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For Future Doctors: Do you want to be a Doctor? …. By Dr Wong Yin Onn

March 28, 2012 by Pagalavan Letchumanan

This is a beautifully written letter by Dr Wong Yin Onn, a Consultant Physician and Associate Professor at Monash Malaysia which you can also read over here http://myhealth-matters.blogspot.com/2012/03/do-you-want-to-be-doctor-by-prof-wong.html and here https://www.facebook.com/groups/179465178830655/#!/groups/179465178830655/doc/198885280221978/. Dr Wong is a senior Consultant Physician who is running a private clinic in JB town. When the Monash campus started in JB in 2006, he was one of the first to offer his service to teach the students. He is an excellent teacher who was thought by the giant, Prof TJ Dhanaraj, the founder dean and Professor of Medicine of University of Malaya, my alma mater as well. University of Malaya medical faculty was one of the best medical school in the world back then! I am sure you know why it deteriorated!

His reply is to the same person who emailed me and said that I am dampening the spirits of many budding doctors. Well, I am just saying the truth and the future prospect and Dr Wong do agree with me in this letter. However, if you have genuine interest in medicine and willing to put up with all the frustration that will come along the way, then by all means go ahead but it will never be a smooth sail.

Do you want to be a Doctor?

Dear Daryl,
Your aunt has asked that I share with you my thoughts on medicine and medical education today.
Let me start by saying that I am most blessed to have trained under your Aunt, Prof Florence Wang, and I recall my time in ward 12A at University hospital under her as a most formative part of my training. Thank you prof!
It has been 3 decades since then and the world has changed. The world of Medicine and medical education has changed beyond even the most imaginative of us all had dared to dream. Some things are good and much detrimental.
I will have to ask you very honestly why you wish to pursue a career in Medicine for this is very important.
Most students simply have very little knowledge of the world of medicine and some very quickly become disillusioned in their clinical years. ALL my students come to me with FULL distinctions or stand at >97 percentile of their cohort; that they are brilliant is without a doubt but sadly many are NOT that motivated to serve humanity. They come into medical school because their results qualify them too, they sing the right well rehearsed song at the interview and because they think it is prestigious, they want to be a medical student!
But the real world of sick humans with all the smell and excrement and drains rapidly reverse all those good feelings, and harsh reality sets in. Osler a great Physician whom your aunt and I both greatly admire said that THE VERY FIRST QUALIFICATION is a Love for Humanity. I believe that that quality is far more important than all the ‘A’s in your result slip.
AS a GOOD doctor, You will be very important. We have plenty of doctors but not many GOOD ones. The future of many lives and families depend on what doctors do and SAY; imagine all the Good or Damage that can be done. But to be a good doctor is NOT easy. I just had a tutorial with my students and told them that the VOLUME of information that they need to read up is so MUCH that any serious student will honestly spent ALL his time doing very little but STUDY. I hope this realisation will help you understand the quality of life you will have as a medical student, or rather the lack of it.
Modern medical education has moved far beyond lecture based learning; here in the Clinical school the word ‘LECTURE’ is OBSCENE and students learn through SDL – Self directed learning. Its philosophy being that the advance of knowledge is so rapid that Students MUST learn to teach themselves rather than being taught formally in a Lecture Hall. This demands very matured and disciplined students for to the lazy student, SDL means Sleeping DeepLy. Are you prepared for years of being a nerd?
Please remember that Doctors are first and foremost Diagnosticians… those training under me MUST not only be skilful in diagnosis and management but also in social skills and leadership. When I was under your aunt, she demanded History taking so detailed and meticulous that ‘War and Peace’ looked like a short story in comparison. Today students speak in SMS like language, and do “Focussed History Taking” instead of Detail History taking. Yes the Art of Clinical diagnosis is dying, and HIgh Touch Medicine being replaced by High Tech Medicine.
In many Once Prestigious Universities which I will not name, Final Year students now teach 3rd year students Clinical Methods!!! Your aunt will tell you that 3 decades ago, only the senior consultants in UM were allowed to teach Clinical Methods as it was considered so very2 important. Osler is certainly turning in his urn!!
In your mind, do you envision yourself as a doctor spending hours talking, feeling, touching, examining the patients….  or a doctor ordering scans and more scans with nary a glance at the nameless poor sick man lying on the bed? Ask yourself that question now.
