection or the protection of confidential information, much of the law in this area is found in the older, punitive legislation of the state. Section 198 of the Penal Code prohibits the destruction of evidence or the provision of false evidence in order to protect the offender from legal punishment. Section 199 makes it an offence to refrain from giving evidence that one is legally bound to give. Section 200 makes it an offence to give false evidence. The next question to be asked is how one can determine when one is bound to give evidence. Section 21 of the Criminal Procedure Code makes it the duty of every person aware of either the commission of, or the intention to commit, a crime, to report to the nearest magistrate’s court or police station. Hence there seems to be a general duty on all persons to report crime. The next point is to consider whether doctors are covered by any specific exceptions. Sections 126-129 of the Evidence Ordinance only cover as confidential, the communications between a lawyer and a client. There is no such immunity available for information that is revealed to the doctor by the patient. Therefore, the cumulative effect of all these provisions is to mandate that the doctor has a duty to inform public authorities

As Sri Lanka is one of the few countries in the world to provide free healthcare to its people, doctors interact with patients in the setting of the government hospital as well as the private hospital. Further, doctors interact with patients when they seek volunteers to participate in medical research. The relationships, rights and liabilities that arise between the parties in these three settings vary from each other, and it is to an examination of these points that we now turn.

4Section 198, Penal Code:“Whoever, knowing or having reason to believe that an offence has been committed, causes any evidence of the commission of that offence to disappear, with the inten-

tion of screening the offender from legal punishment, or with that intention gives any information respecting the offence which he knows or believes to be false, shall, if the offence which he knows

State hospitals: Government hospitals are part of the service sector of the state. It is generally accepted as cost-free to the patient, though patients may be asked to bear certain minimal expenses at times. It is to the state hospitals that all victims of motor traffic accidents, gunshot injuries and crimes are admitted (even though private hospitals do also treat such patients prior to transferring them to the government hospitals). The Police are allowed entry into these hospitals to record evidence, etc. From a purely contractual perspective, we find that since the state pays the doctors, the contractual relationship exists between the state and the doctor, with the patient merely being the beneficiary of the relationship. This is because there is no valuable

consideration passed between the doctor and the patient. Private hospitals: There are many private hospitals in Sri Lanka, especially in the urban city centres. While they are inaccessible to a large percentage of the country’s rural poor, the facilities they afford do make them attractive to many, especially the urban rich. As patients must pay for treatment, there is a contractual relationship between the patient and the doctor (or the patient and the hospital), which is validated by valuable consideration. The contract in such a case is initiated by the patient. Since the police do not have access to the accident or emergency treatment units of these hospitals, such patients are eventually transferred to the state hospitals. However, in non-emergency cases, rich patients may choose to channel doctors to avoid revealing embarrassing details. It cannot be stated with any degree of accuracy whether a doctor confronted with (for example) a case of suspected domestic violence would react any differently were s/he privately channelled as opposed to seeing the patient in his/her ward at the government hospital. However, in the private setting, the doctor is in a contractual relationship with the patient, and the patient’s expectation of confidentiality may be higher in such a situation. What, then, is the doctor to do? There seems to be a consensus that the doctor will treat the patient anyway. As to reporting the incident, (which is mandated by law, and is a duty that the doctor owes the state, regardless of the setting) we have just admitted, through an examination of the law, that this will have to be done as well. Contd. on page 6 or believes to have been committed is punishable with death, be punished with imprisonment of either description for a term which may extend to seven years, and shall also be liable to fine …..”



September, 2013 Contd. from page 4

Ethics of ... The doctor can escape the ethical dilemma by informing the patient that s/he intends to inform the relevant authorities, and counsel the patient accordingly. However, if all doctors do not conform to the same degree of diligence in reporting suspected incidents of crime, (and since many of these types of crime are not publicly known, and are therefore not investigated) the patients will stay away from doctors who do, and consult only those who do not. This will have extremely negative results on the medical profession in particular, and on society in general. Current practice appears to be that the doctor records her/his observations, so that these records are available for future reference. But how good would that be in the case of a crime that should have been brought to the notice of the relevant authorities, so that proper remedial action can be taken? Confidentiality in medical research: Medical research is an important activity for the furtherance of knowledge, skills and attitudes in medical care. As such, it is an important setting where a doctor and patient will interact. Medical practitioners may

