NEWS & VIEWS
GREETINGS FROM VENICE
FZ Zainal MMed (FamMed, UKM), Family Medicine Specialist, Klinik Kesihatan Putrajaya, Malaysia.
Address for correspondence: Dr Zainal Fitri Zakaria, Klinik Kesihatan Putrajaya, No 1 Jalan P9E Presint 9, 62250 Putrajaya, Malaysia. Tel: 03-88883057, Fax: 03-88883054, E-mail: drzainal2000@gmail.com
Zainal FZ. Greetings from Venice. Malaysian Family Physician. 2008;3(1):55-57.
Buongiorno! Ciao!
These are two greetings you will hear often when you are in Venice. Buongiorno means ‘good morning’ and ciao (pronounced ‘chau’) means ‘hello’. Ciao also means good-bye, so people will say ciao when they meet and they will say the same when they leave.
My mission in Venice was to present the ‘Teleprimary Care – Case Mix Project’ at the 23rd Patient Classification System International Working Conference, on behalf of the Ministry of Health’s Primary Care Division. This project was done in collaboration with John Hopkins University (JHU) and World Health Organisation. It is the first Malaysian experience of analysing primary health care data using case mix software. The Lead Investigator is Dr Safurah Jaafar, assisted by the Teleprimary Care (TPC) team.
The conference was organised by an independent organisation called Patient Classification Systems International (PCSI). This organisation creates a network of researchers and users of the case mix concept from health service administration, government agencies, and academia. From the initial focus on the Diagnosis Related Groups (DRG), the association’s goals have expanded to include a broader interest in clustering and grouping techniques of clinical and administrative data for health care management and financing. Essentially, case mix is the science of ‘grouping patients’ to create classes, which are relatively homogenous in respect to the resources used by taking into account severity of illnesses, patient age, co-morbidities and complications. This new group of patient database is very useful for risk adjustment, capitation, predictive modelling and resource distribution.
Travelling alone is less enjoyable when we go to a place which we have never been. A few weeks before my journey, I sought information about Venice and Italy from books, the internet, friends and patients. To ensure I would be always reachable and have no problems abroad, I activated the roaming service of my mobile telephone as well as the Maybank Plus service to allow me to withdraw cash from any ATM abroad.
To reach Venice, I need to transit in Paris, a 12-hour journey from Kuala Lumpur. Luckily this long-haul flight was easier to endure that I thought, thanks to the excellent Malaysian Airlines’ Business Class. The seat was spacious, comfortable; it could be transformed into a flat bed and equipped with a ten-minute massager. The menu had lots of variety and food come in multiple courses. I was absorbed by the multi-channel in-flight entertainment system showing interesting information of popular travel destinations all over the world. There was also language lesson, and I managed to learn a few basic Italian phrases while on board.
It was 7am Malaysian time, almost 6 hours after boarding when I was awakened by an air steward. The view outside the window was still dark and the navigator on the small monitor in front of my seat showed that the plane was flying somewhere above a desert in Afghanistan. The air steward asked me whether I was a medical doctor and whether I could see a French boy who was suffering from diarrhoea and vomiting. I showed him my MMA card and agreed to see the boy.
“Bonjour,” I greeted the boy and his parents in French. After introducing myself I took a brief history from them followed by a quick physical examination on the boy. It seemed that the boy had acute gastroenteritis and oral medication given earlier by the air steward did not help. I asked the steward whether they had any injection. He then led me to a medical container that was only permitted to be opened by a certified medical professional. Fortunately I found a few ampoules of Stemetil and oral rehydration salt in there. After discussing the matter with the boy and his parents, they agreed to the injection. Everyone felt relieved when the injection worked and that was one of the great moments where you really feel that it is worthwhile being a family physician.
I reached the Charles De Gaulle International Airport, Paris, at dawn (6am local time). The temperature outside was 5 degrees Celsius. The airport buildings were scattered in one large area so I have to take a shuttle bus and train to the terminal. The congested tunnel-shaped terminal seemed almost claustrophobic. I had to join a half-mile queue to get my passport stamped. The immigration officer welcomed me with a grim, stern, face and only let me go after I showed him the conference registration letter. Soon after, everyone had to go through a stringent safety screening before we were allowed to enter the departure gate.
I left for Venice with Air France and it took me two hours to reach the Marco Polo International Airport. The Aeroporto di Venezia Marco Polo, as the Italians call it, is named in honour of its famous citizen. It is situated around 7 km north of Venice, on the edge of the lagoon. From there you have a few options to enter Venice either by land or sea. To give me the best possible introduction to the city, I decided to take a water bus.