Yes, the practise of Medicine is in trouble.
Blatant commercialisation, rampant blood tests done without any doctors ordering or supervising, scans and probes of all kinds, are being conducted by laboratories and some doctors misguilded by wants rather than needs. When your aunt was holding the fort at Ward 12A, her ward rounds will start at 8am and the whole entourage of the Professor, Dr HC Ting the lecturer, the Medical Officer, the houseman and the medical students will follow her from bed to bed. The medical student or the houseman will present the LONG DETAIL history and she will then TALK TO EVERY PATIENT WITHOUT EXCEPTION about aspects of the history and personally examine every patient to confirm or correct the juniors’ findings. This of course was a long tedious process and the rounds will stretch till 1pm. But it was the Art of Clinical Diagnosis at its finest. Today, I am sad to report that rounds are spent looking at scans and reports and its a RARE occasion that the Consultant lays his hands on the sick. Sadly I am not exacerating. I wish I am.
Hope lies in every one of us doctors, present and you the future, for the sensible management of patients; YOU remain the hope for untold numbers of patients in the future. Sadly some doctors see patients not as patients but as a disease that needs treatment which provides our source of income. This is nothing new, physicians like Osler had repeatedly cautioned against not forgetting the man behind the disease, and medicine as a calling rather than a business.
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish”.~ Sir William Osler
Many doctors are unhappy with their work or simply too busy to talk, console or listen. Yes thats life in the 21st century where we sms instead of talk. Many just treat the disease and completely ignore the person who has it. We hear endless tales carried by patients of doctors who grunt instead of talk, who are capable only of monosylable conversation and who zip patients in and out of the consultation room with a speed that will make Superman jealous. I try my very best to teach my students the Art of Clinical Diagnosis but even I fear that its a losing uphill battle. My colleagues and I here are led by Prof Khalid who is a old school clinician, and we refuse to belittle the Clinical Art despite the advancing machinery all around us. Students are amazed and impressed by all the wizardry and sometimes to my frustration fail to practise the Clinical Skills as much as I want them to.
Ask yourself Daryl, what do you want? I do not want you to come to medical school and be disillusioned by what you see in the REAL MEDICAL WORLD as compared to the idealised world that we had projected.
Doctors must never forget why we became doctors in the first place, and the wonder of caring for fellow humans. Some may be a bit burnt out. We had in our careers, seen and taken care of more pain and misery than most people. We saw prostitudes, drug addicts, criminals and the worst of humanity. Yes, this is another point that I must raise to you. AIDS today is the TB of your aunt’s era, its everywhere! Most of my students come from very privileged families or they cannot afford the fees! Hence it is a shock to many when confronted with Vagabonds, homeless, addicts, pimps and Prostitutes. All the glamour flushes away when you realise that such folks are among the many that you will encounter daily unless you are in some Beverly Hills practise.
But of course we also treated decent human beings, doting grandmothers and innocent children. No doubt, the demands on our skills and the medical-legal complexities that accompany our practise would have made even the greatest of our medical ancestors shudder. And for this your training is NOT the 5 years of medical school BUT many2 years beyond. Are you prepared for such a LONG time spend in studies and training?
You had read Dr Pagal’s blog and written to him, while he may be harsh and discouraging, much of what he wrote to you with regards to THE SYSTEM has some truth to it. The system is basically dictated by our political masters, a system undeniably sick, and Dr Pagal has written frankly of much of our woes that only drastic administrative tsunamis can repair.
Yes the system only makes it more painful. Long waits for post graduate training positions is the norm now. Regulations as thick as a medical text. Pharmacies selling controlled medicines like sweets. To change that will require one of us to be the next Prof Virchow, plunging head on into politics to make a difference.
In school we rose above the hoard, we were the cream de la cream, and yes I can testify to that in my students. Some are so brilliant they frighten me. We obtained results the envy of most and we strove with pride to enter medical school. Could the same students have done well in other fields? Of course they will shine too!!
In medical school you will work like ants on a long march. You will stare at slides till you see mitochondria in your dreams and memorised volumes of facts and figures. Some of my students are NOT prepared for this; they thought that it will be a smooth passage and when they hear this old Professor here telling them to read XYZ, they simply turn off and zone away. Are you ready for a student life that has NO LIFE??
