We invited Dr Lim Zhuang Li to share his perspective on Sport and Exercise Medicine (SEM) in his home country, Malaysia.

 

 

Tell us more about yourself

Salam Sejahtera! I am Lim Zhuang Li, a Sports and Exercise Medicine (SEM) Physician at Hospital Tengku Ampuan Afzan, Malaysia. I obtained my medical degree (MBBCh) at Cardiff University in Wales and a postgraduate SEM qualification (MSpMed) at the University of Malaya, Kuala Lumpur. I am presently on a clinical attachment at the University Hospital Southampton in the UK, where I am learning about Cardiopulmonary Exercise Testing in Perioperative Medicine.

 

 

I primarily see patients in the clinic for musculoskeletal-related conditions and injuries. Additionally, I oversee most pre- and post-operative rehabilitative care for sports arthroscopy cases. Exercise training is frequently integrated into our treatment approach for various non-communicable diseases. Apart from my clinical responsibilities, I serve as the team physician for junior athletes in Team Malaysia (regional volleyball and swimming). However, most of my patients come from the general population, as our profession is subservient to the Malaysian Ministry of Health (MOH).

I enjoy classical music and endurance sports, competing in various duathlons, triathlons, and marathons most months during my peak competitive years until fatherhood took me on a temporary hiatus from the rigours of training!

People often associate SEM physicians with athletic care. Yet, most patients just want to improve their health and functional well-being. We also occasionally encounter performing artists in our clinical care, such as dancers and instrumentalists, who often suffer from various medical ailments, predominantly musculoskeletal. I believe that the SEM community in Malaysia can play a more active role in managing these ‘unseen’ high-level performers.

 

What is the path to becoming a sport and exercise physician in Malaysia, and what are the main hurdles on this path?

Malaysia’s success in winning the bid to host the 1998 Commonwealth Games was a significant catalyst for establishing SEM as a speciality in the country. One of the requirements for hosting the event was that the host nation had qualified sports physicians stationed at each venue. This led Malaysia to send some of its doctors to Australia for a two-year diploma course in SEM.

At the same time, in 1997, the University of Malaya introduced a Master of Sports Medicine (MSpMed). Unlike our counterparts across the globe, where SEM is an area of particular interest/subspeciality, the training in SEM here is unique as it is viewed as a standalone, independent speciality where the pathway is akin to the route taken by an orthopaedic surgeon, an ophthalmologist or even a psychiatrist traverses to qualify as a specialist. Our first in-house candidate graduated in 2001 through the four-year postgraduate clinical program. Ideally, SEM doctoral applicants should have working experience in orthopaedics, primary care, internal medicine or emergency medicine to be eligible for the subspecialty training program. Before applying, most applicants would have worked for at least four years in various capacities at the MOH. Trainee placement occurs across various general hospitals over the greater Klang Valley, the National Sports Institute (NSI) and other sports science facilities.

Currently, there are more than 73 practising SEM physicians across Malaysia. A recent publication by Hirman (2023)examined speciality presence and needs across Malaysian public health and indicated that SEM is fast approaching 1 in 350,000 specialist to population ratio by 2025. As a comparison, we presently have less than 9,000 medical specialists serving the various Ministry’s facilities in 26 essential speciality areas, including family medicine and public health. SEM physicians work in multiple settings, including the MOH, universities, the NSI, the Ministry of Defence and private practice. A large number of SEM physicians still serve the MOH. Competition to enter the program is increasing yearly, with only four to five physicians graduating annually.

 

How developed is collaborative work in SEM in Malaysia?

Most physicians work in tandem as team physicians within the more popular sports setups such as football, rugby, basketball, and badminton. From a state health perspective, we have good working relationships with the regional sports administrators and teams to oversee medical care for the athletes. Larger sports centres such as the NSI can access more specialised services such as exercise physiology, biomechanics, strength and conditioning, nutrition, psychology and physiotherapy to ensure optimal athletic care. Conversely, physicians from the MOH work closely with sports arthroscopy, arthroplasty, and occasionally hand and microsurgery surgeons, whom we tend to co-manage the pre- and post-rehabilitative care plans. Referrals do arrive from rheumatology, obstetrics and gynaecology, endocrine medicine, and primary care in incorporating targeted prescriptive exercises in managing non-communicable diseases.

