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IN 2012, the medical fraternity was shocked when our previous health minister announced that private institutions will be included as institutions conducting MQE examination. It use to be only UM, UKM and USM. With the announcement, some of the established private universities were selected to conduct the MQE examinations which is basically their own final year examination. The other shocking statement from our minister was that, unlimited number of sitting will be allowed  and the student can choose where they want to sit for the exams. I wrote about it over HERE. Personally, I feel that any professional exam should have a limit. Even nursing board examinations has a limit. Even final year medical school examinations and post-graduate examinations have a limit on the maximum number of sittings. Subsequently , MMC released the amended regulations for MQE and the list of institutions. Section 4(3) of the regulations says that the candidate will be posted to the institution of their choice. Section 5 says that , the candidates have to follow the rules of the institution in resitting of the examinations and imposition of any fee.

Early this year, while I was talking to someone in MMC, I was told that they are going to change the rules again. The new 2015 regulations for MQE has been released and gazetted on 25/03/2015. The new rule says that once MMC finds you eligible to sit for the MQE examination ( if you fulfil the minimum entry requirement), MMC will decide on the institution where you will be sitting the examination (Section 4(3) ). The fee has also been increased to Rm 1 000 for application process (from the previous RM 200). It also says that you can only resit for a maximum of 3 times ! This basically means that if you fail the MQE for 4 consecutive times ( 1 + resit 3 times), you will never be able to practise as a doctor.

Frankly, I feel it is not worth going to an unrecognised university. With the current glut, the situation will only get worst.

Happy Merdeka Day 2015

Peraturan Ujian Kelayakan Perubatan 2015_25032015

While the country is being entertained by our political masters on a daily basis on who will be voted as the stupidest of them all, the medical fraternity was yet again shocked by a picture that was circulated via social media. I received the “picture” early yesterday morning which I felt need further evidence on it’s authenticity before saying anything.Then I was informed that it happened in Johor and in one of the main hospital in Johor Bahru. I was shocked and dumb founded!

IN June 2015, I wrote HERE about professionalism and ethics of doctors. The public view us or use to view us as the most educated group of people. They expect us to behave professionally. In that article, I mentioned that doctors should remain professional at all times, mind our words and should never reveal any personal information of any patients or take any pictures of any patients without their consent. These pictures taken should never be displayed in public domains. It should only be used for teaching purposes in close group discussions.

Unfortunately, a once respected profession is going down the drain. I had predicted many things in this blog over the last 5 years and even in my MMA articles almost 10 years ago. Many, which use to be just “rumours” had become reality. Many accused me of spreading rumours and scarring the future generations but had to swallow their own words along the way. A clerk in a hospital recently said that ” if a SPM result such as this can become a doctor, I should have become one!!“. That’s how bad the SPM results was, of an houseman. Remember my article over HERE ?

There is no doubt that the quality of doctors had deteriorated. I have to admit the fact. No point hiding it anymore. Call a spade a spade!. This picture which shocked me was something that I had never expected for a doctor to do. I can’t even imagine such a thing can happen. Something that I failed to predict! All kind of words are coming out of my mouth but I am trying to be as professional as possible.

When I started to receive news that the picture was authentic and who the doctor was, I was speechless. There goes the reputation of doctors. While in my previous article I spoke on the battle between doctors and proponents of home birth, here we had just shot ourselves. It only takes one person to spoil everything. Would the public trust doctors anymore? We must understand that no matter how the public mistreat us or shout at us ( as I had written many times before), since we became doctors to “help” people, we should just keep quiet and do our work! Just make a police report if you think it is overboard. Recently, a nurse who brought her husband to a district hospital at 1am for palpitation told me that, the doctor said “ Please decide fast where you want to be admitted, I want to sleep!“.

The Star has reported that the matter is being investigated. Interestingly, it says that the doctor in also known to take selfies in operating theatres, OMG! I think it is time for MOH to do something about this. Whatever said, action must be taken against this doctor. MMC should also take action as it is considered a professional misconduct. This should never happen!

 

 

Malaysia has become a laughing-stock of the world over the last few weeks. While TM Net still has not restored my home internet service since the last 2 weeks, luckily I have an alternative internet service to be able to write this blog. ON 8th August 2015, our DG gave an interesting speech at a conference in Port Dickson. The text of the speech can also be read below. From his speech, once again it is beyond doubt that we are running short of post for both Housemen and Medical officer. While HO post are rolling post, where only the waiting period will get longer, the MO post are permanent post. According to DG, MO post are almost 95% full with certain states being over subscribed (borrowed post). I know many who had completed HO this year being posted to East Malaysia.

According to DG, the government need to create about 4 000 new MO post per year for the next 5 years to achieve the desired number of doctors needed (20 000 new post). Do the government has the financial means to do it? Assuming average salary of a MO is RM 6K/month including “On Call”allowance (U44), we need RM 288 million/year for 4000 new MO post. So, 20 000 post will cost RM 1.4 billion in total, not including the rolling salary of the earlier created post ( the actual amount will be much more, cumulatively). I assume we can request for some tax free donation. It is still less than RM 2.6 billion!

The DG has also mentioned something about HO assessment/completion report(CCHT) etc. I am also hearing rumours that the Malaysian Healthcare restructuring is in final stages. The doctor: population ratio has already hit 1: 661 as of 2014, the initial target for 2016! We are 2 years ahead. There are also rumours that HO post will be eventually given on contract basis and subsequent application to MO post will be necessary. Thus CCHT may become important in your MO application process. IT also means that not all those who are completing HO will get their MOship. It is the same in most other countries as well. DG has also mentioned about shift duty for MO which is not applicable at the moment.

Our DG has also been conducting discussion with the Royal Colleges in UK to bring back FRCS program to Malaysia. I hope it will materialise with a proper structured program in Malaysia. It will give an alternative pathway for surgeons wannabe.

 

Full Text of DG of Health’s Keynote Address: ‘Optimising Human Capital And Enhancing Specialist Services’ at the Medical Program Specialists’ Conference 2015
Posted on August 8, 2015 by DG of Health
KEYNOTE ADDRESS

BY DIRECTOR-GENERAL OF HEALTH MALAYSIA

PERSIDANGAN PAKAR PROGRAM PERUBATAN KKM 2015

‘OPTIMISING HUMAN CAPITAL AND ENHANCING SPECIALIST SERVICES’

THISTLE PORT DICKSON RESORT

8th AUGUST 2015

Thank you Mr/Ms Chairperson,

i) Y.Bhg. Datuk Dr. Jeyaindran Tan Sri Sinnadurai

Deputy Director General of Health (Medical)

ii) YBhg. Dato’ Dr.Hj. Azman Bin Abu Bakar

Director of Medical Development

iii) Dr. Abdul Rahim Bin Abdullah

State Health Director of Negeri Sembilan

Hospital directors, Profession & Department Heads, Consultants & Specialists, Ladies & Gentlemen,

Assalamua’laikum wbt, and A Very Good Morning.

Firstly, I would like to thank the organising committee for their effort in ensuring the success of this biennial event. It is my pleasure to welcome all of you to the Medical Program Specialists’ Conference 2015 here in Port Dickson. As we are still in the Aidilfitri mood, I wish all Muslims here ‘Selamat Hari Raya Aidil Fitri’.

It has been two years since our last meeting in Melaka. This biennial event is an important forum for us to interact and keep abreast with current issues and knowledge towards achieving an excellent medical and specialists care delivery system.

All organisations require human capital to function and accomplish their goals. Human Capital is defined by the Oxford Dictionary as ‘the skills, knowledge, and experience possessed by an individual or population, viewed in terms of their value or cost to an organisation or country’. Managing patient care requires a multidisciplinary team approach, and doctors comprising of housemen (HOs), medical officers (MOs) and specialists alike are the most essential members of the team.

Thus the theme of our conference today, ‘Optimising Human Capital and Enhancing Specialist Services’ is pertinent and significant considering that Human Capital is an important component in delivering quality healthcare, particularly specialists.