I take them for tough postings in Internal Medicine, I am among the strictest examiners, I expect the students to flourish in the drudgery of crowded wards, to work till hypoglycaemic on medicine rounds, to perform every procedure required in the book, and of course to pass their exams reasonably well. I expect them to look at X-rays until their eyes turned red. And do I have such students? Yes, I am blessed that many such students have walked the wards with me. And I am proud of them. And I know they will overcome every obstacle invented by our political masters to excel in their fields because they have the fundamental quality to be a good doctor; their love of Humanity and of the Art of Medicine.
You will finally graduate and become a house officer. Yes the field is as packed as sardines from Malaysia to UK to Australia, Dr Pagal is NOT exaggerating when he says that jobs will be difficult to come by soon. But if you are GOOD, you will be wanted!  It’s TOUGH I do not deny that, and TOUGHER as the years pass by, BUT again I emphasize, if you are good, you will be wanted, for the good doctor is a rare specimen.
A few years later, you will pick a specialty, from paediatrics to surgery, family medicine to cardiology, internal medicine to radiology, and shuffled off to more clinics, rounds grand or otherwise, work and studies. And MORE EXAMs. Girlfriend? Oh what Girlfriend!!!
About 20% of my own class are still SINGLE!
In the 80s, new diseases appeared. I still recall with trepidation managing the very first patient admitted to our hospital with AIDS. We knew very little but feared a lot. As registrar, it was my duty to examine him. But again we survived. And learned. Now at almost every bedside teaching, I see patients with HIV. In your generation, you will see many many more new ones, from Avian flu number something to any new thing that crosses species as humanity ravishes the environment. Ready for that?
Your youthful enthusiasm and dedication will push you through the initial years. As young doctors, weren’t we incredible then, if only because we came back to the wards night after night, day after day for emergencies, calls, rounds or simply a ’tissued’ drip. “Bengkak” the nurse will phone and we leave our dinner to struggle with chemo wrecked veins for IV access.
Did you know that your aunt will reprimand the ladies for coming to the wards in pants? It is NOT acceptable then but now almost all my female students come in pants! OOPs sorry Prof for leaking such old tales!
We as doctors try to hold onto our commitment to heal, that wonderful calling. Then we see another world – the realm of the business of medicine, where every disease is a “case” to be investigated.
A very senior Professor tells me she had seen doctors ordering investigations before even taking a history! Here is also the world of the grunting and monosylable doctor, the superman of 2 minute consultations and management. True, the superb rare genius of a diagnostitian may well have obtained all the data that he needed sub- 2 minutes, but the poor human called ‘the patient’ needed at least 6 minutes of compassionate conversation. (By the way, that is why the OSCE exam is 6 minutes long, or SHORT from your examinee viewpoint… now you know how the patient will feel when the consultation is even shorter than this!). Recall that the only reason the woman in labour remembered the attending medical student is because they held her hand while she screamed.
We are the descendents of Aesclepius, the inheritors of all that is noble in the Hippocratic oath. We may fail to change the ideas of many doctors however we may preach from some elusive high moral ground. But as individuals can YOU NOT lose that ideal? If you can, welcome to the world of medicine and modern medical education. You will thrive no matter what! If not, seriously reconsider another vocation.
If we tell our students that the learning of medicine is through their apprenticeship to us their seniors, then we better be sure that we are good role models. Your aunt was a superb clinician and diagnostician and had inspired many of us.
As a future doctor, you can be the hope of the febrile, the breathless and the pregnant.
Do not let what you see in the misadventures of some doctors discourage you. Instead let them be teachers to you for you now know what you do NOT want to be like.
When a doctor have taken medicine to be a business or trade, he will ask what are his achievements — material success, cars, wealth, etc..
When a doctor has taken medicine to be a calling, he will ask what has he become — his character.
I hope we doctors can discern and reflect on what we have become in the practice of medicine, and teach all our young charges, delivering them safely through the long 5 years of protracted labour into a reasonably sane medical world. Daryl, I hope I have helped you somehow. Your aunt, Prof Florence has taught me much, this is my little tribute in return, my Bunga Emas to her.
Thank you
Associate Professor Wong YO.

