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In September 2012, I wrote about Health Facts 2012. The data was till 31/12/2011 which shows that the doctor: population ratio has already reached 1: 791. This figure included all the housemen with the total number of doctors standing at 36 607. The data for 2012 was just released by MOH. The ratio has come down to 1: 758 with the total number of doctors standing at 38 718. However, I feel that the data may not have captured all the housemen who joined the civil service towards the end of the year 2012 (the major bulk).  This is because the rise in the number of doctors seem to be smaller than the year before which is obviously not right (3 626 in 2011 vs 2 111 in 2012) when the number of graduates/medical schools has actually increased! Something is not right about this statistics unless there are about 2000 doctors who either left the country or resigned from being a doctor! . From my MMC sources, I was informed that the number of new doctors reported last year was about 4000, which will make the ratio very much less.

Below, I list the 34 functioning medical schools in Malaysia at the time of writing:

1)    University Malaya (UM)

2)    UNiversiti Kebangsaa n Malaysia (UKM)

3)    Universiti Sains Malaysia (USM) : 2 programmes

4)    Universiti Putra Malaysia (UPM)

5)    UiTM

6)    University Sains Islam Malaysia (USIM)

7)    Universiti Darul Iman

8)    Universiti Sarawak Malaysia (UNIMAS)

9)    Universiti Sabah

10) Universiti Malaysia Kelantan

11) Melaka-Manipal Medical College

12) Monash University Malaysia

13) International Medical University (IMU):  2 batches + twinning program)

14) SEGI University College

15) Allianze College of Medical Sciences (ACMS): 5 programmes

16) Penang Medical College (PMC)

17) Mahsa University College

18) Masterskills University College of Health Sciences (Asian Metropolitan University)

19) Royal College of Medicine Perak (UNIKL) : 2 programmes

20) Universiti Islam Antarabangsa (UIA)

21) Newcastle University Malaysia

22) Perdana University : Graduate Medical School

23) Perdana University : RCSI

24) Inssaniah University College

25) Quest International University Perak

26) Cyberjaya School of Medical Sciences

27) AIMST

28) Taylor’s University College

29) Management and Science University (MSU) : 2 programs

30) University Tunku Abdul Rahman (UTAR)

31) University College Sedaya International (UCSI)

32) University Pertahanan Nasional Malaysia (UPNM)

33) Lincoln University College 

34) University College Shahputra

We have atleast another 2 on the cards : Xiamen University, China (Medicine, Salak Tinggi, 2015) and Shanghai Jiao Tong University, China (Kuching, 2014/2015). Even though the number of medical schools is 34, we have close to 43 medical programs as some of the medical schools conduct more than 1 program/batches.

MMC had only accredited 20 medical programs as of June 2013 as listed over here. This means that only 20 medical programs have produced graduates (not in maximum capacity yet) and the remaining 20 ( about 50%) have yet to produce any graduates. So, everyone who can count will know the situation in near future. If each produces 100 students (most medical schools will need atleast 150 students to make profit), we will have 4000 graduates locally by 2016. Another 1000-2000 will come from overseas, making a total of atleast 6000 graduates annually !! I presume it will hit 8 000 by 2018!

In March 2013, I wrote and published a circular from MOH that almost 95% of the post for MOs has been filled in most states. Today, I received an info via Facebook that almost 80-85% of the post for doctors in Malaysia has been filled ( see below). The shortage now is in Sabah and Sarawak.

As for 1 June 2013

Total Dr Post in KKM/PPUKM/HUKM/HUSM (Uni only have HO):  27573

Filled: 22374 (81%)

Vacant: 5199

Vacancy in Sabah/Sarawak : ~1500

Total HO post: 10387 (about 5 000/each year)

Vacancy: 1707 (16%)

Vacancy in Sabah/Sarawak : ~500

Total MO post: 17186

MO vacancy: 3487 (20%)

Vacancy in Sabah/Sarawak: ~1000

Post filled at present: 80%-84%

Eventhough, new hospitals and posts will be created by the government, the number of new post will not be sufficient to absorb all these graduates. This will likely happen by 2017/2018 when most of the 40 medical programs would have started to produce graduates. Likely, the government may still give Housemanship post on contract basis after which, there will be no guarantee that you will get an MO post. Likely, the compulsory service will be scrapped. How the selection is done remained to be seen. Obviously, government sponsored and public university graduates will be given priority. The rest may need to sit for some sort of exams or evaluation after housemanship.

It is really going to get very messy by then. I just hope our current Health Minister will make some serious attempt to stabilise the situation by closing down some of these sub-par medical schools. Anything related to healthcare sector use to have guaranteed job just a few years ago. Unfortunately, our great Human resource planning has screwed up most of it. We have jobless nurses, radiographers, physiotherapist and recently even teachers! Welcome to the education hub of this region!

Enough said, I hope people will make wise decisions for their future. Never do medicine for wrong reasons…………..

 

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I read 2 interesting articles over the last 2 days. The first was in Malay mail which basically tells the truth of what is happening out there (see below). Many students nowadays do not know what they are getting into. Just because they score a good result in their exams, they feel that they are destined to do courses like medicine, dentistry, engineer, lawyer etc etc. Over the last few weeks I received many queries about which university to choose, which course to choose etc etc. Who am I to tell you which course you should do? It is entirely up to you to find a course that you feel you will have the passion to work for the rest of your life. Talk to people and friends who are working and get a feel of what the job is all about. In this blog I had written what medicine is all about and what kind of life a doctor undergoes. Similarly, you should find out what the other professions do. Unfortunately, many of the students are only interested on whether they will get a job, what is the income going to be and whether they can get a job overseas. Nothing is guaranteed in the future. Job opportunities changes over time. Who would have thought that doctors would become jobless ? But it is happening in many countries including developed countries.

The other article that I found interesting was ” 10 things to give up to become a doctor” which was written over here (see below). All those points had already been mentioned in this blog over the last 3 years. Nothing has changed no matter where you practise. One thing I always tell people is that, you will never become rich with a salaried job. Do you see any millionaires who are not businessman or politicians ? Even doctors are not going to earn a lot of money unless they start their medical business. The difference is, you would have spent tonnes of money studying and years of training even before considering opening a medical business. Furthermore, medical business is a 1 man show unlike other businesses where you can become a boss by the age of 35/40 and the business will run by itself. In medicine, that’s when you even think of starting your business. The era of opening medical business after 4 years of service is coming to an end due to stiff competition. Many GPs are now selling their clinic to companies that are running franchise clinics. That will be the future. You will not be able to run an individual clinic all by yourself. Without panels you will not survive. I just got to know that 1 more clinic just closed down near my place.

The articles below are worth reading…………………….

Tired of doctor, lawyer, engineer and accountant wannabes… — Cass Shan

JULY 26, 2013

JULY 26 — The truth is, most students don’t know much about the world after secondary education. They simply assume that the best career options are to be either a doctor, lawyer, engineer or accountant. And if they are good academically, they automatically get pigeonholed into these career paths.

While these professions are noble and worth aspiring to, too many students simply fail to grasp what it means to have a career and fall for the assumed social status and prestige associated with these careers.

And sure, some can argue that vying for social status and prestige isn’t all that bad, but surely there’s more to a career than that?

The recent spate of students complaining about not being offered courses of their choice is nothing new in Malaysia. Institutionalised racism aside, students should already know that if everyone got the course of their choice, there would be an over supply of doctors, lawyers, engineers and accountants — thereby driving down the market rate and value of these occupations. Thus, demand must exceed supply to ensure the value of these professions.

For those who fail to get a course of their choice; they can appeal or look elsewhere — either going abroad or seeking scholarships (which if they are worthy, they are more likely than not to get). For others who don’t have that option, it may not be such a bad thing to look at other career options.

For one, I sincerely question how many of these applicants are genuinely passionate about these courses they are applying for. True passion is when you are willing to do something for nothing, because just doing it gives you a sense of achievement or satisfaction. I am willing to bet that if the medical profession didn’t pay as much as it does in comparison to other professions, there would be a lot less takers despite it being a noble profession.

For instance, how many people actually grow up saying “My dream is to spend my working hours looking into people’s mouths and attacking cavities?” And yet, dentistry is a competitive course. I’m not saying that dentistry is not something to aspire to but essentially, a lot of students are taken in by the “halo” effect that the medicine line has.

I know a classmate in school who studied nursing because she truly cared for the sick. When offered a chance to pursue her career as a doctor with her already sound knowledge of healthcare, she turned it down as she saw how little doctors interacted with patients compared to nurses and stuck to being a nurse for the pure joy of caring for the sick. Now, Pamela Patricia Perera can truly hold her head high as someone who is truly passionate about helping the sick. How many of our doctor wannabes, if denied the option of studying medicine, would opt for nursing and still get to care for patients? And how many would take the longer path towards being a doctor by becoming a nurse first in their so-called ambition to be a doctor?