Section 199, Penal Code: “Whoever, knowing or having reason to believe that an offence has been committed, intentionally omits to give any information respecting that offence which he is legally bound to give, shall be punished with imprisonment of either description for a term which may extend to six months, or with fine, or with both.” Section 200, Penal Code: “Whoever knowing or having reason to believe that an offence has been committed, gives any information respecting that offence which he knows or believes to be false, shall be punished with imprisonment of either description for a term which may extend to two

ask for information from patients as part of their research. In such a situation, there is a contractual relationship, even though there may be no payment to participants. Confidentiality is usually assured. In such cases, if information is revealed that is vitally important to be known by some other authority (law enforcement, health services, etc), the general consensus is that it should not be divulged, as it was extracted under the promise of confidentiality. In the other scenarios discussed above, there is some leeway, as confidentiality is implied, but not expressly provided for. However, where information is solicited (in instances where it would not normally have been revealed) it is not even legal for the medical practitioner to reveal it to others, as it would breach the contractual promise of confidentiality. Conclusion: The need for regulation: From the ongoing discussion it becomes clear that the handling of confidential patient information is an area clouded in ambiguity in Sri Lanka. If left unaddressed, it can lead to confusion, and discrimination in the treatment given to patients. Countries like Britain and Ireland have guidelines outlining professional conduct

and ethics , which help doctors and other medical care givers to recognize the limits of their responsibilities. There are also some laws such as the Data Protection Act that deal with the protection of confidential information. However, in Sri Lanka we do not have any laws or regulations that deal with the handling of confidential information. Therefore, medical professionals will need to take extra care when dealing with such topics. Since promulgation of new legislation is a time-consuming exercise, it is proposed that we in Sri Lanka should begin with at least a guideline for professional conduct, which includes a section on the handling of confidential information. This will ensure consistency on the part of medical professionals with regard to disclosure. It will also keep patients better informed of their rights and liabilities, which is a vital component of any public health system. —The writer is a Lecturer at the Law Faculty of the University of Colombo and a member of the Ethics Review Committee of the Medical Faculty.

years, or with fine, or with both.”


Section 21, Criminal Procedure Code: “Every person aware-

shall in the absence of reasonable excuse-the burden of proving which shall lie upon the person so aware- forthwith give information to the nearest Magistrate's Court or to the officer in charge of the nearest police station …..

of the commission of or the intention of any other person to commit any offence punishable under the following sections of the Penal Code, namely, 114, 115, 116, 117, 118, 119, 120, 121, 122, 126, 296, 297, 371, 380, 381, 382, 383, 384, 418, 419, 435, 436, 442, 443, 444, 445, and 446; of any sudden or unnatural death or death by violence, or of any death under suspicious circum-

For example, an injury may be reported as being caused by an accidental fall, but the doctor may believe that it is a result of domestic violence. In such cases, there will always be a degree of subjectivity, and therefore, risk.

Britain’s General Medical Council has a publication entitled Confidentiality (2009), which sets out the principles of confidentiality and respect for patients’ privacy that doctors should follow. Available at, accessed on 16th July 201. Ireland’s guide is available at, accessed on 16th July 2013. UK, 1998



September, 2013

SLMA Pre Congress Workshop on Sports Medicine. Dr. Sanjeeva Gunasekara, MBBS, MD Senior Registrar in Paediatric Oncology, National Institute of Cancer, Maharagama. Assistant Secretary, SLMA


LMA in collaboration with The Sports Medicine Institute of the Ministry of Sports organized a workshop on sports medicine on the 10th July 2013 at the Sports Medicine Institute Auditorium. It was felt that such a workshop was an acute need as currently there were no formal training to sports personnel on sports medicine. Due to this reason many elite sportsmen and women had their promising carriers cut short due to injuries or were not able to perform to the best of their abilities. Illegal performance enhancing substance abuse is also raising it’s ugly head in the Sri Lankan sports arena and this was also an issue which was addressed in this workshop. This was attended by sportsmen and women, coaches, trainers, physiotherapists and doctors with special interest in sports medicine. Dr, Harindu Wijesingha, Consultant in Rheumatology and