HOUSEMEN

The number of housemen has increased tremendously from 1,059 in 2006, to 2,319 in 2008 and subsequently 4,991 in 2013. As of March 2015 there are 9,502 HOs in the programme. Currently, there are 10,803 HO posts available in the accredited government houseman training hospitals. With the large number of HOs, specialists need to re-engineer their approach to training with existing resources in order to achieve the objective and maintain the quality of the housemanship programme. Staggered appointment of Housemen has been introduced since August 2014 with the intake currently done every two months. In the meantime, the online system e-housemen has been implemented since March 2015.

MOH has proposed the introduction of a generic logbook and Certificate of Completion of Housemanship Training (CCHT), which is awarded upon completion of the housemanship training. It is hoped that CCHT can be used to determine the ‘level’ of competency of HOs and in pursuant of future specialist training. Meanwhile, the generic logbook is designed to document common procedures that can be done in any discipline. I was made to understand that these two topics have been discussed in the workshops last night and hope there will be a fruitful outcome.

The Honourable Minister of Health is also concerned about the quality of HOs these days, and thus mooted the idea of introducing theoretical assessment during the Induction Course to determine the level of knowledge before the commencement of housemanship training. In addition, to ensure the quality of HOs, MOH has recommended that the minimum requirement to enter medical school be increased from 5Bs to higher grades gradually.

MEDICAL OFFICERS

Similar to HOs, the number of medical officers has also increased from year to year. As of 30th June 2015, there are 15,388 of MOs serving in the MOH. This accounted for 94% of MO posts being filled as compared to the total number of posts available. Although there are about 900 vacant posts currently, the numbers of MOs in certain states like Johor, Perak, Pahang, Kelantan and Melaka however have exceeded their allocated posts.

As we know, more posts are required to cater for the expansion of new facilities, new services and additional workload due to increase of diseases burden, increase in population and demographic changes. The doctor to population ratio in 2014 was 1:661 (inclusive of HOs). However, the doctor to population ratio based on the number of Annual Practising Certificates (APC) was 1:904. In Singapore, the ratio was 1:513 (2014). The ratio in other countries like New Zealand, UK and Korea was 1:365, 1:356 and 1:467 respectively.
The five-year 11th Malaysia Plan also projects the upgrading of selected clinics into advanced clinics that provide a full range of multi-disciplinary services to enhance and support primary healthcare teams. Read more here

On 14th July 2010, YAB Prime Minister announced that to be on par with other developed nations, Malaysia has set a target to achieve a doctor to population ratio of 1: 400 in 2020. Based on this, Malaysia requires about 87,000 doctors with the estimated proportion of 60% and 40% respectively in the government and the private sector. In the government sector, as 90% are serving in MOH, that will account for 47,075 doctors. As currently there are 26,924 posts, therefore MOH will require 20,151 additional posts in 2020. With the ample number of MOs, there is a need to relook at the ‘work processes’ in every department to optimise the resources.

Although postgraduate training focuses on specialist training, MOH also needs to pay more attention to the training of MOs who have been described as ‘the lost tribes of medicine’. Being seniors, specialists should encourage these doctors to enhance their skills and knowledge by attending courses or workshops and guide them to plan their career development.

All junior MOs are encouraged to indicate their interests in the field of choice so as to facilitate them to pursue postgraduate training in that area. Those who have passed MRCP/MRCPCH Part 1/Part A must register to the Medical Development Division for appropriate postings, including rotation in selected subspecialty areas. I also urge all senior specialists to inform their junior doctors who have passed the membership exams to immediately report to Medical Development Division; otherwise their gazettement will not commence. It is worth mentioning here that gazettment of specialists will be based on knowledge, skills and competency as well as appropriate exposure, and not merely time based.

SPECIALISTS: LOCAL MASTERS PROGRAMME & PARALLEL PATHWAY

Specialist and sub-specialist training in various clinical disciplines will continue to be a major concern in order for us to ensure that our nation has the needed numbers to deliver high quality care for individuals as well as population. Currently, there are approximately 9055 specialists in Malaysia, out of which 52% (4698) are serving in MOH. Despite notable achievements of the Masters Programme conducted by local universities, the country is still facing a shortage of specialists to meet requirements of our healthcare facilities.

Local Masters Programme

The Ministry and the universities face many challenges to ensure the smooth running of the Masters programmes. One of the issues is the low passing rate in some of the specialties. This might be related to the capability of candidates as well as to the very nature of specialist training i.e. the standards are very high and only the best and most determined to sacrifice will make it. Therefore, the selection of suitable candidates who are highly committed and motivated to complete their postgraduate training is of utmost importance.

It is important to emphasise on the supervision and monitoring of the trainees to ensure they are equipped with knowledge and skill that befit the specialist. For your information, there are cases of master graduates that need extension in their gazettment period due to competency issues and so far there was one that has failed to be gazetted.
The Health Ministry is committed to meeting the pressing need for more specialists. It is offering more local Master’s scholarships and opening up alternate pathways. Read more here

Parallel Pathway

In order to increase the number of specialists, MOH encourages MOs to pursue postgraduate training program via various parallel pathways such as the membership program. MOH is in the process of strengthening the parallel pathway to make it more structured. YAB Prime Minister, during the PM-Minister Mid Year Review 2014 on 20th August 2014 made the decision that MOH should include the budget or funding in 11th MP for the Parallel System. Through this system, while working with MOH, these doctors can sit for the relevant British qualification/exam for specialist training.

The governance of the Postgraduate Medical Specialist and Subspecialist is needed. In the near future, it is hoped that the newly set up dedicated unit of Postgraduate Medical Specialist and Subspecialist (Deanery) under the Medical Development Division of the Ministry will be able to specifically focus on the planning, implementation, promoting, recruitment, monitoring and accreditation of the programmes for clinical specialists. Subsequently, for more effective management of postgraduate training, units could also be set up at the level of the respective state health departments, hospitals and district health offices.

As you all may know, YB Minister of Health and I had recently visited several colleges in London, Edinburgh and Glasgow where they have agreed in principle to train the trainers, accredit our training centres and conduct membership exams in Malaysia. In addition, several MOUs have been signed between the Royal Colleges of Physicians and Surgeons and Academy of Medicine in the field of Cardiothoracic Surgery, Plastic Surgery, Orthopedics and Family Medicine.

SUBSPECIALISTS

There are currently 1,415 subspecialists including trainees in MOH. This number accounts for 35% of the specialists’ workforce. With the shortage of generalist, subspecialists working in the bigger hospitals are expected to provide general medical or surgical services. To optimise resources, subspecialists should not confine themselves to their subspecialty area unless the hospital is a designated tertiary centre.

In addition, among the existing pool of sub-specialists, a number will resign after completion of their training to work in the more lucrative private sector and this is definitely a great loss for us. On average there are about 150 specialists who leave MOH annually. As of May 2015, there were 95 specialists that have resigned, out of which 25% are subspecialists.

Notably in the 11th Malaysia Plan following the amendments to the Medical Act 1971, all specialists are required to be registered with the National Specialist Registry in order to practice as a specialist in that particular specialty. They have to gain certain years of experience before they can be registered in the NSR, thus it is hoped that the number of resignation will be reduced once this Act is being implemented.

The subspecialty-training programme needs to be enhanced. Subspecialty training should be structured, monitored and adequately supervised with the possibility of an exit assessment for all areas. While there is no denying the importance of developing subspecialist services to enable us to handle the small percentage of highly complex cases but it is crucial to strike a balanced mix of generalists and subspecialists. The trend in developed countries is to train generalists with subspecialty interests. At best, subspecialty care only offers organ-specific, intermittent and episodic care. On the other hand, the vast majority of patients need general and continuous care, which can only be provided by “generalists”.