I know a girl who loved airplanes since she was young, collecting model airplanes and watching “Airwolf” with anticipation in the ‘80s. This is someone who cuts out articles on aircraft engineering when she was in school despite not being requested to by the school syllabus. Not surprisingly, Ruth Anandaraj went on to study aircraft engineering and is now working for Airbus in the UK and will soon be working for Boeing in the US. This is what true passion is about — reading up information about your career choice with hunger in between studying for school exams.

On the other hand, I know a Mara scholarship recipient who studied engineering in the UK (and yes, he was academically bright with straight As) and came back to Malaysia only to ditch a career in engineering. It turned out a career as a sales manager was more rewarding to him and possibly the best turn of events that could have happened where he achieved money, respect and a fancy job title as a sales director at the age of 33 to boot.

Now, how many students say their dream is to be a salesperson? Not many I’m sure. In fact, among the so-called respected community of academic high achievers, a salesperson is akin to being a pariah in society.

I know of an accounting graduate who studied accounting on scholarship (yes, she was sent abroad to the UK) who called a floor of salespersons a “sweatshop” and equated salespeople to being “con artists”. She would never lower herself to that job title, yet she was happy to stay in her prestigious, high-paying, but unfulfilling job.

The point is, there is more to a career than academic results, money and presumed prestige.

A career isn’t necessarily about how good your exams results are. I’m sorry to break the news to you but scoring straight As in our education system only mean you’re good at memorising, it doesn’t guarantee that you are a critical thinker. A career is about whether your personality is the right fit for the job requirement. Many professions in Asia tend to require long hours and — before you make it — most graduates have to climb their way up the salary scale. So you better enjoy your work if you are going to be spending a lot of time in it.

The crucial test — would you do it if you weren’t paid for it — comes to mind.

In the instance of not getting a course you want, the world suddenly opens up with new possibilities. You may find out that nursing helps you care for the sick more than doctors do. Or that you really love doing PR because you love interacting with people more than you do staying in the office. You may find out that a career as a teacher is more rewarding than a fat paycheque when you see the improvements in your students. Or maybe, that “pariah” job as a salesperson is more fulfilling to your go-getter type of personality.

We face many setbacks in life and often, when a door closes, another opens.

Students shouldn’t be preoccupied with prestigious jobs and ask themselves hard questions of what personality type they have. They should ask themselves what they would still do even if there was no money on the table, and that they’d do it because it gives them fulfilment.

Too many students have a myopic view of life after secondary education and think that a prestigious job is the only way up. It may be a way up — but does it truly satisfy you or are you just looking for the next family reunion where you get to proudly mention your job title?

* This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malay Mail Online. 

- See more at: http://www.themalaymailonline.com/what-you-think/article/tired-of-doctor-lawyer-engineer-and-accountant-wannabes-cass-shan#sthash.KiOb9gVJ.dpuf

 

 10 things to give up to be a doctor 

 

BY    

Following a recent article elsewhere which generated an interesting discussion, I started thinking about the things one must give up on the road to becoming a doctor. It’s a long road, beginning with an initial decision, some early voluntary experiences, an application to university and some hard work trying to achieve the barely possible at GCSE and AS / A2.

But it doesn’t even end there. The hard work really only begins at medical school where long hours and repeated exams are considered normal and where you need your patients more than they need you.
There are plenty of things you have to give up along the way, here are my top 10:

1. Your desire to be wealthy
Very few people in medicine ever become hugely wealthy, at least not in Europe. If riches are what you desire there are many many easier ways of getting that involve alot less heartache, money and stress. If you want to be a millionnaire before you’re 30, my advice would be to avoid university altogether. Most doctors are in the profession for genuinely altruistic reasons as well as the satisfaction that comes from knowing that you have the skills and knowledge to save lives and apply these every single day as a routine part of your work.

2. Your desire to change the world
Equally you must, eventually, give up on the idea of becoming some sort of medical superhero who can solve the worlds medical problems one by one. Yes doctors can do some impressive things when applying their skills to the right situation. But remember that however good your intentions, you will not be able to overcome the problems caused by poverty, war, government neglect or abuse, or coorporate profiteering at the expense of the sick. That doesn’t mean you can’t try to help people afflicted by any of these, you’ll just find that you are usually too small to make any real systemic difference.

3. Your free weekends
It starts at medical school when the work starts to pile up, and weekends are sacrificed to meet deadlines and for exam revision. Once you start working as a junior doctor, you’ll find yourself scanning each new doctors rota to work out where your on-call weekends have landed and who can swop with you so that you can still go on that holiday or get married or whatever. There will be sunny weekends when your non-medic friends will be having a barbecue whilst you sweat it out on a ward seeing yet another gastrointestinal bleed wondering why you chose this path.


4. A good nights sleep

Gone are the days where doctors would be on call for 48 or 72 hours and then do a clinic for the boss before retiring to bed. However, modern working arrangements have brought into existence the ‘week of nights’ where you work 4 or 5 and sometimes 7 night shifts in a row.

As someone who has done these I can confirm that doing nights is pretty inhumane. The talk amongst doctors doing nights together often centres around changing specialty or leaving the profession. Don’t worry, it all gets forgotten once normal daytime duties are restored.


5. Your desire to avoid feeling like a fool

You will make mistakes from time to time in this job and your mistakes will all be potentially serious ones, simply because everything you do affects your patients’ lives directly.
Furthermore, there will be times when you have to withstand an onslaught from senior doctors who feel that teaching by humiliation is the only way forward. You will feel like an idiot at times and if the thought of that frightens you you should promptly pick a different profession.


6. Your desire to always put friends and family first

As a doctor your job usually takes priority and you simply cannot shirk your responsibilities simply because you have prior engagements of a personal nature. Over the years I’ve known many difficult situations including a colleague who had to turn down a role as best man for a close friend because nobody could swop his on-call weekend with him and the hospital refused to organise a locum to cover him.

Apart from sickness or bereavement, your first priority will be to your profession. Your friends and family may find that difficult to understand at first. They’ll come round to it with time, especially once they delete your number.

7. Your desire to please everyone.
Whether it’s your friends or family, as above, or your future patients you’d better get used to upsetting people from time to time. Telling your wife you need to postpone an evening engagement because you are still operating on a difficult case, or telling a patient you won’t be operating on them as they only have three months to live, are both likely to be met with upset. Each situation has it’s unique challenges and needs some communication skills, but the bottom line is that you will have times when you will have to make someone want to either hit you or cry in despair.

8. Your creativity
Not many people admit this but medicine takes people who are often very creative and turns them into workaholic, automatons who have little room left in their lives for creativity. If you want evidence for this, go to any dinner party that includes more than one doctor. Chief discussion topic will be work and medicine.That’s partly because anecdotes from doctoring are entertaining, but also because if the medics stray from this conversation topic, they will rapidly expose their banality and limited insights in other areas particularly all things creative.

Much of medicine does not allow much creativity in it’s day to day practice and the intensity of the work beats any desire for creative thinking right out of you before you even realise it’s happening.* Of course whilst accepting this fact you must fight this tendency and attempt to keep up your other interests, otherwise, I can guarantee medicine will invade everything you do.

*There are a few notable exceptions to this!

9. Your desire to stay in one place / live close to friends and family.
Want to do something competitive, like medicine? You have to realise that choosing your location is a luxury and you may have to follow your dream in a less than ideal location. Even after you graduate, having your heart set on one speciality is a sure way to geographical instability. Some people don’t mind this, but some with strong family ties or a mortgage, the need to move frequently is a pain.
I began to come to terms with this when I found that even the most obscure places have hospitals. Working in these places you’re just as likely to meet doctors who have also had to move from here from the other side of the country. It’s a great way to meet people but easy to lose touch once you move on.

10. Good health
You may not know it, but you’re joining a profession that has high rates of physical and mental illness as well as drug and alcohol misuse. Doctors are also less likely to seek help than other professions which all adds to a rather worrying picture.
Although ill health isn’t guaranteed in a medical profession you should realise the future risk now and take steps to formulate good lifestyle habits to minimise your risk factors. A good network of non-medical friends should also protect you from neglecting your own needs while you’re treating your patients.


That’s plenty to sacrifice just for a job isn’t it? However, I guess the reason you’re in medicine (or trying to get in) is that you’ve realised that medicine is not just a job, it’s a whole way of life, that’s difficult to let go of once you’ve decided to enter it, and these sacrifices are simply part of the deal.