Caption: At the gondola stand; Brasilica di San Marco.
As the water bus cruised through various stops around Venice, my jet-lagged eyes were suddenly bedazzled by the spectacular view of this ‘floating’ city. Elusive and enigmatic, Venice is a dreamlike place that defy description. Countless artists have tried with pen and brush to render the shimmering lagoon with its slender bell towers. World-famous for its canals, Venice was built on an archipelago of 118 islands formed by about 150 canals in a shallow lagoon. The islands on which the city is built are connected by about 400 bridges.
A brief stint at Piazza San Marco (St Mark’s Square) is all it takes for me to appreciate Venice’s diverse and rich heritage. Its history can be read in every monument and palazzo; in fact each and every stone bears witness to periods of splendour and past glory. The city could be described as a gigantic open-air museum, visited each year by millions of tourists from all over the world. Founded fifteen hundred years ago, Venice rose to become Europe’s main trading post between the West and the East, and at its height controlled an empire that spread north to the Dolomites and over the sea as far as Cyprus. Nowadays it is no longer a living metropolis but rather the embodiment of a fabulous past; its survival dependant on the people who come to marvel at its relics.
Caption: Pallazo Ducale.
The two prominent buildings at the Piazza are the Basilica di San Marco and the Palazzo Ducale. The Basilica di San Marco is the most mystical and exotic of Europe’s cathedrals. Dan Brown, of ‘The Da Vinci Code’ fame, must have had a field day here. The combination of ancient structures and later decorations is to a great extent what makes the cathedral so bewildering. In contrast, the adjacent building of Palazzo Ducale is decorated with geometric-patterned stonework resembling Islamic art. Perhaps this is one example of Islamic architecture that remains intact to this day. Venice's economic and diplomatic relationship with the Islamic world from the seventh century onwards is well documented. As Byzantium gradually gave way to Islamic caliphates from the eighth century onwards, meeting its ultimate demise in 1453 at the hands of the Ottoman Sultan Mehmet II, Venetians increasingly came into contact with Muslims and their ideas, culture, and way of life. As a result, Venice became Christian Europe's most important interface with the Muslim civilisations of the Near East. During my visit, there was an exhibition entitled ‘Venezia el Islam’ that examined the relationship between Venice and the Islamic world over a thousand-year period, focusing on artistic and cultural ideas.
Caption: water bus cruising under the Rialto Bridge.
Walking north of the piazza would lead you to a labyrinth of medieval streets that are occupied by a variety of shops selling merchandise ranging from souvenirs, antiques, clothes, leather and the famous Murano glass. Many of the first-rate Italian designers and fashion houses are here: Gucci, Armani, Max Mara, Prada, Valentino, United Colors of Benetton, Stefanel, etc. For those with a deep pocket, this is a great place to indulge in shopping. But for me (who prefer to buy things at pasar malam and during mega sales), I can do window shopping.
As one of the most expensive cities in Europe you would expect everything to be expensive in Venice. The small hotel room that I stayed at cost me €140 (RM670) per night. An hour of riding a gondola through the canals will cost you €160 (RM768). You really need to have enough cash in order to enjoy Venice.
Caption: canal.
The conference itself was held on Lido Island; a southern island of Venice about 20 minutes away by boat. The exact venue was at the Palazzo del Cinema where the annual Venice Film Festival (the world’s oldest and most important film festival in Europe after Cannes) is usually held. In contrast with the bustling Venice, Lido is amazingly quiet, serene and peaceful to the point of pleasant somnolence.
With more than 300 participants from 36 countries all over the world, the conference was a great forum for sharing. Every speaker presented his or her own project and enlightened others of his or her experience in using and implementing the case mix system in their country. Dr Safurah was right when she persuaded me to pursue this area. Not everybody involved in the case mix project had a degree in Public Health; there were paediatricians, psychiatrists, rehabilitation physicians, nurses and even economists. To my surprise the person who presented the new version of a German DRG was a surgeon!
As the last speaker that day my nervousness eased a lot after seeing how the others performed. As you would expect, English was spoken with a great variety of accents and intonation, so I didn’t have to worry about my faulty English.
Generally the conference gave me a bird’s eye view on how case mix is implemented in different countries around the globe. While the case mix system is quite established in evaluating a hospital’s performance, it is a new kid on the block in the primary health care sector. Only a few developed countries are experimenting with this in primary care. I hope the knowledge I gained during the conference will be helpful in assisting the Ministry of Health’s Primary Care Division to develop our own primary care case mix system.