The emerging field of perioperative medicine has led to the involvement of SEM to optimise patient fitness and medical conditions before surgery to improve post-operative outcomes. At the University of Malaya Medical Centre, SEM physicians collaborate with anaesthesia and surgical colleagues to lead perioperative cardiopulmonary exercise testing and rehabilitative optimisation of patients undergoing major intra-abdominal surgery such as colorectal, vascular, hepatobiliary, and pancreatic surgery. We know that fitter patients are more likely to experience less intra- and postoperative morbidity. Therefore, getting patients fit for surgery is a growing trend worldwide, and I believe SEM physicians are well-positioned to lead this exciting development in the future.

Nationally, the Malaysian Association of Sports Medicine (MASM) has been the leading representative body for the interest of our wider community. As a speciality, we are working hard to create a collegiate for SEM under the auspices of the Academy of Medicine Malaysia (AMM) to facilitate a more cohesive and united voice for our fraternity.

 

Are exercise physiologists/scientists integrated into your healthcare system, and does health insurance cover their services?

Unfortunately, exercise physiologists are not integrated within the public healthcare system as there are no recognised job positions within the MOH. Nevertheless, some university hospitals have created a pathway for their appointments to be embedded within the broader clinical service, with many MOH physicians eager to see this initiative expanded. Notably, private health insurance does not cover their services.

Nevertheless, exercise physiologists are wholly integrated within the healthcare set-up of our NSI, which manages elite athletes. However, this employment pathway falls under the jurisdiction of the Youth and Sports Ministry and is not led by MOH.

 

What is done in Malaysia to promote SEM among students and young professionals regarding research and clinical opportunities?

Some Malaysian universities offer a short teaching block or clinical exposure to SEM in their undergraduate programs. This is a significant improvement from 10 years ago when SEM was still relatively unknown. More junior doctors are also interested in applying for the SEM training program. Quite a few even undergo a period of clinical attachments to gain exposure and make the necessary contact points before applying for postgraduate training.

However, there is still no established pathway for SEM physicians to pursue an ‘area of special interest’ or ‘sub-speciality training’ within the MOH. This has been a long-standing frustration among the fraternity. However, this year, two candidates have successfully obtained educational grants from the MOH to train in (1) cardiopulmonary exercise testing in perioperative medicine and (2) pain intervention in musculoskeletal medicine. This is a promising development, and we hope it will expand the SEM service repertoire and create pathways for further sub-specialised training.

University-employed physicians presently lead most clinical research work. Placing greater emphasis on research as a more significant aspect of crucial performance indices in work-based appraisals might help encourage more MOH physicians to contribute, as we are guilty of prioritising our clinical service!

In summary, establishing pathways for sub-speciality training and facilitating mandatory research would be a significant step forward to broaden our horizons.

 

If you were Harry Potter, what would you change to SEM in Malaysia?

SEM physicians are often misconstrued as solely treating sports injuries, leading to inquiries about whether we specialise in sports surgery or sports science. However, our practice predominantly involves non-surgical procedures, focusing on comprehensive clinical and medical care. I believe this misunderstanding arises from the terminology (sports and medicine) and the administrative placement of SEM under the broader orthopaedics department, which is predominantly a surgical-led speciality. Occasionally, even my neighbours mistake me for a physiotherapist, as the concept of SEM remains unclear. Notably, we continue to encounter inquiries from ministry authorities regarding our role in healthcare, particularly during transitions to new leadership. Many of my colleagues and I invest significant time explaining our services and skill sets when working in a new hospital or interacting with colleagues from other specialities. I commend our senior SEM consultants and especially our Head of Speciality Service for their persistent efforts in advocating for our profession, ensuring efficient service delivery, implementing effective clinical governance, and fostering strong teamwork to promote the well-being of our patients in the face of adversity.

If I were Harry Potter, I would strive to establish SEM as a rightful independent department based on its merits. This would help dispel current misunderstandings and raise the profile of SEM. This would give SEM physicians the recognition they deserve for their wide range of skills and expertise. Carpe diem!