Well, those are the 10 points I thought were worth including. If you have more I’d love to hear about them.

Leo

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I am sure many of us would have read the article that was published in the Star 2 days ago. You can read it below. This is the first time a title such as that has been published in a main stream newspaper. I had written many times about unethical doctors and how the competitive market is creating more and more of them. It is a known fact, mainly in private sector. Fortunately, the numbers are still small. Unfortunately, the example that this writer pointed out is NOT about unethical practise (at least the first example). The writer obviously do not know how to differentiate between unethical practices and management issues. As for the second case highlighted, it can be. In fact, I had seen many patients who presented with AGE symptoms without any abdominal pain, ending up with an appendicectomy done! However, it is still defendable in the court of law as symptoms can change. MMA has given it’s response over here

Unethical practise is when a doctor does an upper and lower endoscopy in a 16 year old girl presenting with acute gastroenteritis, doing multiple lumpectomy in a 17 year old with lumpy breast, doing upper scope in a patient with neck pain, doing angiogram is a 24 year old with iron deficiency anaemia with no chest pain etc etc! These are the type of unethical practices that we do see, on and off. It is not uncommon as I had written before. Doing further test to rule out any other possibilities/diseases is not unethical. For example, if a middle age heavy smoker comes with chronic cough and left basal pneumonia, you may want to do a CT Thorax to rule out Cancer of the Lung causing proximal obstruction. If not, he may sue you 3 years down the line for missing a cancer. It is a delicate balance between treating a disease and not to miss out something that can be life threatening. The first case is about that, nothing unethical. MMI (Malaysian Medical Indemnity) insurance has just tripled the premium for Obstetrics and Gynaecologist. MMI is a Malaysian based indemnity insurance company unlike MPS (Medical protection Society) which is global society providing indemnity to doctors all over the world, where the rates are much higher. Click on the links to see the rate. This basically shows that the litigation and payout rate in Malaysia is increasing exponentially.  BTW, the doctors consultation and surgical fees are controlled by the government and the rate has not changed since 1998 !

Surprisingly, the same newspaper published another interesting article yesterday. It is about finding reliable doctor !. Well, to be frank, due to some bad apples in the profession, the public are now advised to be more vigilant and find a reliable doctor. The public has the right to choose. BUT how do you choose ? How do you know that the particular doctor is good, reliable and trustworthy ? It is interesting to read Dr Alan Teh’s response over here .The enforcement is weak in Malaysia and the enquiries conducted by MMC is troublesome for the complainant. Thus, not many complains are made. Private hospitals on the other hand rarely takes action against a consultant despite unethical practices as the hospital gets money out of it as well. It is a business entity and profit is what matters.

However, the second article do mention a lot about the reality and future of the medical field. Somehow, I feel that all those that was mentioned came from my blog! It has all been explained in this blog with facts and figures:  oversupply of doctors, competitive private practise, declining income, limited postgraduate opportunities, venturing into aesthetics, beauty therapy, selling supplements etc etc.

MY advise to budding doctors whose sole intention in doing medicine is for money; please don’t do medicine. It is a long way to go and money is what that drives you to do unethical practices. Money that is earned “illegally” will disappear as fast as it comes. I believe that no matter what you do, if you do it sincerely, work hard and be truthful, you can be successful, live a decent and comfortable life.

Beware of unethical doctors

DIFFERENT SPIN BY SHEILA STANLEY

Public regard for the medical profession has dropped and this is due to greedy doctors who dupe patients into undergoing unnecessary procedures and tests.

Society has always had high regard for medical professionals as they represent our path to a healthy mind and body.

We rely on their opinions and medical advice and tend to take their recommendations very seriously.

Currently, however, regard for the medical profession has dropped a little.

This is due to a small number of unethical doctors who have taken advantage of our trust in them and used it to make more money through unnecessary procedures.

More often than not, this happens in private medical institutions.

A number of anecdotal stories among people I know underscore this. Take for example, a recent story told to me by a 33-year-old woman, pregnant with her first child, who went to a private maternity centre to give birth instead of a government hospital.

Her periodic check-ups went along fine until she was about seven months pregnant.

At that point in time, she was informed by her doctors that her blood tests indicated there was something wrong with the child she was carrying and there was a strong possibility that the child had Down Syndrome.

She was informed that she had to go for a number of different tests – all of which would obviously cost a lot of money.

Although she wasn’t that concerned about the cost, she became very afraid for the future of her unborn child.

So, after speaking to her family members, she decided to go to a public hospital to get a second opinion.

At the public hospital, they conducted a number of tests on her.

These were all free under the Malaysian public health system. After results were obtained, she was informed that the baby seemed perfectly fine and she had nothing to worry about.

She then decided to deliver her baby in the public hospital. When her child was born, it was perfect, and there was nothing wrong. Other stories such as this exist, although probably not as horrifying.

There is another story about an eight-year-old boy who suffered from fever, cough and was vomiting for a day.

He did not have any abdominal pains. His father took him to see a general practitioner who then told him to take his son to a particular surgeon at a private medical centre.

At the centre, the surgeon, when examining, pressed down so hard on the boy’s abdomen that it caused him pain.

The surgeon then insisted that the boy had a perforated appendix and insisted that he undergo an operation that very night.

However, about an hour before the surgery, the father, feeling uneasy, decided to get a second opinion. He asked for his son to be discharged and took him to another doctor.

This doctor found that the son did not have a perforated appendix and instead treated him for an upper respiratory tract infection, something common among children of that age.

I am sure that many other stories like these exist out there and readers have been through similar experiences.

The outrage we feel when faced with such incidents has to do with a betrayal of our trust.

As far as I know, doctors take the age-old Hippocratic Oath when they begin practising medicine.

Considered a rite of passage, the oath hinges on the duty of the doctor to practise medicine in an ethical manner, in the best interest of his or her patient.

When faced with stories like these, one can’t help but wonder what has happened to the Hippocratic Oath?

Do doctors these days, especially those in private medical institutions, no longer take this oath?

Or does the making of money trump any public duty they hold to practise their profession in an ethical manner?

It is clear that we have to be aware of our rights as consumers when it comes to doctors as well. In fact, the Malaysian Medical Association (MMA) has procedures where a complaint can be filed against any doctor practising medicine in Malaysia.

To file a formal complaint, the MMA requires the person making the complaint to submit the full facts of the case, clearly stating the allegations against the medical practitioner.

The Consumer Association of Penang also advises consumers on their rights under the Private Healthcare Facilities and Services Regulations 2006.

These regulations provide patients with the right to request and receive information on the estimated charges for services provided as well as other unanticipated charges for routine services.

The public also have the right to complain to the hospital or medical centre in question about any issues they may have about their treatment at the hospital.

In such cases, the private hospital must establish a patient grievance mechanism which includes the appointment of a Patient Relations Officer to act as a liaison between the patient and the hospital.

It is clear that we have to be more aware of our rights when it comes to private medical practitioners.

In many cases, it would involve doing some independent research into the symptoms of the illness and the appropriate care required.

Also, getting a second opinion when doubtful seems to be the best course of action.

Do you have any stories to share on bad encounters with private medical practitioners?

If you do, share them with me, and in my next column, I will share your stories.

It is time we start being more aware of our rights as patients.

> Sheila Stanley is a writer, TV producer and PR/media consultant based in Kuala Lumpur. You can share your thoughts with her on Twitter @sheila_stanley or via e-mail atsheila106@live.ie.

Finding reliable doctors

BY FOONG PEK YEE

CHAN was bleeding profusely from his left nose after he tripped and fell in front of his house in Gopeng.

The nearby general practitioner (GP) whom he sought treatment from told him to go to the Ipoh Hospital (Hospital Raja Permaisuri Bainun), but refused to give him a referral letter.

At the hospital about 30km away, the doctor there told him his blood pressure was 120\80 and the reading was perfect, and that he can go home.

However, his nose was still bleeding then.

When met at his house recently, Chan, in his 70s, said he felt the left side of his body had been weak since the episode.

Over in the Kuala Lumpur Hospital, a young doctor told the sister of a patient, “I have so many patients and some are dying.”

This doctor, who was sitting on the nurses’ counter in the accident and emergency ward and shaking his legs, said this when the woman asked him about her brother’s condition.

She reported the case to the Health Ministry director-general, who also heads the Malaysia Medical Council (MMC).

Any doctor must be registered with the MMC before he can practise in Malaysia.

I believe the two cases are just the tip of the iceberg because victims either do not know how to complain to the MMC or they are afraid of doing so, one reason being the fear of retaliation from the doctor or doctors.