ROLES AND RESPONSIBILITIES OF SPECIALISTS

Specialists including subspecialists play an important role in ensuring the quality of medical services provided by MOH. Thus, specialists should place quality of services and safety of the patients as the highest priority. Senior specialists also need to focus more on patient care and not only administrative issues. Never neglect your patients and let the juniors manage the patients on their own without direct supervision.

I would like to see our specialists be the benchmark for other categories of staff such as house officers, medical officers, nurses and others in providing clinical services to the patients so that we are able to create an effective clinical team. As a specialist, it is important for you to be a team leader and provide leadership in order to ensure effective clinical governance with the emphasis on quality of services and patient safety. This includes good medical practice; evidence-based clinical practice; continuing professional development; and patient, family or community participation in decision-making.

All of you need to play your role as specialists to ensure patient management is being carried out effectively. This will include doing daily, teaching and grand ward rounds to review complicated cases and new cases especially during on calls. Apart from the above tasks, specialists are also required to conduct research and be actively involved in training of junior doctors including HOs and Allied Health Professional.

ON-CALL

In-patient services requires the 24 hours management of patient care by healthcare providers particularly specialists as a team leader, thus the need for specialist to be on-call. For a department that has more than one specialist, the specialists including the Head of Department (HOD) have to do calls on rotation basis. There will be only two tiers of on-call practiced for these departments i.e. specialist and consultant, hence there is no specific HOD call. Likewise for a department that only has a single specialist; he or she has to be on-call daily, which is usually a passive call.

It is crucial that the on-call system be managed with integrity to ensure patient safety. There should not be too many tiers and for each tier the number of specialist on-call must be in accordance with the need and workload. Some departments do not require active calls. Some subspecialty services in smaller hospitals do not require a dedicated subspecialty calls.

Many have suggested that we should relook at our on-call system, working hours and so on. I am open to any constructive suggestions that may help to improve the life of doctors and others in the healthcare profession.

Some have suggested that MOs also work on flexi hours. However if we were to implement this, we will need more MO posts and the on call allowance will be removed. I believe that many hospitals allow post calls off for medical officers as soon as they finish their passing over.

We might consider call sharing where 2 MOs share their calls and each does half of the call every time they are put on the roster. This concept has been implemented in Australia and we need to explore the possibility in doing it here. For those who are on call, make sure you are in hospital and actively review patients and not giving consultations from home.

PROMOTION TO GRED KHAS

Currently there are 953 (23%) specialists who have been promoted to Gred Khas with 48 on Gred Khas A, 140 and 765 respectively in B and C (inclusive of those appointed on contract basis). The promotion exercise will take place when there are vacancies and the posts are very much limited.

There are various criteria that have been identified for the promotion to Gred Khas and not merely the seniority or time based. Other important factors that are being taken into consideration include those who have shown exemplified excellence, those serving the periphery of Sabah and Sarawak and also those with critical specialty and subspecialty. In addition, we also need specialists who are not only good at local level but also recognised at the international level.

It is hoped that MOH can promote those who are well deserved but looking at our current situation; it might be a bit difficult. I understand the frustrations, as it was a long wait for some of you. Due to constraints on promotional posts, MOH has proposed to JPA to consider giving some perks to senior specialists particularly to those on Grade UD53/54.

Great efforts have been made to provide better service schemes and remunerations to encourage doctors to continue serving with the government. Year after year MOH has strived to offer better career pathways for doctors and specialists including faster promotion, increment of specialist and on-call allowances, full paying patient, Saturday elective surgery, privilege to do locum etc. Consequently, it is hoped that all these advantages would encourage the specialists to work harder and give better services to the patients as well as better guidance to the juniors.

INTEGRITY

As the medical practice has become more complex, doctors’ attitudes are also changing. Doctors remain ‘professionals’ but the traditional image of what this means in practice – a selfless clinician, motivated by a strong ethos of service, caring and compassionate is increasingly eroded. Doctors are perceived to be pursuing their own financial interests, and fail to self regulate in a way that guarantees professional competence. There has also been a disturbing change in the attitude among doctors, relating to ethical integrity, professional values and behaviour causing not only serious medico legal problems but also disrepute to the profession.

Doctors are not only required to be technically competent and knowledgeable in the field, but they are also required to embrace the appropriate ethical beliefs and act in a professional manner.

DELIVERY OF SPECIALIST AND SUBSPECIALITY

MOH has produced a Specialty and Sub-specialty Services Framework, which serves as a key driver in leading the path for infrastructure development as well as resource management and allocation.

The target is to provide 10 basic specialty services in minor specialist hospitals, 20 specialties in major specialist hospitals and 45 specialties and sub-specialties in the state hospitals and also 26 specific subspecialty services in each of the 6 zones in Malaysia. So far, only 74.4% of the regional centres have achieved the target of providing the 26 subspecialty services listed in the framework while 79% of the state hospitals are providing the 45 specialties and subspecialties listed. However, only 65.7% of major specialist hospitals and a mere 31.85% of minor specialist hospitals have managed to reach the set target.

MOH also plans to upgrade 4 services such as geriatrics, neurology, palliative care and uro-gynaecology from regional services to be provided at state hospital levels to meet the demands of the ageing population. We have also planned to establish the National Centre of Excellence for Specialised Clinical Skills to enhance the clinical skills of health personnel.

In order to face the challenges in optimising resources, the cluster hospital concept has been introduced in 3 states – namely Melaka, Pahang and Sabah. It has been proven to show positive results; hence the decision to expand the project on a national scale. Clinical leadership at non-specialist hospitals will be strengthened through the hospital cluster concept whereby hospitals within the same geographical location will work together as a unit, share common resources such as assets, amenities and personnel for betterment of patient flow and reduce waiting time for specialist treatment.

Some of the factors that limit the development of specialist services include budget constraints especially in procurement of expensive equipment and facilities as well as support team. There are also shortage of specialists in certain hospitals and specialties due to maldistribution because many refuse to serve in remote areas.

CASEMIX

We have to realise that not only the clinical care of patients is important, but ensuring accuracy and completeness of the clinical documentations are equally essential too as it is also a medico-legal requirement.

Efforts are also being initiated to include or consider Percent (%) Accuracy of Clinical Discharge Documentation, which the Casemix Unit in Medical Development Division will monitor regularly and any recurrence on shortfall should be followed up with Root Cause Analysis. All Heads of Departments and Hospital Directors must play their role. Any national issues must be discussed further with the Medical Development Division.

I also would like to inform that the audit on the clinical documentation accuracy is under the realm of the Hospital Director, as well as all the Heads of Clinical Departments. To make the effort a rewarding activity, the audit activity has to be conducted at a regular interval, at least twice a year and will be followed up by the Casemix Unit.

I urge that all of us, the Senior Doctors, to accomplish our obligation in patient care by monitoring (keep in check) the level of accuracy on the discharge clinical documentation, so as it will attain an overall achievement of more than 70% for every clinical department. I am pleased to note that one session at this conference has been dedicated to the discussion on casemix.

CONCLUSION

Human Capital is an important component in delivering quality healthcare, particularly specialists. As we aspire to become a high-income nation in 2020, our healthcare system needs a medical workforce capable of adapting to change in service needs and the future generations of doctors must have greater understanding of the aspirations and expectations of rakyat.

Doctors must therefore be competent with the relevant knowledge and skills, in addition to the right attitude as well as capability to work as a team. Optimising human capital must be implemented through various strategies, among others through training, delivery of quality service including casemix, innovations such as lean management, cluster hospital concept, NBOS, research, and with good leadership and integrity.

On this note and with Bismillahhirahmannirrahim, it is my great pleasure to declare the Persidangan Pakar Program Perubatan KKM 2015, open. I am sure your participation in this conference will be both useful and rewarding.

Thank you.

