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Archive for December, 2011

Happy New year 2012

Posted in Uncategorized on December 31, 2011| 18 Comments »

It has been almost 2 weeks since I last posted. It has been quite a busy 2 weeks with a lot of things to settle before the new year. Year 2011 has been a relatively good year for me, being my first full year in private practise. So far everything seem to be going on well.

Same can’t be said about the future of medical education and practise in Malaysia. The mushrooming of medical schools is a big screw-up. Unemployed  doctors are going to become a reality. The ministry has already started to give housemanship on contract basis indicating that the system is bursting. I can only say that the situation will get worst soon.

I had given enough advise to many budding doctors to decide on their fate. It is all up to them to analyse and decide on their future. Being a doctor is no more prestigious, money-making or easy life. The salary in government sector after the recent introduction of the new salary scheme (SBPA) is fairly good but getting a job in civil service is going to be the major problem in near future. On the other hand, the income of doctors in private sector is gradually dropping and unethical practises are increasing as a mode of survival. I will write more about this soon.

Well, whatever said, I hope 2012 will be a better year for everyone. I hope it will not turn out to be like the 2012 movie.

Happy New Year 2012 to everyone………………………

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Urgent issues for Higher Education Ministry?

Posted in Education on December 18, 2011| 33 Comments »

The letter below appeared in The Sun, 2 days ago: http://www.thesundaily.my/node/77369. I must say that the retiring public university Professor has said it right! I have been saying all theses since I started blogging. The entire medical education in this country is going down, that is the reality. Not only the undergraduate teaching standards is going down but also the postgraduate standards. I am seeing more and more Master’s graduates who are not competent as before. NO wonder our politicians are going overseas to seek treatment!

Again, God save this country! BTW, I don’t think Higher Education Ministry will be bothered. Education Hub mah……………

Urgent issues for Higher Education Ministry

Posted on 16 December 2011 – 05:06am

I WRITE in response to “Sub-standard housemen” (Nov 8) and “Continuous efforts to improve housemanship training” (Letters, Nov 16) as a professor at a public university in Malaysia offering medical courses.

I agree that deteriorating standards among housemen are partly due to their attitude. However, a large part of the blame lies with the Higher Education Ministry and public universities. Poor attitude had existed among medical students since the early days of medical education in Malaysia. Then, they were identified and given proper guidance while still at university so that they emerged responsible doctors, because medical education then was a sort of apprenticeship. These days, the sheer number of students and the lack of suitably qualified medical lecturers make individual attention virtually impossible and the learning experience diluted.

Teaching in public universities for more than 20 years has given me a firsthand perspective of the downward spiral of the standard of medical schools in Malaysia. Many fellow lecturers who are experts in their disciplines quit universities to establish their own practices. They were replaced by recently graduated and inexperienced doctors and foreign lecturers from countries like Myanmar, Indonesia and Pakistan. In the past, specialists from the Health Ministry (MOH) would join universities as lecturers while medical officers would join as trainee lecturers. In the last two years, even local doctors have stopped joining universities as lecturers or trainee lecturers.

There are a few reasons for this, the most important being the salary inequality between doctors working in MOH hospitals and those who are lecturers in public universities. This began in March 2009 when Prime Minister Datuk Seri Najib Razak announced a new career pathway with time-based promotion for MOH doctors, giving them an instant increase in salary. This caused a disparity of salaries between the two categories – most marked when comparing a doctor at the MOH (RM6,731.54) with a trainee lecturer at a public university (RM4,907.57), both of the same seniority.

Another reason is the lack of transparency in the promotion of medical lecturers. Some who have worked more than 10 years are still senior lecturers while some junior lecturers have been promoted to associate professors within five years. In contrast, all MOH doctors automatically get promoted after a number of years’ service.

To rub salt into the wound, foreign lecturers at public universities are paid more than locals and most are appointed as associated professors or professors despite being less qualified. Better qualified expatriate doctors would have been appointed as lecturers in countries like the UK, US or even Singapore. A majority of foreign doctors in our public universities are those who have been unsuccessful in their applications to these countries.