Rehabilitation and Specialist in Sports Medicine started off the workshop when he talked about “Over Training and player burn out”. He stressed on the importance of individualising training regimens to maximize the benefits as well as the role of adequate recovery after training in preventing injuries. Prof. Arjuna de Silva, Director General of the Sports Medicine Institute covered the topic of “Illegal performance enhancers in sports” and he touched upon the various classes of such drugs, what harm they can do to sportsmen and women as well as internationally accepted surveillance methods to catch offenders. “Sudden death in Sporting arena” was the topic of Dr. Asunga Dunuwila, Consultant Electrophysiologist where he elaborated on possible causes for such deaths, how best to identify individuals at risk early and how to prevent them. The important topic of “Children in Sport” was handled by Dr. B J C Perera, Consultant Paediatrician. Here how children differs from adults with regard to their injuries as well as their capability to handle heavy training schedules was explained and need to tailor made training regimens to suit different

age groups was stressed. Dr. Hillary Suraweera, Consultant Orthopaedic Surgeon and current President of the Sports Medical Association of Sri Lanka talked on “How to handle on-field injuries” with a special emphasis on head injuries and concussion. A major highlight of this talk was the proper transport of patients with head / neck injuries to hospitals. Final session of the workshop was conducted by Dr. C Thurairaja, former President of the Sports Medical Association of Asia and he explained the role of a physician in the support group of a sports team or an individual sportsman or a woman. The individual sessions were followed by a question and answer session where the enthusiasm of the participants was quite evident. All participants agreed that this workshop was quite useful and added another dimension to their knowledge on dealing with sportsmen and women and their were many requests for more training programs on sports medicine to be conducted in the future as well. The SLMA wishes to thank Prof. Arjuna de Silva and Dr. Dhammika Senanayaka of The Sports Medicine Institute for their help in organizing this workshop.

Story: My Wife Doesn't Work ! Conversation between a Husband (H) and a Psychologist (P): P : What do you do for a living Mr. Bandy ? H : I work as an Accountant in a Bank. P : Your Wife ? H : She doesn't work. She's a Housewife only. P : Who makes breakfast for your family in the morning? H : My Wife, because she doesn't work. P : At what time does your wife wake up for making breakfast?


H : She wakes up at around 5 am because she cleans the house first before making breakfast. P : How do your kids go to school? H : My wife takes them to school, because she doesn't work. P : After taking your kids to school, what does she do ? H : She goes to the market, then goes back home for cooking and laundry. You know, she doesn't work.

P : In the evening, after you go back home from office, what do you do ? H : Take rest, because i'm tired due to all day works. P : What does your wife do then ? H : She prepares meals, serving our kids, preparing meals for me and cleaning the dishes, cleaning the house then taking kids to bed. Whom do you think works more, from the story above ???

The daily routines of your wives commence from early morning to late night. That is called 'DOESN'T WORK' ??!! Yes, Being Homemakers do not need Certificate of Study, even High Position, but their ROLE/PART is very important! Appreciate your wives. Because their sacrifices are uncountable. This should be a reminder and reflection for all of us to understand and appreciate each others roles.



September, 2013


Broadening Gender Attitudes to Improve the Health and Wellbeing of Women and Men A Pre-congress workshop

18th Annual Scientific Sessions of the College of Community Physicians of Sri Lanka 21st September 2013 Board Room, Faculty of Medicine, University of Colombo Jointly Organized by

College of Community Physicians of Sri Lanka and The Expert Committee on Women’s Health of the Sri Lanka Medical Association 08.45-09.00 am


09.00-09.05 am

Welcome address

Dr. Susie Perera, President, College of Community Physicians of Sri Lanka

09.05-09.10 am

Introductory remarks and Introducing the Chairpersons

Dr. Nalika Gunawardena, Chairperson, Expert Committee on Women’s Health, SLMA

09.15-10.00 am

Attitudes of men and women in Sri Lanka towards gender-based violence and gender equality - findings of the study, CARE International

Prof. Neloufer de Mel, Professor of English, Department of English, University of Colombo

10.00-10.30 am


10.30-11.15 am

Influence of gender attitudes on sexual and Ms. Ramani Jayasundere Senior Technical Advisor (Law and gender based violence Justice) The Asia Foundation, Sri Lanka

11.15-12.00 pm

Spaces and opportunities to broaden attitudes towards gender in workplaces

Prof. Maithree Wickremasinghe, Director, Centre for Gender Studies, University of Kelaniya

12.00-12.45 pm

Spaces and opportunities for broadening gender attitudes as healthcare professionals

Dr. Lakshman Senanayaka Senior Gynaecologist and Obstetrician, Consultant to UNFPA


Concluding remarks followed by lunch Sponsored by: The World Health Organization

Only 80 participants can be registered Contact: Dr. Shamini Prathapan for registration Email:

6 Continuous Professional Development points will be awarded

All are Welcome!!