Datuk Dr Noor Hisham Abdullah

Director General of Health Malaysia

8th August 2015

In 2012, I wrote 3 parts of the said topic above. The first was on criminal accusation of doctors and the second was on medical negligence. It looks like, the issue that I wrote in my 2nd part is being revisited by the Star today.As I said in my previous article, the current generation of patients are different compared to 20 years ago. They are more demanding, disrespectful and ever ready to sue doctors when something happens. This is something that the budding doctors should realise before doing medicine. The ” I want to help people” rhetoric is not the same as before. You can “help” thousands of patients but a single error will make you to quit medicine all together, not to mention the huge debt that our current generation of students are graduating with. Interestingly, it is the same Generation Y who are becoming doctors and complaining about the working environment/hours. Imagine your own generation will be the ones who will be suing you.

Today’s Star (see below) reported that many private obstetricians are quitting practise due to increasing litigation rate and high indemnity insurance. Well, that is a fact. The number of legal suits is increasing year by year. As our DG mentioned in his reply, the number of O&G suits for MOH last year was 18, an increase by 10 compared to the year before. That is more than 100% increase. As more and more “successful” stories begin to appear in newspaper, more people/lawyers will be going after the doctors. Recently, the court also awarded RM 6million for a spine case in Penang. The name of 3 doctors were clearly mentioned by the news.

With the increasing litigation rate, many O&G specialist are finding it difficult to cope. Their stress level is very high and they can’t afford to make any mistakes. This has resulted in many private O&G consultants pushing away high risk cases to government hospitals. Some have stopped practising Obstetrics and some only does Caesarean sections. I remember when I asked many budding O&G specialist, why they want to do O&G, the answer use to be “ I am dealing with 2 lives and I am happy to deliver a new life to the world“. Well, that was the noble intention. However, this nobel intention is not nobel anymore in this capitalist world. Very few appreciates what we do. In private sector, the word is ” I pay you to deliver my wife. So, no mistakes please!”

The last Cerebral Palsy case was awarded about RM 7 million. I know few more cases pending in high court and one of it is standing at RM 10 million. Due to this increasing amount of awards, almost all indemnity insurance companies had increased their premium since the last 2 years. MMI has increased their premium for Obstetrics by almost 100% with maximum coverage of about RM 5 million. So, if you get sued more than that, you need to pay out of your own pocket. The premium for the RM 5 million coverage is RM 35 000/year. MPS (Medical Protection Society) which is an international organisation and the oldest indemnity insurance scheme, use to cover unlimited amount with occurrence-based coverage. However, starting this year, they have made some adjustment for Obstetrics. They had reduced their premium from about RM 70K+ to about RM 45K. Unfortunately, the maximum coverage in only RM 10 million in aggregate (pending MPS council approval) and it is  “claim-based coverage“. This basically means that you may end up paying out of your own pocket if the council decide to cover only certain percentage of the amount. Furthermore, you must continue paying for years after you stop delivering babies as you must be a member of MPS at the time the legal suit is filed. Legal suits in O&G can appear at your doorsteps 5-10 years after you delivered the baby! Meanwhile, the consultation fees are regulated and limited by the government. So, the consultants can’t charge as they like to support the increasing cost.

This phenomenon will in turn increase the number of patients delivering in government hospitals. At this point, government doctors are indemnified by the government. While I do not know how long this will last, the workload and stress level in government sector will continue to increase. Remember what I said in my previous article? No matter how many doctors we have in government sector, the workload will never reduce as more and more patients are becoming ever more demanding! There is no such thing as easy life, easy money and good future in medicine anymore. Everything that I have been saying in this blog over the last 5 years is slowly appearing in mainstream news. Only those who can handle the tremendous amount of stress and true passion can endeavour. Unfortunately, even then, many will quit.

Unless, the entire healthcare system in this country changes, the situation will not get any better. With the increasing cost and litigation rate in private sector, there will come a time where the private sector will collapse. The government must come up with a Healthcare financing system to address this problem.

Obstetricians are quitting

BY TASHNY SUKUMARAN
PETALING JAYA: Senior obstetricians in private practice in the country are opting out of delivering babies as a result of changes in their professional indemnity coverage.

The shortfall of these specialists is expected to create a rise in the workload in government hospitals, increasing the possibility of sub-standards or delays in maternity care.

The Medical Protection Society (MPS), the world’s leading indemnifier of health professionals, changed its policy for obstetricians and gynaecologists this year – from occurrence-based protection to claims-based coverage, under which these doctors have to pay annual premiums for 25 years.

This means if a doctor retires at 60 after delivering a baby, he or she must continue to pay for the coverage until the age of 85.

According to the MPS, the changes were made because of global challenges and risks associated with obstetric claims and litigation.

In Malaysia, the highest protection coverage is taken up by obstetricians, who used to pay more than RM70,000 a year for unlimited indemnity.

Under the claims-based coverage, the amount to be paid annually is lower but the time frame is longer.

More than 500 obstetricians and gynaecologists are covered under MPS, which has over 4,000 members in Malaysia.

MPS has more than 300,000 doctors, dentists and medical students as members worldwide.

Dr Tang Boon Nee of Subang Jaya Medical Centre said many of her colleagues had decided to stop delivering babies as a result of the change in policy.

“As we are liable for up to 25 years after delivering a child, many of us who are older obstetricians will have to pay for coverage well after retirement,” she said.

Dr Tang, who has been an obstetrician for 20 years, said “phenomenally high” damages had been paid out in obstetric claims.

“There was a case last year in which the amount awarded was RM6.9mil. To protect ourselves, we will have to continue paying MPS well into our retirement because of the claims-based system.

“It is not fair as many of us will not be making that much money,” she said.

KPJ Damansara Specialist Hospital’s Dr Gunasegaran Rajan said the occurrence-based indemnity had no ceiling on coverage, but claims-based was capped at RM10mil.

“Recent payouts have already touched RM7mil, and this can only increase. I would have to pay out my of own pocket if the damages awarded are above RM10mil.”

He said that his best option was to stop practicing obstetrics as the future left him vulnerable.

“It is a great shame that the skills and knowledge many obstetricians have acquired over the past 25 years cannot be used to help Malaysian women’s maternal health due to this policy,” he said.

Another obstetrician and gynaecologist, Dr S. Shankar, said doctors could not run the risk of not being covered.

“We don’t have much choice. Our legislation should come up with a better system, like New Zealand which has a no-fault compensation scheme. Personally I will get out of obstetrics as fast as I can.”

In a statement to The Star, MPS defended its policy change, saying that claims-made protection was the more common form of coverage for obstetricians in many countries.

“Claims-made protection requires members to be in continuous membership both at the time an adverse incident takes place and when it is reported to MPS to make a claim.

“It was introduced to price subscriptions for obstetric risks more accurately and fairly as it can be difficult to predict long-term risks.

“This is because obstetric claims can often arise many years or even decades later,” it said.

MPS assured members that even with the new system they would continue to receive high-quality service and support.

Substandard maternity care possible, warns Health D-G
PETALING JAYA: Health Ministry director-general Datuk Dr Noor Hisham Abdullah said there would be an increase in workload in government hospitals and risk of substandard maternity care if the private sector loses its obstetricians.

“With the obstetrics and gynaecology specialists almost equal in numbers in both sectors, there is definitely going to be increased demand. We will not face a shortage of O&G specialists but rather a mismatch in the distribution and the corresponding workload.”

“It is also important to note that there will be a definite spill-over effect to the neonatal and the anaesthetic services. With this scenario, there will be an increased chance for delayed or substandard care,” he said.

Dr Noor Hisham said the excessive court awards and punitive damages used to penalise doctors would negatively impact doctor-patient relationships.

For the public sector, all negligence claims costs are borne by the Government.

Last year, 18 cases involving obstetric cases were filed against the Ministry of Health, 10 more from the eight recorded in 2013.

A total of 462,626 babies were delivered in both private and public hospitals as well as by private midwives, alternative birthing centres and estate hospitals.

Out of the number, 63,063 were delivered at private hospitals while the most, or 83.9%, were still delivered in public hospitals and clinics.

Meanwhile a medical law lecturer has called for research on the effects of changes to indemnity protection for obstetricians and gynaecologists.