Posted in Education | 27 Comments »

For Future Doctors: NST: Enough doctors in the house?

March 27, 2012 by Pagalavan Letchumanan

The article below appeared in NST today http://www.nst.com.my/opinion/columnist/enough-doctors-in-the-house-1.66656#ixzz1qJoGh1k4. It looks like it is slowly coming out of the bottle. Even though the issue of oversupply of doctors did appear last year, it died off slowly when the “so-called” moratorium was implemented by the cabinet. The moratorium ended up as a joke after that! The article below has some mistakes. The number of medical schools is currently 36 in total and not 30 as mentioned. The total of medical programmes will be more than 40 as many are running 2-4 concurrent medical programmes as mentioned below as well.

The reasons given by our Deputy Health Minister for the increase in number of doctors in civil service: “Among the reasons for the big number, she said, was that more government  scholarships were available for medical studies (from 600 to 800 per year) and  more openings for medical practitioners in the ministry’s health facilities” is laughable. The number of post in civil service has not changed much over the last few years. What has clearly increased is the production of medical graduates.

And if you think it is going to stop at 36, please read the article below the NST article  http://thestar.com.my/education/story.asp?file=/2012/3/25/education/10961119&sec=education which appeared in the Star last Sunday 25/03/2012. The deputy director of Higher Education said this: “About 25 more institutions have indicated their interest but we want to be selective and work with those who are specialists in their fields such as in Medicine, Engineering or Business programmes” WTH!! in the name of education hub!!

I received an email from an unhappy budding doctor who said that I am painting a negative picture and breaking the heart of many aspiring doctors who have genuine interest in doing medicine to help people.  ”in your posts, you also pointed out the fact that doctors now have little or no job security as posts are limited which really dampens our ambitions as even if our intentions were true, to genuinely comfort and assist people in need, with no posts available in the next 5 years, or opportunity to do so, really discourages students like me to even consider it as it seems like pursuing medicine is now a dead end!” 

The facts are right infront of you and it is up to you to decide on your future. There is nothing special about medicine that you must be guaranteed a job! It is just like any other profession where you need to look for a job. The only difference is that medicine is more complicated than any other professions as I have mentioned numerous times before. No government promises you a job. Thus, if you have genuine interest in medicine and not for money, go ahead but be prepared to have a tough life ahead. That is what I am trying to say.

Enough doctors in the house?

By Syed Nazri  | syedn@nst.com.my

ANNUAL RUSH:   Malaysia could be heading for a glut in  five years, say practitioners

THIS is the time of year when so many young Malaysians run towards realising  childhood ambitions, and parental pressure, of becoming a doctor.

Everyone among them seems to want to be a doctor, lawyer or an engineer,  though several years down the road, some might end up being an overworked  politician or an underpaid reporter.

It is the transformation season, one that follows the completion and outcome  of the Sijil Tinggi Persekolahan Malaysia and Sijil Pelajaran Malaysia  examinations. More than half a million of them will start looking at what they  are going to do next. And it’s quite certain that hundreds, if not thousands,  will seek to take up courses related to medicine on their way to becoming  doctors. The straight A+s in SPM came up to almost 600, and that’s only a small  fraction of the doctor hopefuls.

It happens every year; if the high achievers don’t get government  scholarships to do these courses, they will make noise, call up overworked  politicians or write to the newspapers.

But let’s look at things in another perspective and consider what was  revealed in Parliament last week by Deputy Health Minister Datuk Rosnah Abdul  Rashid Shirlin and match it with what doctors themselves think.

Rosnah said: “The number of medical practitioners in the country has  increased significantly with the ministry registering over 21,747 in government  service last year.” (It was recently also reported that there are about 33,000  overall).

Among the reasons for the big number, she said, was that more government  scholarships were available for medical studies (from 600 to 800 per year) and  more openings for medical practitioners in the ministry’s health facilities.

Now, let’s ponder over what came out in the latest issue of Berita MMA, the  monthly newsletter of the Malaysian Medical Association. The following is an  excerpt of an article written by Datuk Dr N. Athimulam. I was told it reflects  the views of most, if not all, doctors. It’s really hot off the press in more  ways than one:

“As per Dec 30, 2011, there were 11 government and 19 private medical  colleges, with about eight offshore recognised medical programmes. The strength  of medical students in each medical faculty varies. Two private colleges in the  southern region with twinning programmes have 1,457 students here and another  1,229 overseas, with a total of 2,686. A newly opened prestigious private  university college has a total of 95 medical students.