Dear SLMA Members, We will be undertaking visits to out-station collaborative activities as listed below. Foundation Sessions in collaboration with The Annual Scientific Congress of Anuradhapura Clinical Society 23rd – 25th October 2013.

Provincial Meetings: a. Jaffna

10th – 12th October 2013

b. Batticaloa

6th – 8th November 2013

c. Matara

20th – 21st November 2013

d. Avissawella 13th December 2013

Please contact the SLMA and give your names if you wish to join us for these activities. Transport will be organised by the SLMA. Expenses for accommodation etc will have to be borne by the participants. Best regards. Dr. B. J. C. Perera President, SLMA


In collaboration with International Network for Availability of Scientific Publications (INASP), Oxford, UK. and The Ceylon Medical Journal

“Scientific Medical Writing Made Easy” At the SLMA Lionel Memorial Auditorium on 28th November 2013 Programme : 7.30–830



Approaching a Writing Project, Choosing a Target Journal and Using Its Instructions to Authors


The Structure of a Scientific Paper – IMRAD format, Title, Abstract, Index words, Introduction


Tea Break


Writing the Methods Section, Results Section and Discussion


Writing the Acknowledgements, References, Preparing Tables and Figures, Cover letter


Basics in writing style, What do editors want?



Afternoon (for small groups) 13:30–14:00

Participants to write short words instead of long phrases from a given note


Writing the missing section of a sample paper given to a small group

15:00–16:00 16:00–16:30 16.30

Presentations by the small groups Evaluation, Distribution of certificates and Conclu sion of the Workshop Tea

Pre-workshop on-line interactive activity (on Moodle) will commence 4 weeks prior to the workshop. It will require a total of 6-8 hours of dedicated on-line time (at your convenience).Prior familiarity with Moodle NOT required.

This workshop has been oversubscribed within 48 hours of first announcement via the SLMA e-mail list.


September, 2013

Quality of Healthcare research fi Dr. Ravi Rannan-Eliya PhD Fellow and Director, Institute for Health Policy Dr. K.C.Shanti Dalpatadu MBBS(Cey),MD(Community Medicine) SL,FCMA(SL) Senior Fellow, Institute for Health Policy, Former DDGHS (Planning), Ministry of Health


he findings of two research studies titled “Quality of inpatient care in public and private hospitals in Sri Lanka” and “Quality of outpatient care in public and private sectors in Sri Lanka – how well do perceptions match reality and what are the implications?”, presented by the Institute of Health Policy (IHP) at the research symposium hosted by the Sri Lanka Medical Association (SLMA), Sri Lanka College of Medical Administrators (SLCMA) and IHP held at the Lionel Memorial Auditorium Colombo 7, on 30 August 2013 evening, were well received and led to a lively discussion. Dr. Nilmini Wijemanne, Research Associate, IHP made the presentations while Dr. Ravi Rannan-Eliya, Fellow and Director, IHP joined the discussion thereafter. The session was chaired by Dr. Palitha Abeykoon, President elect SLMA, who was joined by Dr. Sunil de Alwis, President SLCMA, and Dr. Amal Harsha de Silva, President elect SLCMA at the head table. During the opening remarks they highlighted the importance of good research on quality of healthcare in order to supplement the achievements already made in the health field in our country. Through research work of this nature, both strengths and weaknesses of the current health system could be identified. They observed that this in turn will help to strengthening the health system of the country further. “Do clinical quality and interpersonal quality differ between the public and