Dr Sharon Kaur of Universiti Malaya said the authorities should look at court decisions, amounts awarded and gauge if the changes in policy could have a knock-on effect.

“If private healthcare services are cut, the burden will fall on public services,” she said.

ON the 8th of July 2015, the medical fraternity was yet again shocked with the death of a medical officer from Sg Buloh Hospital. My deepest condolences to the husband and family members of the deceased. Many doctors went to social media and expressed their sorrow and anger against the life that a doctor goes through in our system. Firstly, I had mentioned several times in this blog that our system is as such that it is difficult to change. No matter how many doctors we have, the job will never get any easier. While the housemen are now doing shift duty, they will end up doing “on-calls” like the old days when they become an MO. However, when each hospital and departments get enough MOs, I hope the same shift system could be implemented to MOs. This could vary from one hospital to another as well as one department to another. Each department have their own problems. Once shift system is implemented, MOs will loose their “on-call” allowances,which means a pay cut. When a pilot project of shift system was started in KKs a year ago, most doctors protested. The main reason was due to the lost of RM80/hour overtime allowance and going back home late. The project was not extended further as KKM, while do have enough MOs, did not have enough support staff to run the KKs till 9-10pm daily. However, I feel it will eventually be implemented in KKs.

Secondly, we should not jump into conclusion whenever we hear such an incident. There are many factors that causes an accident. I am sure each and everyone of us would have had minor accidents or near misses during our life time. People die on the road everyday as we have the highest number of road traffic accidents in this region. It could be due to fatigue, car malfunction (as happened to a doctor over HERE) or may not even be entire your fault. I find many become emotional and blame the “on-call” and the system immediately without further investigations. Our DG has given his response over HERE (see below). People must understand that doctors are not the only profession who work long hours. I have seen engineers, accountants, lawyers , contractors etc who also work long hours and go back home late. It is not unique to only medical profession. In JB, we have thousands of people going to work in Singapore daily. They leave their home at 4-5am and return back at around 9-10pm daily, not to forget the 1-2 hours jam they go through daily in each direction. The only difference is the fact that many other professionals can take back home their job except medicine, where we need to finish our work at work and we are dealing with life and death matters. We are also dealing with humans and not machines/computers or structures where mistakes can be tolerated. But again, it is you who chose the profession and we need to work in the system that we have chosen.

No matter, how the system changes, the workload of a doctor will never come down. Even in developed countries like UK, US, Ireland, Canada etc, doctors still work long hours. Only their total number of hours a week is limited. The profession is such that we cannot leave our work unfinished. Emergency happens all the time. I had written about this many many times since I stated blogging.

ON the other hand, the demand and expectation of patients has gone up by leaps and bounds. This is not limited to private hospitals but also in government hospitals. Thus, it increases the workload of each doctors , no matter how many extra doctors we have in a department. The number of patients visiting government hospitals will also increase year by year as the economic situation worsen. Frankly, how many can afford private healthcare if not being supported by insurance. Even insurance have a limit every year. In my hospital, almost 90-95% of the admissions are insurance supported. Very few are cash paying. Most can’t afford anything more than RM 5-10K. FYI, there is no such thing as below RM 5K in a private centre nowadays. Lately, we have been seeing many grouses in the newspaper regarding high charges in private hospital (HERE and HERE). While the consultation fees by doctors are limited by the government, the hospital fees are not regulated. DG has also spoken about this. Almost every consultant in my hospital will receive at least 1 complain a month! That’s how difficult our lives have become. I hope the younger generations will open their eyes on the real life as a doctor rather than the glorious life that the public wants you to believe.

There’s also a you tube video that has been going viral in the social media. It was about a law graduate talking about the reality she faced after she graduated.

In one of my earlier post “Passion vs Debt” I had written on how the younger generations do not understand that passion is one thing but living a life is another. This lady in the video just proves what I have been saying. High expectation that earning a degree will lead to big salary and good life. This is true in almost all profesional field. She also talks about debt and how she struggles to even own a car. From what she says, I can roughly make out where she graduated from. Her degree is not recognised by Bar council which requires her to sit and pass CLP examination in order to practise as a full fledged lawyer. If not, she can only practise as a legal assistant or advisor which would not give you a high enough salary to survive in Klang Valley or any other big towns. What she says is not much different from what most medical graduates are going to face. If you take huge debt to do medicine, whatever salary that you are going to earn will not be enough to live a life. With car loan, house loan, married life coming your way, it will never be what you had expected. I like what she said at the end : it is beyond race and politics! We are in the same ship and we will sink together if people still get carried away with race and religion issues.

Our education system do not teach our students financial literacy. I suggest students to read ” Rich Dad Poor dad” written by Robert Kiyosaki. Also read many of his books which talks about financial literacy. People who chase degrees and salaried job will never be rich. So, never do medicine for wrong  reasons and never take huge debt to do it either………..

Selamat Hari Raya to All Malaysians……………………

Ucapan Takziah buat Keluarga Allahyarhamah Dr Nur Afifah Mohd Ghazi
Posted on July 10, 2015 by DG of Health
KENYATAAN AKHBAR

KETUA PENGARAH KESIHATAN MALAYSIA

UCAPAN TAKZIAH BUAT KELUARGA

ALLAHYARHAMAH DR NUR AFIFAH MOHD GHAZI

Pada 8 Julai 2015 bersamaan 21 Ramadan 1436 Hijrah, kita telah dikejutkan dengan satu tragedi yang menyayatkan hati dengan kembalinya ke Rahmatullah Dr Nur Afifah Mohd Ghazi, seorang Pegawai Perubatan daripada Hospital Sungai Buloh. Allahyarhamah telah terlibat dalam satu kemalangan jalan raya ketika dalam perjalanan pulang setelah bertugas ‘on-call’ pada hari sebelumnya. Bagi pihak Kementerian Kesihatan, saya ingin menyampaikan salam takziah kepada keluarga Allahyarhamah dan mendoakan agar roh Allahyarhamah ditempatkan dengan para syuhada.

Pada pagi 9 Julai 2015, beberapa orang pegawai kanan dari Ibupejabat Kementerian Kesihatan Malaysia, Putrajaya dan Hospital Sungai Buloh telah berpeluang untuk menziarahi keluarga Allahyarhamah di rumah kediaman keluarganya di Taman Sri Putra, Sungai Buloh. Daripada pertemuan dengan Mohd Hafizuddin Azman, suami kepada Allahyarhamah, memang tidak dinafikan Allahyarhamah bertugas ‘on-call’ bersama 5 orang rakan yang lain daripada Jabatan Anestisiologi. Dimaklumkan Allahyarhamah tidak terus pulang pada keesokan harinya setelah ‘passing over’ jam 8.00 pagi kerana beliau telah pun mempunyai rancangan untuk bertemu seseorang bersama suaminya pada tengah hari tersebut. Allahyarhamah hanya pulang sekitar jam 2.30 petang selepas selesai pertemuan yg dijanjikan. Sementara menunggu temujanji, beliau telah pun berehat di bilik ‘on-call’ yang disediakan.

Kementerian Kesihatan mengambil maklum isu-isu yang dipertengahkan di mana ianya telah dikaitkan dengan peristiwa malang ini. Sememangnya tugasan seorang Pegawai Perubatan memang berat terutama apabila melaksanakan tugasan ‘on-call’ dan dalam kes ini, pihak pengurusan hospital telah pun berikhtiar memperbaiki keadaan persekitaran kerja dengan menjadualkan sehingga 6 orang Pegawai Perubatan daripada Jabatan Anestisiologi bertugas ‘on-call’ setiap hari. Tidak dinafikan kemalangan jalan raya mungkin terjadi disebabkan oleh keadaan seseorang yang kepenatan setelah melaksanakan tugasan yang berat, tetapi ianya boleh juga disebabkan faktor-faktor lain yang juga harus dipertimbangkan.