While having a perfect score, like 4 for CGPA (cumulative grade point average) may qualify an STPM student academically to do medicine, it certainly takes more to become a good doctor.

I am not saying that this is reason for the government to reject top scorers who wished to pursue medicine in local public universities.

But I feel it will be good if those wanting to study medicine are aware of what it takes to be a good doctor.

And what is the purpose of their desires of being a doctor.

If one is induced by the perceived earning power of doctors, it may be good to do some research on the situation.

These high income doctors are medical specialists in disciplines in demand, like cardiology, obstetrics, gynaechology and eye surgeons to name a few.

They usually are very skillful, have a good track record and reputation and are attached to big private hospitals.

I do not know the remunerations for specialists in local public hospitals or teaching hospitals.

Apart from that, it is not easy to specialise as there are limited places locally if one somehow could not do it overseas.

Besides being expensive to specialise abroad, it is also very competitive in terms of getting a good place to do so.

The country does face a shortage of specialists, for now.

However, its capacity to train specialists is limited because the requirements for training facilities are very stringent.

Well, if one somehow is contented to just become a doctor or general practitioner, the market out there is also increasingly competitive.

In June 2010, MCA president Datuk Seri Dr Chua Soi Lek said there would be an oversupply of doctors in five to six years’ time.

The former health minister, who is a doctor by training, said the country, produced some 4,500 doctors a year starting 2011 and would see the 30,000 doctors in 2010 doubling to between 55,000 and 60,000 doctors by 2015 or 2016.

Even if the government somehow can absorb the doctors in local public hospitals, I supposed the doctors must be prepared to be posted to wherever their services are needed.

And I will not be surprised when a time will come, likely in the near future, that doctors who wish to join government service will need to be shortlisted for interviews first, and no longer wait to be posted.

It is a situation of supply more than demand, and, not surprisingly, doctors could join the ranks of the jobless through oversupply.

There is also a bright side, though.

Assuming meritocracy is in place, the patient care and the country’s healthcare standards stand to gain when there is a big pool of doctors to choose from.

And some arrogant or rude doctors will think twice if they think they are a cut above the rest.

For those who want to be a GP, the market is very competitive, if not saturated.

Private clinics are usually set up in towns and cities where the demand is there.

It seems GPs also have to seek to be panel doctors to boost their business these days.

The mushrooming of 1Malaysia Clinics in urban and rural areas is also another concern for GPs.

I heard there are also GPs who diversify their business, like selling health food and supplements.

A friend of mine told me a husband-and-wife team of doctors from Malacca are no longer practising medicine, but using their titles to peddle expensive health supplements in the name of disease prevention.

I have heard that many doctors are also going into aesthetic medicine and peddling skincare products to their patients.

With supply more than demand for doctors, there will certainly come a time when more and more doctors have to find alternative jobs or business to survive.

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Over the last 2 weeks, I have been receiving numerous emails and blog queries about which university he/she should choose to do medicine. It is rather surprising to see that each student seem to be have received at least 3 university/college offers to do medicine ! This is what happens when you have close to 36 medical schools with almost 45 medical programs. It is surely an Air Asia theme like scenario “Now, everyone can become a doctor…….” This does not include those who go to various other countries to do medicine. Shockingly, after writing so much about medicine in this blog, I still get questions that I find rather irritating at times. There are many students out there ( some are already 4th/5th year medical student) who still do not understand about degree recognition issue and post-graduate educations. They still think they can go to another country and easily get a job! They still think that postgraduate education is as simple as reading books and sitting for exams. Gosh, what do our schools teach the current generation of students ! They really fulfil the criteria of “katak bawah tempurung” .

As I have been saying many times over the last 3 years, just imagine the glut of doctors that we are going to face in 3-4 years time. When the market is saturated, the income of all doctors will decline. Even now, I see new clinics being open just few doors away from another clinic. That is how competitive it has become. In fact, I was just informed that some insurance companies have started to reduce their consultation fees for doctors by at least half ! If you don’t agree, they will go to another doctor who will ! The newer GPs will obviously agree, to get some income, rather than nothing. To add salt to the wound, our Health Ministry is planning to open another 40-50 1Malaysia clinics throughout the country as mentioned here and below. The 1Care system is still being kept under the carpet till further announcement.

In January 2012, I wrote an article on how doctors in US are going broke. Well, the situation has not changed much. The latest news from US says that many private practices are being closed/sold due to poor income (insurance companies have started to slash the payment), increasing litigation rate and high maintenance cost. Thus, many of the specialist are running back to hospital based practices with a fixed income. The situation is the same in many other countries as well. Even in Malaysia, some of the private hospitals have started to employ doctors compared to “self-employed version” which use to be the norm for a long time. This clearly shows that we are now at the mercy of the private hospitals and they can now demand what they want. A fixed income means that your income will be generally lower with higher tax, since you can’t play around with your tax. Furthermore, your income will not be much of a difference from what a government consultant earns.

The declining income has increased the amount of unethical practices. Whatever said , a private practice is a business to earn income for a living. Once you are used to a specific amount of income, you will try to achieve it no mater what. Thus, unethical practices will surface. That’s why I alway tell people that,never let money to buy over you. Keep your commitment low and earn a decent living. Medical business is a “one man” show. If anything happens to you, your income is ZERO!

 

Doctors bail out on their practices

By Parija Kavilanz  @CNNMoney July 16, 2013: 9:18 AM E

docotrs selling practices cobbDr. Patrick Cobb sold his private oncology practice in December 2012. “It just wasn’t feasible for us to stay in practice,” he said.

NEW YORK (CNNMoney)

Doctors who own private practices are looking for a way out. Fed up with their rising business expenses and shrinking payouts from insurers, many are selling their practices to hospitals.

It’s happening nationwide and has picked up pace, said Tony Stajduhar, president at Jackson & Coker, a physician recruitment firm.

Experts say the number of physicians unloading their practices to hospitals is up 30% to 40% in the last five years. Doctors who sell typically become employees of the hospital, as do the people who work for them.

The reasons for the trend vary. Doctors are tired of the hassle of filing insurance claims and collecting payments from patients and want to only focus on medicine again, Stajduhar said.

Obamacare has also created more fear of the unknown. Doctors are worried that new regulations will add to their administrative work and require them to pour more money into their businesses, Stajduhar said.

Related Story: One doctor gave up on health care in America

Dr. Patrick Cobb, an oncologist in Montana, sold his 30-year group practice Frontier Cancer Center to a hospital in December. His practice was struggling for years even before health reform passed.

Changes in chemotherapy drug reimbursements badly hurt the business, he said. In cancer treatment, patients don’t buy the drugs themselves. Oncologists buy the drugs and then bill insurers for the cost. Medicare significantly reduced reimbursements in 2003 for chemotherapy drugs.

That was a turning point, said Cobb. “We spent millions on drugs that we bought directly from distributors. When reimbursements fell, our costs went up,” he said. Cobb and four other oncologists at the practice took pay cuts to offset declining revenues, but it wasn’t enough. In 2008, the practice closed one of its four locations.

Cobb and his partners looked for a buyer in 2012 and found one in Billings, Mont.-based St. Vincent Healthcare. The hospital system hired Cobb and the rest of the practice’s staff. “It just wasn’t feasible for us to stay in practice,” said Cobb.

Related Story: Doctors driven to bankruptcy

The cycle of hospitals buying private practices has happened before. In the early 1990s, hospitals went on a buying spree as a way to get access to more patients, said Thomas Anthony, an attorney with Frost Brown Todd in Cincinnati. At the time, it was a sellers’ market and the deals were financially rewarding for doctors.

This time, the market dynamics are different. Doctors are eager to sell and might not be able to make as much as they did in the first wave of acquisitions, said Anthony.

But, for sure, hospitals are buying.

As more of Obamacare is put in place, hospitals are rushing to increase their market share in anticipation of millions more Americans getting access to health care. Buying practices is a quick way to do that, Anthony said. And more private practice doctors want to enjoy steady salaries and hours again as hospital employees.

Dr. Dwayne Smith, a bariatric surgeon, sold his group practice to a hospital two years ago. His practice was profitable but costs were creeping higher in recent years because of shrinking reimbursements.

Related Story: Why doctors can’t stay afloat

One big cost coming down the pike was tied to electronic medical records. Federal law gives physicians until 2015 to implement digital records technology or face a 1% reduction in Medicare payments.

“This would have been a very difficult investment for us,” said Smith.

Smith’s practice approached Cincinnati-based St. Elizabeth Healthcare in 2011 with an offer to sell. The hospital bought the practice and Smith became a hospital employee. He’s happy with the decision even though he has had to adjust to the loss of autonomy.