private sectors” was the main research question posed, and was common to both studies. Making use of the healthcare quality dimensions postulated by Avedis Donabedian in 1980 that looked at the structural, process and outcome characteristics, this study focused on the aspects related to the latter two. The study was conducted in three districts, Colombo, Gampaha and Galle, and was funded by the World Bank. With regard to in-patient quality, the study covered 11 government and 10 private sector hospitals. Review of inpatient medical records to analyze care using tracers as well as other conditions was the approach used to measure process quality (i.e. what providers actually did). Acute myocardial infarction, acute asthma and childbirth were the tracer conditions selected for their commonness. In addition, the study also analyzed quality of care for stroke, transient ischaemic attack, acute exacerbation of COPD, heart failure, dengue and pneumonia. All these conditions complied with strict inclusion criteria based on ICD coding. A retrospective study of medical records of 2,523 patients in the public and 1,815 in the private sector was carried out for this purpose. In-patient quality indicators, which were 55 in total, were also categorized into indicators pertaining to resource intensity (subdivided as low, medium and high), drug prescribing and clinical area (which looked into assessment and investigations, management and outcomes). In summary, the salientfindings that surfaced from the in-patient study were that the quality of care was fairly similar in both public and private sectors, although the public sector was slightly better. However, the private sector performed better in areas that were resource intensive. The smaller hospitals, both in the public and private sector, tended to perform slightly better

than their bigger counterparts in relation to low resource intensity indicators. The second study, which focused on outpatient quality of care and patient satisfaction, looked at process quality of care as well as patient perceptions. It was conducted in 10 outpatient departments (OPD) of government hospitals and in 66 general practitioner (GP) settings covering the private sector. A total of 1,971 patients, from both sectors, had been approached for the consent to participate. There were 1,027 patients in the public sector and 944 in the private who participated in the study. While 98.8% of the patents had consented for the observation of consultations, 97.8% of them participated in the exit survey as well. After obtaining permission from individual patients and attending physicians, patient consultations were observed by trained observers, who at the same time analyzed the quality of care using tracer conditions. There were a total of 39 quality indicators grouped into two broad categories in relation to clinical conditions and clinical areas. Clinical condition related indicators included diarrhoea, cough, hypertension, diabetes, asthma and pregnancy. Each indicator was categorized by clinical area also (history, examination, investigation and management and the patient education). An exit survey recorded the responses related to patient satisfaction and socio-economic background including ethnicity. The patient satisfaction component enquired about the technical quality, interpersonal relations, physical structure and overall impression about the encounter. All the indicators used, both for in-patient and outpatient quality, were reviewed by a panel of clinicians. The study concluded that, with regard to outpatients, the overall quality, diagnosis and treatment were similar between the public and private sectors.

September, 2013


findings led to lively discussion Patient satisfaction rates reflected this finding as overall satisfaction and satisfaction with technical aspects being similar between the two sectors. However, patients in the private sector received more time and advice from the attending physicians. Also, the satisfaction with interpersonal quality and structural components (eg. cleanliness of the facility) were better in the private sector. On the other hand, with regard to the socioeconomic and ethnic groups, there were no large systematic differences seen. The two presentations were followed by an open discussion, which was moderated by Dr. Ranjan Dias, Chairperson Working Group on Healthcare Quality and Safety of the SLMA and Dr. W. Karandagoda, Director Medical Services, Lanka Hospitals. Many in the audience, including health managers, consultants, general practioners, post-graduate trainees, medical administrators, journalists and patient rights activists joined in a lively discussion that ensued. Dr. Rannan-Eliya and Dr. Wijemanne answered the queries related to the study. A common sentiment shared by many of the participants was the need for more studies of this nature. As the country lacks authentic studies on healthcare quality covering large number of people and geographical areas, this study would serve as a benchmark opined some observers. At the same time concerns were raised over the need for future studies including more districts to cover all the provinces of the country. The event was attended by over fifty participants.

Dr. Palitha Abeykoon, President elect SLMA, Dr. Sunil de Alwis, President SLCMA and Dr. Amal Harsha de Silva, President elect SLCMA