“On an average, if there are 500 students in each college, then there should  be 15,000 medical students in Malaysia,” Dr Athimulam, a past president of MMA,  wrote.

He added that about 10 years ago, the authorities introduced a requirement  referred to as NOC (no objection certificate) to regulate the number by making  sure that only really qualified students could take up medicine.

This ruling, however, has not been adhered to. And as a result, he said, the  number of Malaysian medical students overseas has increased to “easily more than  25,000″, mostly in the Middle East, Indonesia, Russia and Ukraine.

Dr Athimulam further wrote: “The government intends to achieve a target of  87,177 doctors by 2020, by which time the country’s population is projected to  be 35 million.

“The Health Ministry has set a target ratio of one doctor to every 400  people by 2020″, but he expressed fear that there could now be as many as 10,000  medical interns every year, which means that the government target for 2020  “will be reached by 2017″.

Then the cruncher: “Unless the government controls medical education, there  may be a glut of doctors by 2017 or 2018.”

The way things are going, I don’t know for sure whether it is good or bad.  On one hand, Malaysians aspire to take the country to become a developed and  high-income nation in a few years.

Which means a sufficient number of doctors.

But on the flipside, are we doing it the right way and not compromising on  quality?

Whatever it is, this paper is offering a timely service to post-school  Malaysians about career choices and the right courses, including medicine.

The New Straits Times will publish a weekly pullout starting today that will  serve as a guide to students intending to pursue higher education. Be sure to  get your copy.

Read more:  Enough doctors in the house? – Columnist – New Straits Times http://www.nst.com.my/opinion/columnist/enough-doctors-in-the-house-1.66656#ixzz1qJoGh1k4

M’sia set to be education hub

By KAREN CHAPMAN educate@thestar.com.my

The country aspires to become the regional learning centre by focusing on its strengths in four key areas.

THANKS to a landmark partnership agreement between the Higher Education Ministry, Universiti Teknologi Mara (UiTM) and the world-renowned Massachu­setts Institute of Technology (MIT), the country is set to become the knowledge capital for logistics and supply chain management in Asia.

 Dr Mahender says a supply chain comprises everything involved in creating a product, from raw materials to finished goods.

This has resulted in the formation of the Malaysian Institute for Supply Chain Innovation (Misi) in Shah Alam.

Dedicated to postgraduate supply chain education and research, Misi will serve as MIT’s Asian hub in the university’s international network of centres, which is known as the Global SCALE (Supply Chain and Logistics Excellence) Network.

The other centres in the network are the MIT Centre for Transportation and Logistics (MIT CTL), the Zaragoza Logistics Centre in Spain and the Centre for Latin American Logistics Innovation in Colombia.

Modelled after a leading supply chain management programme at the MIT CTL, Misi rector Dr Mahender Singh explained that Misi will offer both Master’s and Doctoral programmes in supply chain management and logistics.

“The Master’s programme will start in August this year while the Doctoral programme is scheduled for next year,” he said.

In addition, Misi will offer short courses under its Executive Development Programme as well as conduct research and corporate outreach activities for global and local firms that operate in the Southeast Asia region.

“The MIT Global SCALE Network is an international alliance of leading-edge research and education centres, dedicated to the development and dissemination of global innovation in supply chain and logistics. It was launched by the MIT CTL with the opening of the centre in Spain in 2004 followed by another one in Colombia in 2008.

“Collectively, the SCALE Network, which includes CTL, now spans four continents,” he said.

 Prof Siti Hamisah says the ministry wants to be selective when deciding on a foreign branch campus to be set up in the country

Explaining the meaning of supply chain education and research, Dr Mahender who has been seconded from MIT, said supply chain management (SCM) is one of the key areas within the business management space.

“A supply chain comprises everything involved in creating a product, from raw materials to finished goods. It is the art and science of bringing raw materials from their source, converting it into products and moving them to the multiple consumer locations in the most efficient manner to make the business profitable.