In his letter, the director-general of health said the Malaysian Medical Council has set the standard in the recognition of universities offering medical programmes. However, many universities still do not meet these standards. In a recent report by the Malaysian Qualifying Agency, the university at which I currently work failed to conform to these standards.

A lack of urgency by the Higher Education Ministry in addressing these issues will have dire consequences. The next generation of doctors will no longer be the professionals we once held in high esteem. They are going to be the ones caring for us in our old age and our lives will be in their hands.

Retiring Professor
via email

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For Future Doctors: The Change is coming ……………………..

Posted in Education on December 15, 2011| 40 Comments »

The entire Malaysian healthcare system will change soon. The Government started talking about National Healthcare Financing Scheme (NHFS) since the mid 1990s but due to various political reasons it was postponed many times. However, I feel the government will eventually introduce this change after the next general election. All plans are ready on paper, just waiting for the proper time for implementation. It is targeted to start in 2014 under the name of 1Care system. The letter below in Malaysiakini explains the impact of the scheme to the citizens.
 
The 1Care system will start by incorporating the GPs into primary health care system. It is a way for the government to reduce their load in government clinics. Now, before every one gets excited thinking that GPs are going to benefit, please check the system in more detail.
 
Every employed person will have to contribute to this scheme, similar like EPF. Certain percentage of your salary will be deducted monthly as a contribution to this NHFS. I heard government servants will be exempted but they can only seek treatment from government clinics/hospitals. I am sure you will know who will run this scheme, based on past experience of corporatization ! Basically, this scheme will allocate a certain amount of money for each private citizens of Malaysia. I was told that it would be in a range of about RM4K per year. Every citizen need to register with a GP and can only seek treatment from that particular GP whether they like it or not. If you decide to choose someone else, you need to pay on your own. Zoning will be implemented with only certain number of GPs will be included in each zone. GPs must sign a contract with NHFS to become a panel clinic. Each of these GPs will be allocated about 1500-2000 patients. GPs with Primary Care Diploma or Family Physicians Specialist will be given preference. Every GP will only be paid certain amount of fee for each of their consultation and the number of visits per year will be limited. Only certain medications listed as “standard drugs” under the scheme will be allowed to be prescribed and paid by the scheme as mentioned below ( so the GPs may lose the profits from meds). Once the citizen finishes his/her allocation, highly likely, they have to go back to the government clinic. However, I also heard that the GPs may be forced to provide free service for the remaining number of visits as part of social obligation to the community. I am not sure where and how the government clinics are going to be placed in this system.
 
Once the primary healthcare integration is complete under the NHFS, the government hospitals will be corporatised. For those who are new in MOH, the corporatisation of government hospitals were supposed to be implemented in 1998/1999. Most of the new hospitals like Selayang, Ampang, Sg Buloh, Sultan Ismail hospitals were supposed to be run by corporate bodies. Fortunately, due to the 1999 political crisis involving the sacking of Anwar Ibrahim etc, the entire plan was postponed. Soon, it will be revived under the 1Care system. Once corporatised, each hospitals will be an autonomous hospital. Each hospital will decide on how many doctors they will employ, how many housemen they will train and how many specialist they need. There are not obliged to provide job to everyone. All graduates will need to apply to the individual hospitals for a job. Incompetent ones may be kicked out. However, it is a long way to go before this happens as I was informed that the corporatisation of hospitals will only take place about 3-4 years after the primary care integration, if everything goes well. The entire restructuring exercise will take about 15 years from 2014. Once everything is complete, the NHFS will be paying for both public and private sectors(with certain limit), by which time both may become one system. The “semi-government” corporatised hospitals will still be subsidised heavily by the government. Personal insurance will be used to top up the payment for private hospitals once the NHFS limit is achieved.
 
At this point of time, no one knows what will be the final outcome of the implementation of this scheme. What I have written above is from MMA magazines and people who attended the technical workshop on 1Care system. Some facts can be obtained from http://www.mma.org.my/Portals/0/MMA.October%2010.vol.40.issue10%20Web.pdf and the subsequent MMA Magazines till Nov 2011. Whatever it is, young doctors can forget about earning big money as a doctor in the future. Life is not going to be easy and even getting a job is not going to be guaranteed.
 