Dr. Nilmini Wijemanne

Dr. Ravi Rannan-Eliya

Dr. Ranjan Dias and Dr. W. Karandagoda

The participants



September, 2013

Jawatte Lunatic Asylum:

the forgotten relict of the colonial era Nalaka Mendis, Emeritus Professor of Psychiatry, University of Colombo


n western countries, since the nineteen-seventies and -eighties a number of new housing, office, cultural and health projects have come up in renovated and remodeled asylums which have become redundant as a result of relocation of mental health care services to General hospitals and Community facilities. It is interesting that in Sri Lanka, the Urban Development Authority together with the Defense Ministry is in the process of renovating a one hundredand-twenty-five year old colonial building located between the independence square and Bullers Road. I am referring to the Jawatte Lunatic Asylum established in the late eighteen-seventies at the south-eastern edge of Cinnamon Gardens, threeand-a -half miles from Queens House in an area known as “Kumbikelle”. It is indeed a coincidence that in 1876 Governor Sir William Gregory referring to the new proposal to build an Asylum in Colombo said “The building will be a credit to the Colony”, and “while every modern appliance for the comfort of the inmates is provided, the building whether the exact present plan be adhered to or modified, will be from its structural merits and decorative character of the grounds attached to it one of the future ornaments of this city”.

Emergence of asylums in Europe- The Lunatic Asylum is a

product of nineteenth century Europe and reflected the predominant approach towards care of those with “lunacy”. Similarly the disappearance of “Asylum Care” and the emergence of “Community Care” is a twentieth century phenomenon, which evolved in Europe as a result of social, scientific and political developments. This revolution has had far reaching


influences all over the world and my aim is to briefly touch on some of the important aspects of this development from a clinical perspective in the colonial and post- colonial period. This review is based on reports on the subject available in the National Archives in Colombo and scholarly work. People with deviant or bizarre behavior appeared to have been cared for by their families from early times. In the early part of the nineteenth century in European countries, with the introduction of “Moral Care”, an approach in line with the care of the sick, Asylums came into being. The tranquil living environment away from crowded centres, engagement in leisure, appropriate food, work and community living was thought to be therapeutic to facilitate early recovery from lunacy. These institutions were established to provide compassionate care with least possible restraint, confinement and control. Dr. John Connolly the Superintendent of Hanwell Asylum, the first purpose built asylum expressed the underlying philosophy that led to the emergence of asylums in the west thus “man of rank comes

in, ragged and, dirty, and unshaven and with the pallor of a dungeon upon him; wild in aspect, and as if crazed beyond recovery. He has passed months in a lonely apartment, looking out on a dead wall; generally fastened in a chair [...] Liberty to walk at all hours of the cheerful day in gardens or fields, and care and attention, metamorphose him into the well dressed and well bred gentleman he used to be”. Most of the asylums were built on a “Pavilion Model” where a central administrative block was connected to two wings on either side, each wing having patient areas with the administration and services located in the middle block. Meticulous attention was paid to organization of spaces in order to provide ventilation, light, water supply, sewage disposal, washing, storage, cooking, easy supervision and care of mentally ill with different grades of seriousness. During the Victorian period large ornate imposing buildings with well landscaped gardens in tranquil surroundings were created in many western countries, away from cities. Similar Asylums were erected in the colonies too. Contd. on page 20


September, 2013 Contd. from page 18

Jawatte Lunatic Asylum... Disappearance of Asylums -Why did asylums disappear from western countries?

Firstly due to the deterioration of standards of care in the Asylums which led to “incarceration” of ‘lunatics’ rather than “treating” them. Towards the beginning of the twentieth century some asylums in western countries could not invest adequately to sustain trained staff, facilities, treatment approaches and funds to provide good quality care. Compassionate and humane care approaches gradually turned into custodial care in prison-like institutions with hardly any opportunity for the inmates to lead an active, sociable life under hygienic conditions. Asylums in general acquired a bad reputation over the years for ill-treatment, cruelty, neglect, inactivity, violation of rights and incarceration of helpless people which were brought to the notice of the public by activists. Asylums were looked upon with ridicule and disgust and were seen as “loony bins” or “nut-houses”. Secondly, the emergence of an alternative model of care. In the sixties

due to a considerable amount of professional, social and political activism the emerging model of “Community Care” replaced the asylum concept. Biological, psychological and social factors interacting in a complex manner were thought to result in various types and grades of mental distress or disease. The nature of the disease processes was better understood. This approach coincided with the emergence of a new generation of very effective medicines which could be dispensed to patients in General Hospital wards or at home. Recognition and respect of human rights of the mentally ill, reforms of mental health legislation, the changing public attitudes towards mental illness, emergence of psychosocial care, and the advantages of offering treatment close to home have been additional factors responsible for this new development, now called “Community Care”.