“We teach students a variety of skills since the domain of SCM needs a very diverse set of capabilities,” he said.

The students learn quantitative as well as qualitative methods to make supply chain performance improvements. The complexity in supply chain arises due to the routine movements of products and service across country boundaries.

“The students also learn about the financial and informational aspects of the business as it relates to the performance of the supply chain directly,” he added.

Using the actual data and description of their problems, he said researchers may decide to use mathematical tools to model the problem and find a better way to find a superior solution, or devise better solutions after conducting a qualitative analysis of the available data.

The signing of the landmark partnership agreement was witnessed by Prime Minister Datuk Seri Najib Tun Razak last year, who commended the three parties for their efforts, which supported the nation’s aspirations to strengthen higher education and to be a regional education hub.

“With Misi’s establishment, I believe that research and development in logistics and supply chain industry will propel and accelerate other industries for the benefit of the nation,” said Najib at the time.

Higher Education Minister Datuk Seri Mohamed Khaled Nordin said it was heartening that MIT chose Malaysia to host its overseas centre.

“The partnership is significant because China and Singapore had expressed interest in hosting the centre,” he said.

He said the ministry had selected UiTM to be MIT’s partner as the local university had a long history of offering transport and logistics programmes up to postgraduate level.

In terms of higher education institutions as of October last year, there are 20 public universities, 26 private universities, 23 private university colleges, 28 polytechnics, 74 community colleges, 434 private colleges and several branch campuses of foreign universities.

On the possibility of setting up more branch campuses of foreign universities here, Higher Education Ministry deputy director-general (private higher education institutions) Prof Datin Dr Siti Hamisah Tapsir said the ministry wanted to be more selective when doing so.

Working with the best

“About 25 more institutions have indicated their interest but we want to be selective and work with those who are specialists in their fields such as in Medicine, Engineering or Business programmes,” she said.

Giving examples, she said these included the partnerships between Misi and MIT, Perdana University and Johns Hopkins University and Royal College of Surgeons, Newcastle University Medicine Malaysia, Southamp­ton University and Reading University.

“Heriot-Watt University will set up a branch campus in Putrajaya,” she added.

According to the Heriot-Watt University website, it has been chosen to establish a new campus in Malaysia at an investment of £20mil (RM98.4mil).

It said the university was chosen as winner of a major international tender by the Malaysian Government and Putrajaya Holdings Sdn Bhd, in recognition of its strong reputation for creating diverse research and development opportunities and solid strong track record of success in linking with industry, commerce and the wider society. The new, purpose-built campus will create opportunities for up to 4,000 undergraduate and postgraduate students to study a range of courses in science, engineering, business, mathematics and design, with a view to gaining a UK-recognised degree.

Recent figures show there are 87,322 international students in Malaysia (24,617 in public institutions and 62,705 in private institutions). 9,002 of these international students are pursuing PhDs, 11,673 Masters and 35,347 their Bachelor degrees while the rest are attending diploma and certificate-level courses.

The ministry is targeting 200,000 international students enrolled in the country’s higher education institutions by 2020.

Prof Siti Hamisah said the Government is planning to expand the roles of its Education Malaysia offices (formerly known as Malaysian Students’ Department (MSD)).

“It will be like a one-stop centre where foreign students can seek more information on studying in Malaysia as well as better able to handle the recruitment of foreign students. It is similar to British Council,” she said.

To become a higher education hub, Prof Siti Hamisah said the ministry has identified four areas that will put the country in a better position to attract foreign students.

These are Islamic banking and finance, advanced engineering, hospitality and health sciences.

Mohamed Khaled said last year that by focusing on the four key areas rather than in too many disciplines, Malaysia would be able to strengthen and develop its position as a higher learning education hub.

Posted in Education | 16 Comments »

An Interesting referral letter!

March 24, 2012 by Pagalavan Letchumanan

Today, I received an interesting referral letter, not from a doctor but a pharmacist! The letter was actually directed to a government hospital but the patient decided to come and see me.

It is interesting to see that a pharmacy can treat patients and even write a referral letter to the hospital !!. According to the patient, they saw a “doctor” but I don’t see any doctor’s name in this letter. Only a pharmacist has signed the letter. I presume the pharmacist was wearing a white coat and thus the patient thought he or she is a doctor. The pharmacy has been prescribing medications for this patient over the last 1-2 weeks and decided to refer to the nearest government hospital with a plan : “provide a brain scan (MRI)”. I also like this sentence ” cluster migraine without etiology“.