Walaubagaimapun, Kementerian Kesihatan mengambil maklum semua cadangan yang telah disarankan dan akan terus mengambil langkah-langkah penambahbaikan dari masa ke semasa. Semua fakta perlulah diteliti terlebih dahulu sebelum sesuatu keputusan itu dilaksanakan.

Innalillahi wa inna ilaihi roji’un

DATUK DR. NOOR HISHAM BIN ABDULLAH

Ketua Pengarah Kesihatan Malaysia

Kementerian Kesihatan Malaysia

10 Julai 2015

I wrote about the Australian Internship Crisis in 2012 over HERE and HERE. While in Malaysia, PMC students are considering going to Ireland for Internship, the Australian government has introduced some measures to reduce the Internship crisis. I must warn PMC students that many doctors are leaving Ireland due to poor pay and poor working condition, including long working hours. That’s the reason why Irish Medical Council has recognised Malaysian housemanship training. They need more doctors to replace those who are leaving to UK, Australia and New Zealand. You can read over HERE and HERE.

IN 2012 , I wrote that Australia is facing internship crisis and it should worsen further. I also wrote several times on local graduates who passed AMC exams but never manage to get internship post. Many had to come back to Malaysia to do housemanship. They skipped housemanship in Malaysia, being confident that they will be guaranteed a job in Australia if they pass AMC exams. I had always said that passing entrance exams do not guarantee you a job anywhere.

One of my blog reader sent me some interesting information on what is happening in Australia. For those who have time, you can read THIS interesting document by Medical Training Review Panel which is almost close to 300 pages long. It has many interesting facts. If you look at page 52 and 53, you will realise that only 10 Monash Malaysia graduates were given internship post for 2014 (look under the table). You will also notice that only 6 graduates of AMC exams were given internship post. Page 11 is also interesting to read. At page 18, you will realise that there are 18 accredited medical schools in Australia. 60% of them(comprising 60% of students) are graduate entry program (interesting info from page 18-31). Page 42 to 49 also has some interesting information regarding the number of international student graduates.

At page 51 , you will realise that they have started a program known as Commonwealth Medical Internship (CMI) initiative. For those international students graduating from Australian onshore medical schools who did not manage to get the usual internship in public service hospitals, you are eligible to apply for CMI. The CMI document is over HERE. In 2014, out of 497 international medical graduates, 277 manage to get internship and another 76 were given under the CMI program. So, either 144 remaining students did not apply or did not get internship program in either pathway. Most students who go to Australia do not come back unless they are sponsored by their government and required to come back.

The CMI initiative places graduates in private hospitals, general practise and rural health care centres coordinated by private hospitals. Definitely, this is not an ideal setting for internship training. At page 16, you will realise that Monash Malaysia and IMU twinning program graduates are NOT eligible for CMI program! This CMI program also comes with a bond. You are required to serve rural area for atleast 48 weeks as a return of service obligation ( see page 19). There is a penalty if you breach the contract.

I thank Nav for giving me the link to this documents. Basically what I am trying to say is that the situation in other countries are also tight when it comes to internship placement. You need to think wisely before investing close to RM 1 million if you intend to send your child to Australia to do medicine and planning to migrate. Never do medicine if you intend to migrate!

 

Medical school graduates set for training in Ireland
Published: 24 June 2015 11:50 AM
Penang Medical College (PMC) graduates from the class of 2015 may apply for internship in Ireland.

PMC is the only medical school outside the EU whose graduates have this privilege.

This internship is recognised by the Malaysian Medical Council (MMC) and the medical councils of many other countries.

Penang Medical College is wholly owned by the world-renowned Royal College of Surgeons in Ireland (RCSI) and University College Dublin (UCD).

All 97 graduates received their sought medical degrees: MB BCh BAO (Bachelor of Medicine, Bachelor of Surgery and Bachelor of Obstetrics) from the National University of Ireland (NUI), the RCSI or UCD, officially becoming doctors with globally recognised qualifications.

Malaysian graduates are also guaranteed houseman positions in Malaysia, recognised by the Irish Medical Council (IMC).

“Over the years, PMC has been contributing to healthcare worldwide, and in Malaysia in particular, through its globally-recognised doctors graduating from Penang, or the RCSI and UCD campuses in Dublin,” said PMC President, ceo and Dean, Professor Amir Khir.

“As PMC moves forward to position itself to play a larger role as a leading medical degree education provider in the region and beyond, PMC graduates are the future doctors of the world with an international network of healthcare professionals as a resource.”

The graduate doctors also received licentiates from the RCSI and the Royal College Physicians in Ireland (RCPI).

PMC students spend their first two-and-a-half years in either RCSI or UCD medical schools, where they undergo intensive pre-clinical training.

They are also taught by experienced scientists and leading medical doctors in their respective fields.

PMC students then return to Penang for clinical training for two-and-a-half years at PMC. – June 24, 2015.

 

Nine in 10 medical students may leave Ireland on qualifying
Culture of ‘intention to migrate’ across all six of State’s medical training schools

 

Nine out of 10 medical students plan to leave or are “contemplating” leaving Ireland when they qualify, a new study involving the State’s six training schools has found.
Career opportunities, working conditions and lifestyle are cited as the top three factors for migration by some 88 per cent of over 2,000 students surveyed.
The study led by NUI Galway (NUIG) and published on Thursday has found pay was not a key issue among the respondents.
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Generation Emigration: Irish Times site for Irish abroad
The Irish Hospital Consultants’ Association had said highly trained doctors are being “driven out”.
The study’s supervisor, NUIG senior lecturer in social and preventive medicine Dr Diarmuid O’Donovan, has called for action to retain medical graduates and attract back those who have already emigrated.
Staff at HSE West’s public health department and at the Royal College of Surgeons in Ireland, University of Limerick, University College Cork, University College Dublin and Trinity College Dublin were involved with NUIG in the study, published in the open access journal Human Resources for Health.
Work and lifestyle
Some 1,519 of the 2,000-plus medical students surveyed were Irish, and some 85 per cent of the total identified career opportunities as a determining factor in going abroad. Some 83 per cent identified working conditions, and 80 per cent identified lifestyle as factors.
Some 34.3 per cent said they were “definitely” planning to migrate, and a further 53.3 per cent said they were contemplating it – a total of almost 88 per cent.
Final-year NUIG medical student Pishoy Gouda, the principal investigator, said previous studies on this theme had focused on graduates, whereas this analysis involved junior, intermediate and senior students in the six medical schools.
“We found the outcome alarming, as it shows that even pre-med and first-year students are thinking about leaving already,” he said. It reflected a “widespread culture of intention to migrate” in the medical schools.
Career stages
While medical graduates traditionally sought experience abroad, the research indicated there were several opportunities during different career stages to leave.
“This outflow of qualified personnel may represent a financial loss to the Irish healthcare system,” he noted.
Almost two-thirds said they did not have a great understanding of the training following graduation, and one-third surveyed also indicated they had a poor understanding of how the Irish healthcare system worked.
Mr Gouda said postgraduate opportunities should also be made more accessible to non-EU students trained in Ireland. European working laws make it difficult for non-EU graduates of Irish medical schools to obtain Irish intern or pre-registration/ foundation-year positions.
Dr O’Donovan said the outflow of human capital meant Ireland was having to make enormous efforts to attract medical staff from other countries, including developing nations.
“ Not only is this a problem for Irish recruitment, but we need to be mindful of World Health Organisation guidelines on international recruitment and taking skilled personnel away from countries that have medical staff shortages,” Dr O’Donovan noted.

 

IN 2012, I wrote THIS. The article was about the reduction of compulsory service for Dentist from 3 years to 2 years. Since 2001 , it was 3 years compulsory service. It was mentioned that there were 400% increase in the number of dental graduates since 2002 (when the compulsory service was increased from 2 years to 3 years). While the actual numbers are still small, it was good enough to fill up the total number of post in civil service. However, I still feel that the private sector still needs a lot of dentist. The fact remains that many Malaysians are not bothered about dental hygiene.