The Borella asylum- The need to establish an asylum for the care of the insane in Ceylon arose when it was noticed that a number of lunatics were languishing in jails, and conse-

quently in 1839 the lunacy ordinance was enacted giving the Governor the power to establish asylums. Initially Lunatics were housed in the Leper Asylum and in 1847 they were transferred to the new Asylum built in Borella largely due to the efforts of Dr. Christopher Elliot and Governor Stewart McKenzie. Apart from the first Superintendent who was an assistant to famous Dr. Connolly of the Hanwell Asylum, London, all the successors were Ceylonese. With minimum resources and trained staff the Asylum progressed very well and developed into an institution of good standing with new forms of care including employment, recreation, leisure and existing treatment approaches.

Joint clinical meeting of SLMA with the Monargala Clinical Society. Dr Shyamale Samaranayaka MBBS, DFM, DCH, MD (Family Medicine), MRCGP (Int) Senior Lecturer in Family Medicine Faculty of Medical Sciences University of Sri Jayewardenepura Assistant Secretary, SLMA 2013


oint clinical meeting of Sri Lanka Medical Association with the Monaragala Clinical Society was held on 2nd May 2013 at the Auditorium of the District General Hospital (DGH), Monaragala. This programme mainly addressed the issues pertaining to the region according to the request made by the


doctors practicing in Monaragala. The meeting was well attended by the doctors in the Monaragala district. Dr. R M D Rathnayake, MS of DGH Monaragala welcomed the gathering. Dr. B J C Perera, the President Sri Lanka Medical Association emphasized the role of SLMA in providing continued medical education to the doctor across the country. Dr. Nirodha de Silva, Consultant Physician of the Base Hospital, Diyatalawa discussed the management of leptospirosis and shared the experience from the recent outbreak. Prof Aswini Fernando, Associate Profes-

sor, Department of Paediatrics, Faculty of Medicine, University of Kelaniya, enlightened the audience about the unseen problem, non-accidental injuries in children, which is known to be common in the region and when to suspect it to intervene early. Dr. Shyamalee Samaranayaka, Senior Lecturer in Family Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura spoke on rational use of antibiotics and pointed out the importance of rational prescribing to be cost effective and to prevent the emergence of antibiotic resistance. Contd. on page 22


September, 2013 Contd. from page 20

Joint clinical meeting... Principles of wound dressing in a patient with burns, was discussed by Dr. Yasas Abeywickrama, Consultant Plastic Surgeon, Colombo North Teaching Hospital. He spoke about the basic principles as well as recent advances in burns wound management. Dr Wasantha Wijenayake, Consultant Surgeon, National Hospital Sri Lanka did a session on fluid management in a surgical patient. He discussed about calculating fluid requirements and the different types of commonly used fluids and when to use what fluids. Dr Malik Fernando, the Secretary of the SLMA Snakebite Committee introduced the new guideline for management of snakebites to the audience and gave a brief outline on the identification and management of common bites. This followed a joint session by

velopmental delay in children. Dr. Samanmali highlighted the importance of early recognition of developmental delays and when to suspect and how to confirm them. Dr. Leenika focused her presentation on early identification of children with autism. Dr. Bandusiri Rathnayake, Consultant Physician, DGH Monaragala extended his gratitude to Sri Lanka Medical Association for organising this event and thanked all the doctors for their participation. Along with the main clinical programme, there were two other programmes conducted for nurses and other health care providers. Nurses’ programme was on key principles and new developments in immunization. This was facilitated by Dr. Kalyani Guruge, Consultant Paediatrician, Vice President of

SLMA and Dr. Sudath Peiris, Assistant Epidemiologist from the Epidemiology Unit. Sixty three nurses from Monaragala district participated in this programme. The health education session on personal hygiene and disease prevention for the health care workers was conducted by the courtesy of Reckitt Benckiser. During this session participants were educated on hand washing, body hygiene and keeping the hospital environment clean and safe. All three sessions in Monaragala ended as very successful progammes and were well appreciated by the participants.