The issue of pharmacists acting like doctors has been going on for a long time but unfortunately the enforcement is really weak. Even though raids are conducted but very minimal. Pharmacist is not allowed to diagnose, do investigations and treat patients. Their job is just to dispense medications on doctor’s prescription and to explain the side effects of the medications. They also act as  an adviser to the doctors in terms of dosages etc. I have seen pharmacist who even conduct routine  blood sugar, HBA1c and BP monitoring for patients. They even adjust medication dosages and prescribe new medicines, taking over GPs work.

I can only see this situation getting worst as pharmacist are also learning to survive. Soon, they may even employ our jobless doctors to work with them as an adviser! Who knows? anything can happen in this bolehland……………….. I am going to send this letter to MOH and see what action they are going to take.

Posted in Politics | 15 Comments »

For Future Doctors: The Future is bleak………. indeed!

March 19, 2012 by Pagalavan Letchumanan

Yesterday (18/03/2012), the Malaysian Medical Association Johor Branch had its AGM for 2012. It was a special occasion as the President of MMA and the SCHOMOS Chairperson were present to have a dialogue session with all the members. It was a fruitful meeting and many issues concerning the medical fraternity were discussed. We also got to know the latest happening that will change the future of medical profession in this country.

1)      Housemanship

 The declining standards of medical education and oversupply of doctors were discussed. It is indeed true that the number of housemen is reaching an unimaginable level and MOH is very much aware of this. To cover this up, MOH has come up with the shift duty system and to allocate more district hospitals for training. Most hospital’s housemanship post is fully occupied. The ratio of housemen to specialist supposed to be 5: 1. Unfortunately, the way MOH calculates this figure is rather odd as they include all specialists in the hospital including radiologists, pathologist, ophthalmologist, ENT surgeons etc where housemen are never placed. So, in reality there are not enough trainers for all the housemen who are currently in the system.

The oversupply of doctors is a harsh reality which is going to happen anytime soon. MMA has discussed this issue with MOH but unfortunately MOH puts the blame on MOHE. The moratorium is just eyewash. It is very clear that it is all about money and the only people who can stop this rot will be the general public and not MMA. Whenever MMA brings up this issue to MOH or MOHE, they are accused of being selfish and avoiding competition! Thus, it is very clear that they want to flood the market with doctors and no one is going to guarantee you a job.

The maximum period to complete your housemanship is 3 years. Anyone who does not complete the housemanship in 3 years will be automatically terminated.  Any houseman who is caught doing “locum” will be automatically terminated.

It is indeed true that MMC may soon remove the 4 years compulsory service under pressure. It is no more a rumour as I have mentioned before. It basically means that after 2 years of housemanship which is given on contract basis, there is no guarantee that you will get a job. You will have to apply to get a job in civil service or open a clinic (with license to kill). You can also forget about postgraduate education if you do not get a job in public sector.

2)      Postgraduate education

It is also true that you are only eligible to apply for Master’s programme on 5th year of service (2+3 years). The number of Master’s post is gradually being increased due to political pressure. It is way too many compared to what the universities can really handle. The quality of Master’s graduates is slowly dropping and many consultants in hospitals have voiced out their concern. We are now seeing Master’s graduates who can’t do simple surgeries. Fresh Master’s graduates are teaching Master’s students in the universities!

Those who quit Master’s programme or who failed 4 times (meaning disqualified) will still need to serve their bond with the government and repay the JPA scholarship.

3)      Insurance companies

One of the GPs brought up the issue about insurance companies cutting the consultation fees and threatening doctors. It seems that many of these insurance companies and MCOs are requesting doctors to reduce their fee if their contract is going to be renewed. If you refuse they will find another GP who is willing. The situation has reached a critical stage to the extent that some newly opened GP clinics are willing to be paid only RM5 per consultation!! How desperate the situation has made of some doctors!

With the removal of compulsory service, many of these unemployed doctors will end up opening a clinic to survive. These doctors would probably even accept RM1 per consultation! Someone in this blog commented about competition some time ago, so here you are………..