Now, barely 3 years later, it is now being reduced to 1 year !. It was announced by the Minister of Health on 14/06/2015. The reason: tremendous increase in the number of graduates !. Sounds familiar ? The only reason why the same is not being done for doctors is because the MMC is reluctant to do it. If it does happen, we will be seeing countless number of incompetent doctors having ” license to kill” out there. I feel the time will come for MMC to reduce the compulsory service. BUT I would prefer if they can introduce an entry or exit exam to filter out the incompetent ones rather that reducing the compulsory service.

Definitely, we do not want to end up like what is happening in India, as published by Reuters over HERE (see below). Again, much of what is written in that article may sound very familiar! Medical Education should never be commercialised!

So, when will be our doctor’s turn to have ” license to kill”?

Selamat Menyambut Bulan Ramadhan

Only one-year mandatory service

KUALA LUMPUR: The compulsory service for all dentistry graduates will be reduced from two years to one year effective July, said Health Minister Datuk Seri Dr S. Subramaniam.

He said graduates who had registered with the Malaysian Dental Council would be placed under the ministry to undergo possible training.

The move, he said, was due to the tremendous increase in the number of graduates of up to 30%, as well as to ensure that new graduates would continue to serve under the mi­­nis­try.

“In the one-year compulsory service, we will give them adequate training so that they have the knowledge and skills to be competent dentists.

“For those who served their compulsory one year, they may join the private sector or if they wish to continue training elsewhere or do postgraduate studies, they may do so,” he told a press conference after launching the Malaysian International Dental Exhibition and Conference (Midec) here yesterday.

Also present were the ministry’s Oral Health Division principal director Datuk Dr Khairiyah Abdul Muttalib and Midec organising chairman Dr Shalini Kanagasingam.

Why India’s medical schools are plagued with fraud

Reuters
The Reuters probe also found that recruiting companies routinely provide medical colleges with doctors to pose as full-time faculty members to pass government inspections.
MUZAFFARNAGAR (India), June 16, 2015:
Last December, Dilshad Chaudhry travelled with about 100 of his fellow villagers by bus to a local Indian medical-school hospital. They’d been told that foreign doctors were coming to tour the facility, and check-ups would be free.
There was nothing wrong with Chaudhry; he was accompanying his brother, who had a back problem. But “every person was told to lie in a bed even if they’re not sick,” he said.
The 20-year-old electrician said he never saw any foreign physicians that day, but the hospital’s Indian doctors kept checking that the phony patients were in bed. “They wanted to make sure no one escaped,” he said.

That was the same month government inspectors visited the hospital, which is at Muzaffarnagar Medical College, 80 miles northeast of New Delhi. The inspectors checked, among other things, whether there were enough patients to provide students with adequate clinical experience. They determined there were.
But a year earlier, inspectors had found that most of the college hospital’s outpatients “were fake and dummy and seems to be hired from nearby slum area”, according to the official report.
“In paediatric ward all children were admitted … without any medical problem and were hired from nearby area!!!!!”
“I am not very keen to reply,” said Dr Anil Agarwal, the school’s principal, when asked about the episode with Chaudhry.
India’s system for training doctors is broken. It is plagued by rampant fraud and unprofessional teaching practices, exacerbating the public health challenge facing this fast-growing but still poor nation of about 1.25 billion people.
The ramifications spread beyond the country’s borders: India is the world’s largest exporter of doctors, with about 47,000 currently practicing in the United States and about 25,000 in the United Kingdom.

Schools and scandals
In a four-month investigation, Reuters has documented the full extent of the fraud in India’s medical-education system. It found, among other things, that more than one out of every six of the country’s 398 medical schools has been accused of cheating, according to Indian government records and court filings.
The Reuters probe also found that recruiting companies routinely provide medical colleges with doctors to pose as full-time faculty members to pass government inspections.
To demonstrate that teaching hospitals have enough patients to provide students with clinical experience, colleges round up healthy people to pretend they are sick.
Government records show that since 2010, at least 69 Indian medical colleges and teaching hospitals have been accused of such transgressions or other significant failings, including rigging entrance exams or accepting bribes to admit students.
Two dozen of the schools have been recommended for outright closure by the regulator.
Paying bribes — often in the guise of “donations” — to gain admission to Indian medical schools is widespread, according to India’s health ministry, doctors and college officials.
“The next generation of doctors is being taught to cheat and deceive before they even enter the classroom,” said Dr. Anand Rai.
He exposed a massive cheating ring involving medical school entrance exams in the central Indian state of Madhya Pradesh in 2013. Rai was given police protection after he received death threats following the bust.
The poor state of India’s medical education reflects a health system in crisis. The country has the highest rates of mortality from diarrhea, pneumonia and tuberculosis, creating pressure to train more physicians.
Patients are regularly denied treatment at public hospitals that are so overcrowded, often the only way to see a doctor is to pay a bribe.
The causes of the crisis are manifold: Too few doctors. A government-backed surge in private medical schools which, to boost revenue, frequently charge under-the-table fees for admission.
Outdated government regulations that, for example, require college libraries to keep paper copies of medical journals and penalize those that subscribe instead to online editions.
Charged with maintaining “excellence in medical education” is the Medical Council of India(MCI). But this government body is itself mired in controversy. Its prior president currently faces bribery allegations.
The council is the subject of a mountain of lawsuits, many of them pitting it against medical schools challenging its findings. The cases often drag on for years.
“The best medical schools in India are absolutely world class,” said David Gordon, president of the World Federation for Medical Education.
But, he added, the Indian government’s process of accrediting a “huge” number of recently opened, private medical schools “has at times been highly dubious”.
India has been rocked by a series of recent medical scandals, including doctors accused of serious crimes.
In November, a group of junior doctors at a medical college in the eastern city of Kolkata allegedly tied a suspected mobile phone thief to a pillar, slashed him with a razor and beat him to death with bamboo sticks, according to local police.
Nine of the accused men remain in jail; they deny murder charges, say lawyers involved in the case. Three suspects remain at large.

The scalpel thrower
The system’s problems are felt abroad, too. Tens of thousands of India’s medical graduates practice overseas, particularly in the United States, Britain, Australia and Canada.
All of these countries require additional training before graduates of Indian medical schools can practice, and the vast majority of the doctors have unblemished records.
But regulatory documents show that in both Britain and Australia, more graduates of Indian medical schools lost their right to practice medicine in the past five years than did doctors from any other foreign country.
In the United Kingdom, between 2008 and 2014, Indian-trained doctors were four times more likely to lose their right to practice than British-trained doctors, according to records of Britain’s General Medical Council. (The U.S. and Canada lack publicly available centralized databases of disciplined doctors.)
The British cases include that of Dr Tajeshwar Singh Aulakh, who received his medical degree in 1999 from Punjabi University in Patiala, India, according to Indian government records.
He was assisting during a hip operation in 2008 in Shropshire, England, when he allegedly grabbed a scalpel, slashed the patient’s stitches and threw it toward a nurse, according to British government records. The United Kingdom later struck him off its list of approved physicians. He could not be reached for comment.
The Australian cases include that of Dr Suhail Durani, who graduated from an Indian government medical college in the northern city of Jammu in 2003. He was imprisoned in Perth for more than 18 months after being convicted in 2011 of sexually assaulting a female diabetic patient who had shown up in the emergency room with symptoms of a potentially serious illness.
In an interview, Durani maintained his innocence and described his medical training in Indiaas excellent. He currently is not practicing medicine.
Dr Ramesh Mehta, vice president of the Global Association of Physicians of Indian Origin, said there are “major problems” with some private Indian medical schools. But he added that a doctor’s success depends as much on “personality and attitude” as on his or her college training.