“My hours are better. I’m not spending hours on administrative work or worrying about my business,” said Smith.

The private practice model is very expensive to operate, said John Dubis, CEO of St. Elizabeth Healthcare. “That’s why it’s diminishing,” he said. Most of the 300 physicians employed by the hospital’s specialty physicians group have come from private practices.

Said Cobb, the oncologist: “We have a joke that there are two kinds of private practices left in America. Those that sold to hospitals and those that are about to be sold.” To top of page

Are you a private practice oncologist struggling to keep the business going? E-mail Parija Kavilanz and you could be featured in an upcoming story for CNNMoney.com.

 

40 To 50 More 1Malaysia Clinics To Be Set Up From Next Year

KUALA LUMPUR, July 18 (Bernama) — Forty to 50 more 1Malaysia clinics (K1M) will be set up nationwide from next year to meet the demand from the public, especially in the rural areas.

Health Minister Datuk Seri Dr S. Subramaniam said the clinics would be concentrated in areas with many residents from the low-income group.

“Despite grumblings from the operators of private clinics when K1M was set up, K1M still receive encouraging response from the people because of the low charge imposed.

“It is a successful 1Malaysia product and can benefit the people by ensuring a good level of healthcare,” he told reporters after attending a gathering, here, Thursday night.

There are now more than 200 K1M nationwide serving about 1.5 million people with the minimum charge of RM1 for citizens and RM15 for non-citizens.

K1M is one of the initiatives under the 1Malaysia concept mooted by Prime Minister Datuk Seri Najib Tun Razak.

– BERNAMA

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I received the following “prescription” from a friend of mine! It is definitely a prescription from a government hospital as you can clearly see. I can also say that it is likely from a medical department looking at the types of medication being prescribed ! In my last blog post, I was talking about how  some pharmacist are treating patients like doctors and giving dual sulphanlyureas. Unfortunately, the situation among doctors is also getting bad to worst.

For those who do not realise, please look at the last medication that was prescribed:  “GlaxoSmithKline 250mg bd” !! This is NOT a name of a medication. It is the name of a pharmaceutical company aka GSK. I still can’t figure out what it should have been. I hope some of this blog readers can give me an idea or make a guess.

I was informed that in many of the new medical schools locally and overseas, pharmacology is not being thought as it use to be. They expect the student to learn along the way. It could also be due to the fact that a pharmacist always follows and plays an active role in the management of patients in other countries. Unfortunately, we have a long way to go, even though many general hospitals have started to do so.

In this case mentioned, I am sure the pharmacist would have picked up the mistake. As for the doctor, even though it would not have caused any serious problem to the patient (since the drug does not exist), prescription errors does cause serious harm ! Thus, it is important for any doctor to check their prescription properly before giving it to the patient.

Laughter is the BEST medicine………………

 

IMG-20130704-WA000

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In March 2012, I wrote an article of the same topic. It was about a referral letter from a pharmacist who was managing the patient’s Diabetes and his diabetic foot. Patient ended up with a BKA. The Ministry always says that despite all the unofficial complains about pharmacist acting like doctors, there are no official complaints. Thus, I decided to send the letter and an official complain to Jabatan Kesihatan Negeri and MOH. Both the UKAPS and Bahagian Penguatkuasaan Pharmacy came to see me and I provided all the info, even the patient’s particulars. Unfortunately, during the interview by the person from Bahagian Pharmacy, I was told that diabetic medications are Class C drugs and thus, can be prescribed by a pharmacist without a prescription ! Of course I know that but should they be managing the patient like a doctor? She claim that they should not and should advise the patient to go and see a doctor. After that, I did not get any feedback from both Jabatan Kesihatan and MOH.

Last week, I received another interesting referral letter, as attached. Surprisingly, it is from the same pharmacist!! It looks like the pharmacy is still alive and kicking and doing the same stuff again. A patient with Diabetic foot was taking multiple types of medications from this pharmacy for the last 1 month (after an initial treatment at another private hospital), including antibiotics! She was given Metformin, Gliclazide MR, Glipizide, Galvus and Unasyn ! I never knew you can give 2 different types of sulphanylurea for the same patient. Worst still, the treating pharmacist do not even know the renal status of this patient!

Another shocking thing about this letter is the instructions given. She is practically ordering the “specialist” on what suppose to be done for this patient. As a Consultant myself, I do not write letters like this, even if I were to refer the patient to a MO in KK etc. However, this “so-called” pharmacologist has written what we should do, like providing X-rays and Scans to look at the extent of infection, to provide surgical intervention  etc. Very interesting and daring indeed. A BKA had to be done for this patient due to late presentation with almost gangrenous Left foot.

Well, in this Bolehland, anyone can do anything. I had again sent this letter to Jabatan Kesihatan and would like to see their response. In fact, I had seen several patient who had visited this pharmacy who claim that there is a doctor in the pharmacy! It looks like they are behaving like a doctor and our ill-informed patients believe that they are doctors. One patient even told me that it is doctors who are running this pharmacy!! WTH!

 

final letter

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I received an interesting info today from both the FMT News and the Star. In May 2012, I wrote this. When our great, previous Health Minister announced that 16 medical institutions will conduct MQE exams, which include few private medical schools, I did not agree. I felt that a standardised MQE exams conducted by MMC will be a better option, like GMC. Furthermore, allowing private medical schools to conduct this exam is not acceptable, as far as I am concerned, as these are profit orientated organisations and MMC will not be able to monitor the exam standards. As I wrote before, every of this universities have different curriculum and different format of exams. Monash do not even have a final year exam! We all know that our previous DG was an apple polisher!

Both the article above (attached below) says that MMC has withdrawn MQE exams in private institution. However, nothing is mentioned on MMC’s website. If it is true, I feel that our current DG, Dato Hisham is doing a good job. I just hope he will continue to bring good standards of medical education and practice to this country. I also feel that Dato Subra’s comment is a valid comment as this decision is MMC’s decision and nothing to do with MOH. MMC should be an independent body to monitor the standards of medical graduates. It should never be influenced by politics.

Now, coming to the parents and students who complain about this. Firstly, it is not the MMC’s or MOH’s fault when you do your MBBS in an unrecognised university. The list is available on MMC’s website (last updated 11/06/2013) for everyone to see. If you graduate from an unrecognised university, you must sit and pass the MQE exams. It is the law under Medical Act 1971 (amended 2012). It is the same for any other country. In fact, for some countries, as long as you graduate outside their country, you need to sit for an entrance exam (UK, Australia, US etc). Unfortunately, our society is an ignorant society. I still have queries in this blog asking about recognition of their medical schools when it is easily available on the net. I still have parents and students who feel that no matter where they do medicine, they can work anywhere in this world ! Some get cheated in broad daylight by agents and medical schools when WHO/Avicenna/IMEI listing is used as a form of “international” recognition of the medical school ! I am also amused when they say that their degree is recognised by EU but not Malaysia. I wonder whether they can use their degree to get a job in any of the EU countries including Ireland and UK?

Day by day I am hearing horror stories about our increasing number of new doctors. Some do not even know basic medicine for which you spend 5 years in a medical school. The shift system is only making the situation worst. I just hope our new DG would do something about it. Forget about foreign medical schools, our very own 36 medical schools also need proper accreditation to be done. If they do not comply to MMC’s standard, they should not be recognised. I have written many times in this blog about all the hanky panky things that goes on in some of the medical colleges in this Bolehland.

Finally, we definitely do not want doctors who do this :

IMG-20130609-WA000

 

Medical grads in limbo, want govt help

Athi Shankar

| June 21, 2013

With the Malaysian Qualifying Examination at private institutions cancelled, hundreds of doctors from unscheduled universities are in limbo.

GEORGE TOWN: There are some 450 jobless but qualified medical doctors in Malaysia from unrecognised universities abroad.

Last year they were given a lifeline when the Malaysian Medical Council allowed them to sit for the Medical Qualifying Examination (MQE) at private medical universities.

As a result more of these unscheduled doctors managed to pass MQE last year than previous years.

But their respite was short-lived when MMC suddenly cancelled this year’s MQE intake in private universities without any explanation.

Now the qualified doctors are in limbo.

Led by Penang Consumers Protection Association (PCPA) K Koris Atan, some of these unscheduled doctors sought the help of new Health Minister Dr S Subramaniam.

They met Dr Subramaniam on June 10 in Putrajaya, hoping that the MIC strongman would somehow end their predicament. But, they returned home dismayed by his indifferent ministerial response.

After listening to them for only eight minutes, the minister finally told them that “I can’t do much on this matter.”

Koris said the medical doctors were terribly upset with Subramaniam’s tepid response.