This is another interesting write up which you may be interested: http://blog.limkitsiang.com/2011/05/18/1care-outpatient-scheme-middlemen-didahulukan/
 
With 1 Care, the choice will not be there
Dr Steven KW Chow
2:42PM Dec 13, 2011

The 1 Care health system transformation plan for Malaysia is now in the process of being sold to the public.

To our knowledge, the development of the blueprint is being fast-tracked and that the detailed plan to implement 1 Care will be ready as early as 2012.

Technical working groups are already hard at work on this. As the term technical working group implies, it is the technical details are being worked out – not the decision for plan for a new health system. Thus, we are way past the “still in planning process” (The Star, May 13, 2011).

We must address certain issues that are raised before implementation.

We are told that the new health system will be in the substance and form of the NHS of the UK. We strongly urge for a critical rethinking of this for the following reasons:

1. Existing Primary Care Provides Better Accessibility and Choice

The primary care model of the NHS has many failings. The picture from the NHS shows that it is not the proven mechanism to facilitate appropriate access to higher level of care. In the UK, this system requires patients to make appointments with the GP, even for acute conditions. As a result, the A&E Departments of hospitals are jammed with patients and waiting lists for cold cases to see the doctor or undergo surgery is long.

On the other hand, Malaysia has a better healthcare system. We had good KPIs reported in the latest National Health Accounts Report. Our health system has been praised in many international reviews and articles published in journals.

In Malaysia, government health facilities have a good system of referral and provide the safety net for the poor. Those who can afford to pay out-of-pocket consult private doctors. This is a good balance of those seeking private and public healthcare.

What the government really needs to do is protect those using private care from exorbitant charges and being over serviced. This can be handled by strict enforcement of the relevant provisions in the existing Private Healthcare Facilities and Services Act1998/Regulations 2006.

There is choice with the present system. With 1-Care this choice will not be there. The patient and public pay upfront in the form of insurance or taxes. If they do not want the doctors or the service that is allocated, they will have to pay again for what they choose.

2. 1 Care will cost more

Worldwide it is recognised that a system based on general taxation is the most efficient and equitable.

Experiences from many countries have shown that the rise of healthcare cost is higher when other forms of healthcare financing are introduced.

Instead of finding another method of financing, including social health insurance, to improve efficiency through provision of greater choice and better control on cost of health care delivery, the MOH should look internally on wastage and efficiency and improve the government system to be better than the private sector as shown by experiences in Singapore and Hong Kong where the public prefers the public system.

The 2002 Report of the Study on “ Healthcare Reform Initiatives in Malaysia” by three Health Ministry-appointed consultants led by Donald S Shepard have clearly diagnosed the important issues of healthcare delivery in Malaysia and proposed solutions.

Cost-wise, the consultants “calculated that in the year 2000, the average ambulatory consultation (public facility) outside of a specialised hospital (including average prescriptions and laboratory services associated with that visit) costs RM91, while the average inpatients stay cost RM1,091 (or RM286 per day).

In contrast, the fee for an amublatory visit, RM1, has not increased in years and covers only one percent of the economic cost of an average visit”. This does not include the economic cost of long waiting time and time off work.

We know that the average cost for a GP outpatient consultation including prescriptions would only be between RM30 to RM50. Waiting time is shorter. Thus it is clearly cheaper and more efficent to just outsource this ambulatory outpatients to the existing robust GP system thereby releasing the public system to concentrate on secondary and tertiary care. The recovery economic cost of a shorter waiting time will also benefit the patient and the community.

3. Transformation versus Evolution

The overall recommendation of this extensive study based on the diagnosis of our healthcare system was for the country to proceed with “limited reform”.

This reform “should improve the management of the public healthcare services so that they can provide better working conditions for their staff,fill critical vacancies,enhance responsiveness to population’s needs and wants, and maintain an equitable basis for financing healthcare services”.

