Doctor, my blood pressure is normal already, so I stopped taking the medicine.
Almost every general practitioner (GP) has heard some version of this sentence.
And from the patient’s point of view, it sounds perfectly logical.
When the fever disappears, we stop taking fever medicine.
When the cough improves, we stop the cough mixture. So when the blood pressure becomes normal, why continue the tablet?
The problem, of course, is that the blood pressure may be normal precisely because the tablet is working!
Stopping it because the reading has improved is akin to switching off the refrigerator because the food has been adequately chilled.
That small misunderstanding illustrates a much larger challenge facing Malaysian healthcare.
We have become accustomed to thinking about medicine in a series of episodes.
Fever. Cough. Pain. Medicine. Recovery. Done.
This model works reasonably well for short illnesses but far less well for the conditions that will increasingly determine how healthy we remain as we grow older.
Creeping in silently
Hypertension does not respect consultation episodes.
Neither does diabetes.
Neither do obesity, kidney disease, cardiovascular risk, frailty, dementia or many mental-health conditions – they unfold quietly across the years.
A stroke can happen in the morning. But the risk that leads to it may have been building silently for a decade.
The ambulance sees the final event. The emergency department sees the paralysis. The computed tomography (CT) scan sees the damaged brain.
But long before that morning, there may have been dozens of opportunities to change the trajectory: rising blood pressure, increasing weight, smoking, poorly controlled diabetes, missed doctor’s appointments, medication stopped because the patient felt well, or abnormal results that were never followed through.
Healthcare becomes most visible when disease becomes dramatic.
Primary care matters because it can intervene while disease is still quiet.
That requires a fundamental change in how we see the GP.
The GP of tomorrow cannot remain primarily a doctor of episodes. The GP must increasingly become a doctor of journeys.
Take diabetes, for example.
Good diabetes care is not simply about lowering today’s glucose reading.
It means watching kidney function before kidney failure develops. It means managing cardiovascular risk before a heart attack occurs.
It means checking the feet before an ulcer appears, ensuring appropriate eye assessment before vision is damaged, reviewing medication, supporting realistic lifestyle changes and continuing the conversation when motivation fades.
The most important consultation may not be the one in which something dramatic happens.
It may be the ordinary review in which nothing dramatic is allowed to happen.
Who checks on the old?
The same is true for an elderly patient taking medicines for several conditions.
She may have hypertension, diabetes, osteoarthritis and mild kidney impairment.
She may have prescriptions from three different doctors and each prescription may be entirely reasonable.
But somebody still has to ask if she can actually manage all these tablets.
Why has she fallen twice?
Is she becoming frail?
Is she eating adequately?
Can she hear the instructions we are giving?
Is her memory changing?
And is the daughter bringing her to every appointment becoming exhausted as a caregiver?
Journeying with the GP
The human body does not live in medical departments.
Neither should healthcare.
Mental health presents the same challenge. Anxiety may arrive as palpitations. Depression may arrive as fatigue. Burnout may masquerade as headache, insomnia or “gastric”.
The doctor who sees only today’s symptom may repeatedly treat the symptom.
But the doctor who knows the patient’s history has a better chance of recognising the pattern. This is why continuity is not merely sentimental but is clinical information.
A blood-pressure reading has more meaning when the doctor knows what the previous 10 readings were.
A 5kg weight loss means something different when the doctor knows whether it was intentional.
A patient repeatedly complaining of “gastric” symptoms may look different to a doctor who remembers that the same patient has recently stopped sleeping, lost interest in work and has become unusually withdrawn.
Knowing the patient does not replace medical science but it gives medical science context.
Continuity also changes the meaning of follow-up.
Patients sometimes ask: “Doctor, I feel okay. Why must I come back?”
Sometimes, a follow-up is not an inconvenience surrounding treatment but a part of treatment.
The apparently uneventful blood pressure review may help prevent a future stroke.
The medication review may prevent an elderly patient from falling.
The repeat kidney test may identify deterioration while there is still time to intervene.
The second conversation about smoking may succeed when the first conversation did not.
These are not glamorous moments. But they are the daily mechanics of prevention. Clinics therefore need to change too.
Good chronic disease management cannot depend entirely on whether one doctor happens to remember that a patient has disappeared for six months.
Modern primary care needs systems: reliable electronic records, recall mechanisms, chronic-disease registers, vaccination histories, preventive care reminders, medication reviews and ways of identifying patients who repeatedly disappear from follow-ups.
A good doctor needs a memory. A good clinic needs one as well.
Patients, too, may need to reconsider the idea that healthcare begins only when symptoms appear.
Prevention first
Much of preventive medicine feels inconvenient because its benefit belongs to a future version of ourselves whom we have not yet met.
We take time off work for a blood pressure review when we feel perfectly well. We repeat a blood test even though nothing hurts. We discuss weight, smoking or exercise today because the disease we are trying to prevent may still be years away.
That can be a difficult proposition to sell.
But prevention has always involved acting before the danger feels urgent.
Policymakers must recognise the same reality.
Society cannot demand sophisticated chronic disease management while organising and financing primary care as though every consultation were still a quick cough-and-cold visit.
Prevention, counselling and care coordination take time.
Reviewing five medicines takes longer than manufacturing five medicines.
If the healthcare system values only activity and volume, it should not be surprised when activity and volume are what it gets.
The future must increasingly value what actually matters: better disease control, earlier intervention, appropriate referral, medication safety, prevention and continuity.
This does not mean every patient must be forced through a rigid gatekeeping system.
Nor does it mean the GP should replace specialists.
Quite the opposite.
A good GP should know what belongs in primary care and recognise quickly what does not.
The specialist brings focused expertise when a condition requires it.
The hospital manages acute, advanced and highly specialised care.
The GP provides continuity, manages complexity that can safely remain in the community, identifies deterioration early, prevents avoidable decline where possible, and ensures that patients reach specialist care when specialist expertise is needed.
The different parts of medicine should complement one another, not compete.
That is what it means to move from treating episodes to caring for journeys.
Malaysia does not simply need more encounters with healthcare.
It needs better continuity between those encounters.
And that leads to the next challenge.
We already have thousands of clinics, hospitals, laboratories, pharmacies and doctors.
Yet too often, the patient is still expected to connect them all.
Dr Carollyn Kek Chee Yen is president of the Private Medical Practitioners’ Association of Selangor and Kuala Lumpur (PMPASKL), Dr Chang Chee Seong is the honorary secretary, and Dr Eugene Chooi is the immediate past president. This is the second in a five-part weekly series on the future of general practice in Malaysia. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