“He just washed his hands off the issue,” said Koris. Also present with Koris were Hindraf advisor N Ganesan and seven affected doctors, who spoke on condition of anonymity.

Recognised elsewhere

The doctors graduated from unrecognised medical universities in Romania and Ukraine.

They have also passed the European Union examination for medical graduates to obtain practising licences.

But these medical graduates from unrecognised universities need to pass the MQE in order to start their housemanship and be registered as medical doctors in Malaysia.

Previously unscheduled medical graduates from unrecognised foreign universities could only sit for the MQE at three local universities – Universiti Malaya (UM), Universiti Kebangsaan Malaysia (UKM) and Universiti Sains Malaysia (USM).

But the number of those unscheduled doctors who managed to pass the examinations was extremely low.

Last year however, many unscheduled doctors managed to pass MQE when MMC expanded the examination to private medical institutions AIMST University, Melaka-Manipal Medical College and Monash University Sunway Campus.

Now that too had stopped for reasons best know to MMC and the Health Ministry.

“Until today no one knows why MQE was suddenly stopped this year.

“The doctors and their families are in dilemma,” said Ganesan.

In a lurch

Although qualified as doctors recognised by European and Commonwealth countries, he said they were left in a lurch in Malaysia because their degrees were not recognised by the government.

Currently MMC recognises 375 universities in over 30 countries.

Each medical graduate spends about RM200,000 to 300,000 to complete a six-year medical degree course in unscheduled universities abroad.

It’s cheaper than the over RM500,000 needed to pursue a medical course in Malaysia.

Ganesan said some unscheduled doctors were forced to sit at home unable to get employment, while some have taken up jobs unrelated to their medical degrees.

Some are working in pharmaceutical warehouses, as car salesman and insurance agents, and some had resorted to selling different products to make a living.

Several others have left Malaysia to earn a livelihood as medical doctor in foreign land.

“We are qualified professionals, and yet we are unrecognised by our very own government when others recognise us.

“The MQE path too had been closed now.

“We want to serve the country but we are denied the chance,” said the disappointed doctors.

Hindraf will refer the issue to Deputy Minister in the Prime Minister Department, Senator P Waythamoorthy.

“The government should end its flip-flop and step in immediately to address this issue,” said Ganesan.

- See more at: http://www.freemalaysiatoday.com/category/nation/2013/06/21/medical-grads-in-limbo-want-govt-intervention/#sthash.Om5N7viF.dpuf

 

Govt should help medical grads in limbo, says Hindraf

GEORGE TOWN: The Hindu Rights Action Force (Hindraf) has called on the Government to help medical graduates from universities that are no longer recognised.

Hindraf adviser N. Ganesan claimed that the Malaysian Medical Council (MMC) had put the graduates in a spot when it limited the number of universities offering the Medical Qualifying Examination (MQE).

He said the MMC had stopped private universities, which had earlier conducted the exam, from doing so.

Only public universities are allowed to do so now.

“It is unfair for the MMC to take such a move without considering the impact on medical graduates from the unscheduled universities.

“It is baffling that their qualifications are recognised by the European Union (EU) but not the MMC,” he said, adding that most of the graduates were from universities in Romania and Russia.

One of the affected graduates, who was present at the press conference with her parents, said it was tough for her and her friends to become full-fledged doctors without passing the MQE.

“Right now, I have no choice but to find other medical-related jobs.

“But this is not easy as each job requires me to hold a practising licence, which can only be obtained if I pass the MQE,” said the 32-year-old who wished to remain anonymous.

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I had written many times before that most budding doctors feel that by being a doctor  they are going to do wonders. Only when they start their working life will they realise that it is not what they thought. Yes, medicine has evolved with a lot of new medications, new surgical techniques and new discoveries. Unfortunately, how many of these can actually cure you ? Why do we still see people dying of infections like Pneumonia, Meningitis etc when we have so many different types of antibiotics compared to 30 years ago? I still see my patients succumb to pneumonia, Dengue and Diabetic foot etc. With so many advanced cardiology techniques, we still have patients dying of Acute heart attack. Frankly, to be alive you need a lot of luck and faith. It is not about what doctors can do. Doctor’s job is to diagnose and administer treatment. After that it all depends on luck! Even though the life expectancy has increased but we are seeing more younger people dying of chronic diseases. And there is NO cure for chronic diseases. We have medication just to control it!

Over the last few weeks, I have had many elderly patients with multiple co-morbidities being admitted under my care. Call me conservative, but right from those days I had always believed in informing the relatives the hard truth. I will inform them from day one itself that there is nothing much I can do and very high chance that the condition will deteriorate. I will inform them the possible options that are available. These are patients who are suffering from irreversible medical conditions and have reached their terminal event. Ventilating these patients will never be my option. You just have to put yourself as the patient and decide what would you want at that time.

There are many doctors out there who will listen to relatives than making a sound clinical decision in the best interest of the patient. I have had doctors who ventilate a terminally ill advanced cancer patients and even a patient who has been bed bound for the last 2 years due to a stroke. Will this change the outcome ? It will only prolong the suffering of the patient. In private sector, it is just a waste of money for the relatives. No matter how painful it is to say that we can’t do anything for the patient, it has to be done. Remember what this doctors said in his last speech ?

Let me give you an example. I just saw a 81-year-old frail looking lady. She was diagnosed to have Ca Head of Pancreas with biliary obstruction and liver mets 6 months ago. If I was the doctor, I would have just suggested stenting of the bile duct and go for palliative care. Unfortunately, someone out there in a neighbouring country decided to go for a major surgery (Whipple’s procedure) after subjecting the patient to ERCP, EUS and tissue biopsy. Intraoperatively, they felt that it is at an advanced stage and decided to do a triple bypass surgery instead. Logically speaking, why did they even attempt the surgery in a 81-year-old lady with the CT scans already showing metastasis ? Is it because the family requested or someone wants to be a hero? A good doctor would have just advised her to go for palliative care and symptomatic relieve. Now, the same doctor who did the surgery told the patient to go back and rest at home as nothing much can be done!! Shouldn’t this been told when the diagnosis was made? The story is just for everyone to ponder upon! The family spend huge amount of money for something that did not do any good for the patient.

The article below was circulated in Facebook and emails about a month ago. It appeared over here. Every budding doctor and doctors themselves should read this article below, written by a family physician. It is the truth and definitely I do not want someone ventilating me, putting me on a tracheostomy tube, NG tube and being bed bound for the rest of my life, if I survive. I rather die peacefully. What’s important is that my family will be taken care of by leaving behind adequate insurance and a will. As I cross halfway of general life expectancy, I have done all those.

Well, after 16 years of service as a doctor and almost 3 years of being “on-call” daily in a private hospital, for the first time (except Singapore) I am bringing my family for an overseas vacation. I could not afford to do this for a long time. Thus I will be off my blog from 30/05/2013 till 9/06/2013. It is a long trip to the Theme Park city of the world. …………………

How Doctors Die
It’s Not Like the Rest of Us, But It Should Be

by Dr Ken Murray

Years ago, Charlie, a highly respected orthopaedist and a
mentor of mine, found a lump in his stomach. He had a surgeon explore
the area, and the diagnosis was pancreatic cancer. This surgeon was
one of the best in the country. He had even invented a new procedure
for this exact cancer that could triple a patient’s five-year-survival
odds–from 5 percent to 15 percent–albeit with a poor quality of life.

Charlie was uninterested. He went home the next day, closed
his practice, and never set foot in a hospital again. He focused on
spending time with family and feeling as good as possible. Several
months later, he died at home. He got no chemotherapy, radiation, or
surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die,
too. And they don’t die like the rest of us. What’s unusual about them
is not how much treatment they get compared to most Americans, but how
little. For all the time they spend fending off the deaths of others,
they tend to be fairly serene when faced with death themselves. They
know exactly what is going to happen, they know the choices, and they
generally have access to any sort of medical care they could want. But
they go gently.