4. Improving stakeholders’ feedback for 1-Care Consultation

The cost and implications of 1-Care affects all. Judging from the concerns expressed by many doctors and the public in the media, it is clear that those so called stakeholders that are invited for discussion are:

1. Either not real representative of the profession
2. Or the stakeholders are not providing feedback
3. Or the stakeholders are some favoured few

It will be good governance to inform the public who the stakeholders are (in name and organisation) to ensure that they are truly representative and to include more public representation like patient groups, consumers, employer representatives and more NGOs.

5. Corporatisation of Public Hospitals.

The 1 Care systems requires corporatisation of public hospitals – the establishment of administratively autonomous hospitals through devolution of authority from federal control, a variant of corporatisation ala IJN. This will be in line with the seamless integration of private and public healthcare facilities.

This is clearly not possible as private facilities are profit-driven as compare to public facilities which is socially-driven. Furthermore this is contradictory to that reassurance given by the health minister in 1998 that the government will not corporatise public hospitals.

At the end of the day one would create a huge profit-driven monster that will be impossible to control as the regulator (i.e. the government) will also be an operator of the industry via its GLCs.

DR STEVEN KW CHOW is president of the Federation of Private Medical Practitioners’ Associations Malaysia.

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For Future Doctors: Similar fate for doctors?

Posted in Education on December 10, 2011| 70 Comments »

I read the news below in today’s Star and I began to wonder whether this will be the fate of our doctors in the future. I was informed that MOH has already started to give contracts for housemanship. This basically means that after 2 years of housemanship, there is no guarantee that the contract will be renewed for MO. This puts you equivalent to a temporary teacher under contract and the same problems will occur. Most likely, the contract will only be renewed on you accepting where you are going to be posted, as the number of post is going to be very much limited. E.g: if MOH asked you to go to Limbang, Sarawak as a MO and you refuse, MOH will not renew your contract which basically means you are jobless! You also need to apply for a job in government sector after housemanship.Of course, government sponsored students will be given priority.

As David Quek mentioned in his speech (http://myhealth-matters.blogspot.com/2011/11/standards-of-medical-education-in.html), SPA is asking MMC to remove the compulsory service so that the government do not need to provide a job to you after housemanship. There are a lot of implications if all these comes true. Firstly, an inexperienced doctor is not going to be a good GP. With litigations rate going up everywhere, these doctors will not survive with the public demand. They will be sued all the time. Secondly, if you do not get a job in civil service, you can forget about postgraduate training and applying for Master’s. At this point of time, only training in government hospitals is recognised. Even if you get a contract job, it does not mean you will be posted where you want to. Your training can still be compromised. The way I see it, there is going to be a lot of chronic medical officers in near future with little post-graduate opportunities. This is when your basic medical degree recognition is going to be very important in finding a job/postgraduate training somewhere else in this world.

Even Academy of Medicine Malaysia is very much worried about postgraduate opportunities in near future. Residency style training is being considered to shorten the training programme and produce specialist faster but this need to be carefully deliberated. It’s implication to our healthcare system also need to be considered as not all our hospitals are equipped with all speciality.

Soon, the title of the news will be “Temporary doctors protest unfavourable terms in contract!…………………..”

Temporary teachers protest unfavourable terms in contract

By KANG SOON CHEN
educate@thestar.com.my

KAJANG: A group of temporary teachers protested outside the Hulu Langat education district office over new terms in their service contracts.

They claimed they were at a disadvantage with the new terms.

Under the new contract, their salaries will be reduced from RM2,500 to RM2,300 and they will not receive allowances or EPF contributions from the government as of next year.

The terms, effective Oct 15 this year, also pointed out that the teachers had to return the allowances and EPF paid to them for October and November.

They were also disgruntled that they would not get paid for the December school holidays.

“It is unfair,” said the group’s spokesman.

“The terms of the new contract overwrite the earlier one that we signed this year and that was supposed to be effective until the end of the year,” she said, adding that they would lose their jobs if they failed to comply.

“There was also no guarantee that we will be absorbed into permanent positions.”