Fake degrees
About 45% of the people in India who practice medicine have no formal training, according to the Indian Medical Association. These 700,000 unqualified doctors have been found practicing at some of India’s biggest hospitals, giving diagnoses, prescribing medicines and even conducting surgery.
Balwant Rai Arora, a Delhi resident in his 90s, said in an interview that he issued more than 50,000 fake medical degrees from his home until his forgery ring was broken up by the police in 2011. Each buyer paid about US$100 (RM375) for a degree from fictitious colleges. Arora was twice convicted and jailed for forgery.
“There is a shortage of doctors in India. I am just helping people with some medical experience get jobs,” said Arora. “I haven’t done anything wrong.”
India currently has about 840,000 doctors — or about seven physicians for every 10,000 people. That compares with about 25 in the United States and 32 in Europe, according to the World Health Organization.
The shortfall has persisted despite India having the most medical schools of any nation. That’s because the size of graduating classes is small — typically 100 to 150 students.
Indeed, gaining admission to India’s top medical schools is akin to winning the lottery. The All India Institute of Medical Sciences in New Delhi has been rated the best medical school in India Today magazine’s past five annual surveys.
According to the registrar’s office, it takes in only 72 students for its undergraduate course each year out of about 80,000 to 90,000 who apply — an acceptance rate of less than one-tenth of 1%. As in theUnited Kingdom, most medical school students attend an undergraduate programme.
Similarly, Christian Medical College, a top-ranked school in the southern city of Vellore, received 39,974 applications this year for 100 places, according to a school official — an acceptance rate of 0.25%. By contrast, the acceptance rate at Harvard Medical School for its entering class in 2014 was 3.5%.
Health ministry officials and doctors say India’s medical-education system began to falter following a surge in new, private medical colleges that opened across the country during the past few decades, often in remote areas.
In 1980, there were 100 government-run medical schools and 11 private medical colleges. Thirty-five years later, the number of government medical colleges has nearly doubled.
The number of private medical schools, meanwhile, has risen nearly twenty-fold, according to the Medical Council of India. There are now 183 government medical colleges and 215 private ones.

‘Little better than quacks’
Many of the private colleges have been set up by businessmen and politicians who have no experience operating medical or educational institutions, said MCI officials.
Sujatha Rao, who served as India’s health secretary from 2009 to 2010, said the boom in private colleges was driven by a change in the law in the early 1990s to make it easier to open new schools because the government was struggling to find the money to build public medical schools.
“The market has been flooded with doctors so poorly trained they are little better than quacks,” Rao told Reuters.
Not that a legitimate degree necessarily makes a difference.
A study in India published in 2012 compared doctors holding medical degrees with untrained practitioners. It found “no differences in the likelihood of providers’ giving a diagnosis or providing the correct treatment”.
The study, funded by the Bill & Melinda Gates Foundation, concluded that in India, “training in and of itself is not a guarantor of high quality”.
Last year, an individual described as a “concerned” student at a rural government medical college in Ambajogai, in western India, posted a letter online with a litany of allegations about the school, Swami Ramanand Teerth Rural Medical College.
There were professors who existed only on paper, he alleged, and “no clinics and no lectures” for students in the medicine and surgery departments. Conditions were unsanitary at the hospital, and pigs and donkeys roamed the campus, he wrote. The writer also alleged that students had to pay bribes to pass exams.
“We are not taught in this medical college,” the letter stated. Students have graduated “without even attending a single day”. The writer said the letter had been sent to various government agencies and health officials.
Records from the Medical Council of India, the body charged with maintaining the country’s medical education standards, show that an inspection of the college this January found numerous deficiencies, including a shortage of faculty, residents and lecture theaters.
Dr Nareshkumar S. Dhaniwala, who served as the principal of the college between 2011 and 2013, said “there is some truth in the letter”.
Animals, such as pigs and cows, do roam the campus, teachers and students don’t turn up for lessons, and there is a scarcity of running water in the dormitories, he said. And before he joined, he said, he heard students had to pay to pass final exams.
“I found the students were not very interested in studying, they don’t come to classes, they don’t come to clinics,” Dhaniwala said.
“Medical education has gone downhill all over the country because the teachers are not as devoted as they used to be.”
Sudhir Deshmukh, the college’s current principal, did not respond to requests for comment.
The Medical Council of India, which was established by the government in 1934 and oversees medical education, has itself been swirling in controversy.
Dr Ketan Desai, the council’s former president, faces criminal charges related to his arrest in 2010 for allegedly conspiring to receive a bribe to recommend authorizing a private medical college to accept more students. The case is still pending; Desai has denied the charges.

‘Junk body’
In interviews, medical school officials complained that the MCI had onerous inspection requirements that were outdated and arbitrary.
“The Medical Council of India is a junk body,” said Dr A. K. Asthana, principal and dean of Subharti Medical College in the northern city of Meerut, which has been accused of demanding illegal fees for admission. Asthana denies the allegations.
The council has tried — unsuccessfully so far — to close the school. “I’m totally frustrated with the MCI. Totally frustrated,” he said.
Dr Vedprakash Mishra, the head of MCI’s academic committee, told Reuters that the agency has created “discipline and accountability” among medical colleges by imposing fines and, in several cases, prohibiting schools from admitting students for up to two years.
“We don’t compromise and mitigate on the requirements,” he said.
Asked about allegations of corruption within MCI itself, Mishra abruptly ended the interview. “This is not what I want to be discussing,” he said.
Under the government’s current regulations, private medical colleges generally must have campuses on at least 20 acres of land. Because urban real estate in India is expensive, many schools open in rural areas where recruiting qualified, full-time doctors to teach is difficult because pay scales are low and living conditions are tough.
Interviews and MCI records show that some private colleges solve the problem by cheating — they recruit doctors to pose as full-time faculty members during government inspections. The physicians work there for just a few days or weeks.
Two MCI officials estimated that there are several hundred Indian companies involved in recruiting them.
In October, a doctor in New Delhi received an email from a local company called Hi Impact Consultants with the subject line: “Urgent requirement of doctors for MCI Inspection in Ghaziabad”
The email offered up to 20,000 rupees a day (about RM1,163)) if the doctor appeared for an inspection at Saraswathi Institute of Medical Sciences in Hapur, east of New Delhi. The doctor, who requested anonymity, has no connection with the college.
“If interested please revert back ASAP,” the email concluded. The sender described itself as “a Medical Executive Search firm”.
In an interview, Sanjeev Priyadershi, Hi Impact’s executive director, confirmed that the firm had tried to recruit doctors to appear during government inspections at medical colleges where they don’t normally work.
“My client wanted to hire full-time faculty members for inspection purposes,” he said.
Dr Shailendra K. Vajpeyee, the principal of Saraswathi, said the college is constantly struggling to recruit qualified professors. Vajpeyee said he knew of Hi Impact Consultants, but denied he had employed them during his 18-month tenure.
“I don’t know why that email was sent” by the company, he said. He declined to comment further about the matter.

‘Biased inspectors’
At Muzaffarnagar Medical College, where electrician Dilshad Chaudhry was taken in December, students can read medical journals and books in a sprawling, circular library and take classes in clean and modern lecture halls.
But finding enough patients to provide students with clinical experience at rural, private teaching hospitals like Muzaffarnagar is a challenge. Many people in rural India simply can’t afford the cost of treatment.
School principal Agarwal denied the allegations by MCI inspectors that the college’s hospital had inflated its number of patients during a 2013 inspection.
“Sometimes the inspectors are biased, that is for sure,” he said. He also denied the hospital had ever recruited local villagers to pose as patients.
But Dr Vaibhav Jain, a former student at the college, told Reuters that the hospital would conduct “free check-up camps”, to lure rural villagers to the facility on inspection days.
He said the hospital sometimes would promise free ultrasounds, but only a small number of people would be tested. Villagers often later complained about it to students at a clinic in Bilaspur where he worked, he said.
“We used to say we can’t do anything, the machine was not working,” he said.
Medical education is in trouble across India, said Jain. “The truth is that many medical students aren’t prepared to be doctors when they finish” college.
“And the result is the patient suffers.”

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