Of course, doctors don’t want to die; they want to live.
But they know enough about modern medicine to know its limits. And
they know enough about death to know what all people fear most: dying
in pain, and dying alone. They’ve talked about this with their
families. They want to be sure, when the time comes, that no heroic
measures will happen–that they will never experience, during their
last moments on earth, someone breaking their ribs in an attempt to
resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call
“futile care” being performed on people. That’s when doctors bring the
cutting edge of technology to bear on a grievously ill person near the
end of life. The patient will get cut open, perforated with tubes,
hooked up to machines, and assaulted with drugs. All of this occurs in
the Intensive Care Unit at a cost of tens of thousands of dollars a
day. What it buys is misery we would not inflict on a terrorist. I
cannot count the number of times fellow physicians have told me, in
words that vary only slightly, “Promise me if you find me like this
that you’ll kill me.” They mean it. Some medical personnel wear
medallions stamped “NO CODE” to tell physicians not to perform CPR on
them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is
anguishing. Physicians are trained to gather information without
revealing any of their own feelings, but in private, among fellow
doctors, they’ll vent. “How can anyone do that to their family
members?” they’ll ask. I suspect it’s one reason physicians have
higher rates of alcohol abuse and depression than professionals in
most other fields. I know it’s one reason I stopped participating in
hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much
care that they wouldn’t want for themselves? The simple, or
not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in
which someone has lost consciousness and been admitted to an emergency
room. As is so often the case, no one has made a plan for this
situation, and shocked and scared family members find themselves
caught up in a maze of choices. They’re overwhelmed. When doctors ask
if they want “everything” done, they answer yes. Then the nightmare
begins. Sometimes, a family really means “do everything,” but often
they just mean “do everything that’s reasonable.” The problem is that
they may not know what’s reasonable, nor, in their confusion and
sorrow, will they ask about it or hear what a physician may be telling
them. For their part, doctors told to do “everything” will do it,
whether it is reasonable or not.

The above scenario is a common one. Feeding into the
problem are unrealistic expectations of what doctors can accomplish.
Many people think of CPR as a reliable lifesaver when, in fact, the
results are usually poor. I’ve had hundreds of people brought to me in
the emergency room after getting CPR. Exactly one, a healthy man who’d
had no heart troubles (for those who want specifics, he had a “tension
pneumothorax”), walked out of the hospital. If a patient suffers from
severe illness, old age, or a terminal disease, the odds of a good
outcome from CPR are infinitesimal, while the odds of suffering are
overwhelming. Poor knowledge and misguided expectations lead to a lot
of bad decisions.

But of course it’s not just patients making these things
happen. Doctors play an enabling role, too. The trouble is that even
doctors who hate to administer futile care must find a way to address
the wishes of patients and families. Imagine, once again, the
emergency room with those grieving, possibly hysterical, family
members. They do not know the doctor. Establishing trust and
confidence under such circumstances is a very delicate thing. People
are prepared to think the doctor is acting out of base motives, trying
to save time, or money, or effort, especially if the doctor is
advising against further treatment.

Some doctors are stronger communicators than others, and
some doctors are more adamant, but the pressures they all face are
similar. When I faced circumstances involving end-of-life choices, I
adopted the approach of laying out only the options that I thought
were reasonable (as I would in any situation) as early in the process
as possible. When patients or families brought up unreasonable
choices, I would discuss the issue in layman’s terms that portrayed
the downsides clearly. If patients or families still insisted on
treatments I considered pointless or harmful, I would offer to
transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some
of those transfers still haunt me. One of the patients of whom I was
most fond was an attorney from a famous political family. She had
severe diabetes and terrible circulation, and, at one point, she
developed a painful sore on her foot. Knowing the hazards of
hospitals, I did everything I could to keep her from resorting to
surgery. Still, she sought out outside experts with whom I had no
relationship. Not knowing as much about her as I did, they decided to
perform bypass surgery on her chronically clogged blood vessels in
both legs. This didn’t restore her circulation, and the surgical
wounds wouldn’t heal. Her feet became gangrenous, and she endured
bilateral leg amputations. Two weeks later, in the famous medical
center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in
such stories, but in many ways all the parties are simply victims of a
larger system that encourages excessive treatment. In some unfortunate
cases, doctors use the fee-for-service model to do everything they
can, no matter how pointless, to make money. More commonly, though,
doctors are fearful of litigation and do whatever they’re asked, with
little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system
can still swallow people up. One of my patients was a man named Jack,
a 78-year-old who had been ill for years and undergone about 15 major
surgical procedures. He explained to me that he never, under any
circumstances, wanted to be placed on life support machines again. One
Saturday, however, Jack suffered a massive stroke and got admitted to
the emergency room unconscious, without his wife. Doctors did
everything possible to resuscitate him and put him on life support in
the ICU. This was Jack’s worst nightmare. When I arrived at the
hospital and took over Jack’s care, I spoke to his wife and to
hospital staff, bringing in my office notes with his care preferences.
Then I turned off the life support machines and sat with him. He died
two hours later.

Even with all his wishes documented, Jack hadn’t died as
he’d hoped. The system had intervened. One of the nurses, I later
found out, even reported my unplugging of Jack to the authorities as a
possible homicide. Nothing came of it, of course; Jack’s wishes had
been spelled out explicitly, and he’d left the paperwork to prove it.
But the prospect of a police investigation is terrifying for any
physician. I could far more easily have left Jack on life support
against his stated wishes, prolonging his life, and his suffering, a
few more weeks. I would even have made a little more money, and
Medicare would have ended up with an additional $500,000 bill. It’s no
wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the
consequences of this constantly. Almost anyone can find a way to die
in peace at home, and pain can be managed better than ever. Hospice
care, which focuses on providing terminally ill patients with comfort
and dignity rather than on futile cures, provides most people with
much better final days. Amazingly, studies have found that people
placed in hospice care often live longer than people with the same
disease who are seeking active cures. I was struck to hear on the
radio recently that the famous reporter Tom Wicker had “died
peacefully at home, surrounded by his family.” Such stories are,
thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by
the light of a flashlight–or torch) had a seizure that turned out to
be the result of lung cancer that had gone to his brain. I arranged
for him to see various specialists, and we learned that with
aggressive treatment of his condition, including three to five
hospital visits a week for chemotherapy, he would live perhaps four
months. Ultimately, Torch decided against any treatment and simply
took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that
he enjoyed, having fun together like we hadn’t had in decades. We went
to Disneyland, his first time. We’d hang out at home. Torch was a
sports nut, and he was very happy to watch sports and eat my cooking.
He even gained a bit of weight, eating his favorite foods rather than
hospital foods. He had no serious pain, and he remained high-spirited.
One day, he didn’t wake up. He spent the next three days in a
coma-like sleep and then died. The cost of his medical care for those
eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of
quality, not just quantity. Don’t most of us? If there is a state of
the art of end-of-life care, it is this: death with dignity. As for
me, my physician has my choices. They were easy to make, as they are
for most physicians. There will be no heroics, and I will go gentle
into that good night. Like my mentor Charlie. Like my cousin Torch.
Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family
Medicine at USC.

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The new cabinet line-up was announced today. Since MCA refused to accept any cabinet post due to their worst performance in history, MIC is given the Health Minister post. For the 2nd time, MOH is now being headed by a doctor. Dr Subra is a dermatologist by training and was running his own clinic in Malacca before venturing into politics. However, if his record as Human Resource Minister is anything to go by, his performance can be questionable. Other that this appointment, there is nothing great about the cabinet line-up. Appointing Wathyamoorthy as a Deputy Minister in PM’s department is not a good move. HINDRAF was once declared illegal and all their top leaders were detained under ISA in 2007. Wathya ran away to UK till his return last year. During this time, all the main stream medias condemned the movement as racist and influencing the Indians to go against the government. Unfortunately, it is now a component party of BN and given a Deputy Minister post. So, what say you MIC and IPF? Who is the representative of the Indians under Najib’s cabinet?

Anyway, I hope Dr Subra can put MOH in order again. The recent news about an Houseman becoming a bogus policeman is rather disturbing. Remember what I said before about the deteriorating quality of students who are doing medicine nowadays? Even though this is an isolated case, I am sure it questions on how such a person can become a MBBS holder in the first place. Why was he involved in this crime? Was he in huge debt? I had always said that you should NEVER take huge loans to do medicine. It will take a lifetime to settle it. I know many who do illegal locums to settle their loan which include Car loan etc which will come later. Due to social status, many parents force their child to buy big cars and add more loans to their already huge debt. When the jobless scenario hits the market, many more doctors may land up in illegal activities as what happens in many other countries.

The jobless scenario of nurses hit the market end of last year. Many were left with at least RM 60K PTPTN loan. The government tried it’s best to absorb some into the civil service but could only do so for about 1600 of them. I know many nurses who are asking for a job in GP clinics and even working as Customer Care staffs in some hospitals. The quality is questionable and many do not even have any credits in SPM despite MOHE enforcing at least 3 credits. However, to enter civil service, they need atleast 5 credits!! Was MOHE sleeping? BTW, I still do not understand the logic of combining MOHE and MOE into 1 Ministry but have 2 Ministers!! Who makes the decisions? The minister who was running the MOHE is now the MB of Johor!