In March, Education director-general Datuk Seri Abdul Ghafar Mahmud announced that 6,000 of the 13,000 temporary teachers were ready to be absorbed as permanent teachers.

Deputy Education Minister Datuk Dr Wee Ka Siong said the ministry was working on a solution to end their predicament.

Earlier, he had said the government’s decision to absorb temporary teachers into permanent posts had resulted in insufficient funds to pay their salaries.

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Arrogance or stupidity?

Posted in Education on December 4, 2011| 66 Comments »

Sometimes I really get annoyed and pissed off with some of the junior doctors and the frontliners. If they are not into treating patients and care for patients, then they should just quit and find another job. Over the last few weeks I have come across few cases that was mismanaged even after being referred by a consultant (obviously from a private sector). Some how, some of these frontliners are arrogant and feel that they should not take any ideas/opinion from private specialist. I will give you these examples:

1) A 60-year-old man who has Mitral stenosis, AF , Diabetes and Gout came to see me for frequent attack of Gout. He is being planned for valve replacement surgery soon. His diabetic is being followed up by a Klinik Kesihatan(KK) and under insulin therapy. I noticed that his diabetes is not well controlled despite being planned for surgery soon within the next 2 months. This is a well-educated english speaking patient. His FBS was 15 and HBA1C was > 10%. Thus I advised him to adjust his insulin dose by himself by educating the patient to monitor his blood sugar at home regularly. I also managed his gout accordingly. 2 weeks later, he came back to see me and what he told me really irritated me. It seems that the MO in the KK refuse to see him since he had seek advise from a private consultant. He claim that the patient must only listen to him!! I wonder why is the blood sugar not well controlled then?  Then I realised another stupidity that this MO is doing! When I looked at the little green book that all diabetics carry, I noted that his so-called “FBS” was always between 4-6.0 mmol/L while his own home GM monitoring was above 10 mmol/L all the time.

So I asked the patient ” Do you go fasting when they take the  blood? ”

Answer:  ” Yes and I also take my insulin before I go to see them???? WTH!! no wonder his blood sugar is low when he goes to KK. Sometimes, he even gets hypoglycaemia symptoms while waiting to take blood.

Is this arrogance or stupidity?

2) A 38 weeks pregnant mother was noted to have IUGR by a KK MO. She was referred to the specialist clinic of a GH. Patient’s referral letter was seen by a MO at the clinic and given appointment in 2 week’s time!! WTH, by then she will be 40 weeks pregnant. Even me, who had not done O&G for 15 years, knows that IUGR need to be delivered by 38 weeks! The patient was shocked and came to my hospital for opinion.

3) A 30 weeks pregnant mother was diagnosed by a private consultant to have Placenta Praevia Type 2 with previous scar, possible placenta accreta was considered. She was referred to a GH after spoken to the MO on call. Now she is 36 weeks pregnant and no proper plan has been made for her. In fact, she has not even seen or followed up by any specialist up to today. Only once it was written ” discussed with DR so ….so” . Such a high risk patient being followed up by MO with no proper delivery plan??? what the hell is happening?

4) A 20-year-old boy who became paraplegic after a MVA was admitted to our hospital for UTI sepsis (Pseudomonas MRO organism). He was on halovest. He was started on Sulperazon and the fever settled on 2nd day. He had appointment at GH the next day for removal of halovest. Our Ortho consultant wrote a letter to the GH doctor to admit this patient and con’t the antibiotic for atleast another 4 days. When the patient saw the doctor at GH, the letter was read but just thrown to the side. The halovest was removed, T unasyn was prescribed and the patient was not admitted. 3 days later, fever spiked again and readmitted at my hospital. Despite a letter from a private consultant, the opinion was ignored! Now, the patient has to spend more money!

 Some how I feel that the newer generation of doctors and even specialist are becoming more uncaring and only interested in finishing their work and going back home. This, along with arrogance is screwing up the system. However, they don’t seem to realise their stupidity and the fact that patients are getting smarter. Sooner or later, lawyer’s letters going to reach their doorstep and the government is not going to cover you!

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