Dr. Samanmali Sumanasena, Senior Lecturer, Department of Paediatrics, Faculty of Medicine, Colombo and Dr. Leenika Wijerathne, Senior Lecturer, Department of Psychiatry, Faculty of Medicine, University of Kelaniya on early identification of deContd. from page 2

Newborn Screening for... The program challenges are yet to perceive, however the dedicated team of the NMU and Prof. Sujeewa Amarasena of Department of Pediatrics is willing to offer the maximal possible care to the entire country. New cadre request has already made but yet to materialize. Therefore, preparations of request forms (including pasting filter paper and enveloping) as well as data entry are handled by students of the Faculty of Medicine (medical and allied health students). Sample analysis is handled by three young technical officers and without their commitment nothing will be successful. Main-


tenance of the web site is handled by Mr. Asela Weerasekara, of the Faculty IT Unit. I wish to acknowledge all who have been instrumental in this program. Further with special thank to the Dr. Dhammica Rowel of the Family Health Bureau for her continuous support and guidance. The Chairman and staff of the NRC never let us down in this program and make sure sufficient funds are available to us. I wish to reiterate that this is not a profit making service but more a community service project of the Faculty of Medicine, University of Ruhuna.

References: 1.Nanayakkara DKK (2007) The Practice and Limitations of Screening for Congenital Hypothyroidism in Selected Hospitals in Sri Lanka. PhD thesis, University of Peradeniya 2.Manjula Hettiarachchi, Chandrani Liyanage and Nayana Liyanarachchi (2009) Screening newborns for congenital hypothyroidism. Ceylon Medical Journal. 54(1): 29-30 3.Manjula Hettiarachchi (2009) Setting up a regional network to screen newborns for congenital hypothyroidism in Southern province in Sri Lanka. Galle Medical Journal, 14 (1) 59-61.


September, 2013



Sunday 15th September 2013



Lionel Memorial Auditorium, 6, Wijerama Mw., Colombo 07

AGENDA Session I


Dr. B J C Perera/Dr. Palitha Abeykoon

8.30 - 8.45 am

Welcome Address - Dr. B J C Perera

8.45 - 8.55 am

Introduction & Cadre - Dr. Champika Wickramasinghe

8.55 - 9.05 am

Medicine & Finer Specialities


Dr. Ananda Wijewickrama

- Dr. M K Ragunathan 9.05 - 9.15 am

Post Graduate Training Programme -

Prof. Jayantha Jayawardana

9.15 - 9.25 am

Psychiatry - Dr. Raveen Hanwella

9.25 - 9.35 am


Session II Chairman - Dr. Dudley P Perera 9.40 - 9.50 am

Armed Services - Dr. N E L W Jayasekera

9.50 -10.00 am

Medical Administration


Dr. Sunil de Alwis

10.00 -10.10 am

Venereology - Dr. Jayadari Ranathunga

10.10 -10.20 am

Paediatrics - Prof. Sujeewa Amarasena

10.20 -10.30 am

Universities - Prof. Vajira H W Dissanayake

10.30 -10.40 am

QUESTIONS 10.40 am – 11.00 am


Session III Chairman - Dr. V Murali 11.00 -11.10 am

Obstetrics & Gynaecology

11.10 -11.20 am

Dermatology - Dr. Indira Kahawita

11.20 -11.30 am

General Practice - Dr. Jayantha Thambar

11.30 -11.40 am

Pathology - Dr. Isha Prematillake

11.40 -11.50 am

Private Sector - Dr. Samanthi de Silva

11.50 -12.00 noon



Dr. Hemantha Perera

Session IV Chairman - Dr. Shanti Dalpatadu 12.00 -12.10 pm

Surgery & Finer Specialities

12.10 -12.20 pm

Microbiology - Dr. Malka Dassanayake

12.20 -12.30 pm

Community Medicine - Dr. Paba Palihawadana

12.30 -12.40 pm

Forensic Medicine - Dr. Ajith Tennakoon

12.40 -12.50 pm



Prof. Ranil Fernando

Session V Chairman - Dr. S Sridharan 12.50 - 01.00 pm


01.00 - 01.10 pm

Radiology - Dr. Udari Liyanage

01.10 - 01.20 pm


01.20 - 01.30 pm

Otorhinolaryngology - Dr. Shantha Perera

01.30 - 01.40 pm



Dr. Kumuduni Ranatunga

- Dr. Madhuwanthi Dissanayake


Slmanews 2013 09  
Slmanews 2013 09  

The official news paper of the Sri Lanka Medical Association