After the jobless scenario issue, the government has now enforced a minimum of 5 credits to enter nursing college. A little bit too late, I must say! This will definitely affect the intake of nursing colleges if enforced strictly. I hope MMC will also review its criteria and improve on the quality of the medical schools. The jobless scenario will definitely hit the medical profession soon. With the new Minister and a New DG, I hope something drastic can be taken to improve the quality of medical intakes and graduates.

Junior doc turns bad

Houseman impersonated police officer during robbery with three others
TUESDAY, MAY 14, 2013 – 10:56
Location:
IPOH

 

 toy pistol and other items seizedBUSTED: The toy pistol and other items seized from the group

A 26-YEAR-OLD houseman may have to forgo his dreams of becoming a doctor after he, and three others, were detained in relation to a robbery.

The man, who was pursuing his housemanship at Raja Pemaisuri Bainun Hospital, had also impersonated a police officer during the incident.

In confirming the arrest, Ipoh City Police chief ACP Sum Chang Keong said a 30-yearold businessman was driving his car along Jalan Dato Onn Jaafar when it was blocked by another car with four occupants at 4.25am.

One of the passengers from the car, dressed in an ASP police vest, alighted from the vehicle and punched the victim’s chest before he introduced himself as a CID police personnel.

“The man then pointed a black object, which resembled a pistol, and demanded the driver hand over RM350 or follow them to Sungai Senam police station,” Sum said.

At this juncture, another accomplice alighted from the car, and together with the houseman, got into the victim’s car and went to a bank in Jalan Sultan Idris Shah.

Upon arriving at the bank’s ATM, the robbers increased the amount to RM450. The victim then tried to call a friend for assistance, but was stopped by one of the suspects, who also seized his identity card.

Luckily for the businessman, a police car was dispatched to the scene after the Pekan Baru police station received a tip-off about the incident.

“The two police personnel spoke to the ‘officer’, who informed them he was from the Sungai Senam police station,” Sum said.

When the policemen asked for his authority card, the “ASP” flashed a Malaysian Special Ranger Agency card with his personal particulars.

Realising something amiss, the police officers took the four men to the Pekan Baru police station to conduct further investigations. They also seized the vest with the “officer’s” name tag, the authority card, a police cap, a pair of handcuff s, a toy pistol and two sets of keys.

The car which the four men were driving in was registered under the houseman’s name.

“The case is being investigated under Section 395 of the Penal Code for robbery and Section 6 of the Firearms Act,” Sum added.

The four have been remanded until May 17 to facilitate investigations.

Number of nursing students in Malaysia set to drop

JOHOR BARU – The number of students enrolling in nursing courses in Malaysia is expected to decrease as many students are finding it hard to meet the new entry requirement set by higher education ministry.

Institut Sains dan Teknologi Darul Takzim Chief Executive Officer Shahrul Azila Mohd Salleh said the entry requirement used to be three credit passes but last year, it was changed to five credit passes for nursing students.

“We hope the higher education ministry will review the change as many students are not meeting the mark,” he said after the institute’s seventh convocation here yesterday.

Shahrul said other private higher education institutions were also facing the same problem.

“For the last intake, we managed to enrol 240 to 300 students, but we expect the number to drop to 20 per cent for the intake next year,” he said.

He said the institute would submit an official application to the ministry to review the matter.

Shahrul said that if the institute could not fill the enrolment quota for nursing, it would have no choice but to accept international students from Singapore, Indonesia, the Philippines and China.

“We had quality graduates in the nursing course and among them were students with three credit passes,” he said, adding that the entry requirement should remain at three credit passes to appeal to a wider intake.

Earlier, a total of 411 students obtained their diplomas for various courses including business management, accounting and information technology during the convocation ceremony held at Persada Johor Convention Centre.

The recipient of the institute’s Executive Chairman Award, Siti Zulaikha Zulkifli, 21, said the key to her success was to be brave to ask questions.

“Besides revisions, I do not hesitate to speak up and approach my lecturers if I have questions,” said the Diploma in Accountancy student. She plans to move on to Universiti Kebangsaan Malaysia. Number of nursing students in M’sia set to drop

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I am very sure  a lot of us would have read the article in The Sun 2 days ago. It was about the petition that was sent to DPM from a group of Malaysian students graduating from Australian medical schools seeking our government’s intervention in securing an internship place in Australia. I wrote about this issue and the petition concerned almost 3 months ago over here. I had given my views. The person who initiated this petition is a self sponsored student but majority who signed it were government scholars. BTW, I don’t think our Minister of Higher Education knows anything about internship in medicine based on his reply over here. He probably thinks “internship” here means equivalent to internship in other fields where they do it as part of their course. This reply in The Sun is interesting to read.

Now, coming back to the topic above. I mentioned in my last post that I will reveal some changing strategies of medical schools in getting students. IMU, the first and most established private medical school in Malaysia, has sent out a survey to their alumni and students asking for their opinion on the introduction of USMLE preparatory course. What interest me the most was the content of the message that was sent out. Every single issue that I had written in this blog that many refuse to believe over the years has been reinforced and confirmed by this message below:

Below is an important update on postgraduate medical training opportunities and survey:A special invitation from Dr. Mei Ling Young, Provost of IMU

Dear IMU alumni and students,

IMU would like to help our students and graduates develop  career paths.

Up tofairly recently, medical, dental, pharmacy and nursing graduates did not

need to worry about having jobs. This is  now changing rapidly. Even for the

medical graduates, competition is becoming intense and those who have added

degrees,postgraduate training and experience will have more options.

For the medical graduate, IMU is planning to run USMLE preparatory courses.

The USMLE is a licensing examination which is mandatory for doctors who wish to

undertake postgraduate clinical studies or work in the US. It will be a big project as

we can see that the demand is going to increase. The main reason for this is that

the medical graduate is starting to face very serious difficulties getting postgraduate

openings. For those with a Malaysian degree there are only about 800 places for

about 4000 medical graduates a year. The waiting time for this bottleneck can be

over 5 years.

The traditional outlets, for those who have trained overseas, are in the UK,

Ireland and Australasia. Opportunities for training in these countries are

becoming increasingly limited. All these countries are, for the first time,

having difficulties placing their own graduates in house jobs, a situation

never heard of before.

The cause for this is the establishment of new medical schools over 10 years ago and

the ramping up of numbers enrolled in established medical schools, many going up

from 150 to over 350. This had been in response to a lack of doctors.

An analysis of the situation shows that the US is still hungry for doctors and will be

so for the foreseeable future. There are also many opportunities for postgraduate

training (residencies) leading to specialist qualifications in various specialty boards.

These qualifications are in Malaysia, Singapore and many other countries. The

survey below is to give us an idea as to how many of our students and graduates

(both IMU and PMS) are interested  to do the USMLE. It will take only a minute to

complete the questionnaire. Because this problem, of difficulties getting

postgraduate places is going to worsen for medical graduates,  it is important for

IMU to start this project as soon as possible. Thank you.

Click to proceed to survey
https://www.surveymonkey.com/s/CWQ7NCP

Regards,

Dr. Mei Ling Young

Provost of IMU

However, I would like to reiterate that sitting and passing the USMLE exams do not guarantee you a residency post or  a training post in US. Yes, US is still short of doctors simply because many of their own citizens are not interested in being one. The high litigation rate and demanding population are some of the reasons quoted. Oh, don’t forget the high indemnity insurance rate, so much so, it is even higher than the income they earn in a year for some speciality. There was once a saying that there were more doctors resigning in US than being produced, not sure how true was that statement.

USMLE exam is needed for anyone to be able to work in US. It consist of 3 Steps with 2 parts in Step 2. It does not come cheap either. Just this year, the fees has been increased again as mentioned here.  Despite spending huge amount of money, there is NO guarantee that you will get a residency post. If you look at the ECFMG fact card over here, you will realise that only 40% of the Non-US citizen IMG got a matching for the year 2012. If you look at the ECFMG annual report over here (page 20), you will realise that Malaysia is not even in the top 45 countries from where the IMGs are coming from! The highest IMGs are from India (16%). Despite that, I just received a comment from a doctor from India who said this “Fed up of applying to every match, sir. Not getting matched. So quit trying. Looking for other opportunities based on usmle credentials like abu dhabi, malaysia, sir” .

I got no issue of IMU conducting this course but they make it sound like it is very easy for students who pass USMLE to get a training post in US. I think it will be as tough as getting a specialist training post anywhere else in the world. You are competing with the whole world! BTW, IMU is not the only university encouraging students to sit for USMLE. Few of the newer medical schools in Malaysia  have also started to promote USMLE for their students.

Well, once someone said that we will become a maid (aka graduates) exporting nation by 2020. It looks like we will also become a doctor exporting nation soon………………

Welcome to GTP, government  Transformation Program…………………

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