It basically means that doctor’s income will gradually reduce and many may just earn enough to survive. It is also unavoidable that the dispensing rights of doctors will eventually be removed.

The 1Care system is still in planning stages and nothing has been finalised. So, we just have to wait and see.

4)      Liberalisation of Health Sector

In Budget 2012, our PM has announced the liberalisation of many subsectors which includes health sector. The MMA has voiced out its concern regarding this matter as proper monitoring mechanism is not in place yet http://www.themalaysianinsider.com/litee/malaysia/article/mma-putrajaya-gambling-with-nations-health-by-liberalising-medical-sector/. Unfortunately, it is unavoidable once again. Since February 2012, the government has allowed private hospital of 100% foreign equity to be set up in Malaysia. They are also allowed to hire foreign consultants as long as their degree is recognised by MMC/NSR. By September 2012, foreign specialist/doctors will be able to set up their clinics in Malaysia!!

Unfortunately, the amended Medical Act 1971 is yet to be tabled in Parliament. Thus, the National Specialist Register (NSR) is not compulsory at this point in time. So, where is the monitoring system to make sure that these “so-called” specialists are indeed what they claim to be? Someone can set up a “proctologist” clinic beside yours and earn a decent living! Even now, there are some private hospitals which are hiring “so-called” specialist “trained” in some other country without NSR registration. Private hospitals are profit driven and what they are interested is only money and not quality. With the poor monitoring system, these doctors can easily get away with whatever they are doing and the rakyat will eventually be the victim.

Over the last 24 months since I started blogging I have been constantly saying that the future is bleak for doctors. Guaranteed job, good money and life are the reasons why many choose medicine. That is the fact! Forget about helping people, curing the sick etc which is actually the minority. Whatever said, at the end of the day, it is a profession to earn a living. Unfortunately, many people believe that just because they spend RM 500 000 to RM 1 million to do medicine, the return of investment is high!! It is a total misconception that the public is totally unaware.  Our society is just obsessed in getting their children to become a doctor for glamour and social status. That must change!

Secondly, doctors are so disunited that the government can just do what they want. The only organisation that we have is MMA but unfortunately how many of you guys who are reading this are even members of MMA? How many of you are even interested to fight for the betterment of future doctors? I have done my part and still contributing to the betterment of doctors in this country. I created this blog to educate the public/future doctors as I realised that many are not aware the mess that they are getting into. MMA received a lot of bad publicity recently but it is still the only organisation to fight for doctors.

The future is indeed bleak……………………….

Posted in Education, Politics | 115 Comments »

Money! Money! Money…………Lots of Money Part 2

March 17, 2012 by Pagalavan Letchumanan

On 2/03/2012, I wrote about this college http://pagalavan.com/2012/03/02/money-money-money-lots-of-money/which is offering an offshore twinning programme in Ukraine with 3 unrecognised universities but will be recognised when it is done via them! A genius formula which definitely will make more colleges to work out similar programmes like this. Then I was sent this link http://www.lincoln.edu.my/courses/doctor-courses/doctor-of-medicine-md-luc-offshore-ivano-ukraine-.html by a student who proudly said that he is going to enroll in this college as it is cheap and recognised in Malaysia. The link went missing subsequently(wonder why?) and a downgraded link http://www.lincoln.edu.my/courses/doctor-courses/doctor-of-medicine-md-luc-offshore.html appeared with just the newspaper cuttings.

When the previous link was still online, there was a 1 page write-up about the course and I manage to copy this sentence when I replied to the student ” Lincoln University College Off shore program has been approved by the Malaysian government namely, Malaysian Qualifications Agency ( MQA),Ministry of Higher Education ( MOHE ) and Malaysian Medical Council ( MMC ) , whose Officials have visited the respective universities and have certified that the educational level at these universities are of high quality and meet to the world standards”. Then I wondered why the names of these universities were not listed here : http://mmc.gov.my/v1/docs/Jadual%20Kedua%2011-12-09.pdf. I really got no idea what is going on!! Is MMC sleeping ?

Today, I was sent this link http://www.freemalaysiatoday.com/category/nation/2012/03/16/something-not-right-with-mmc/ as below. Something fishy is going on. I can bet with the bottom of my dollar that LUC will not be able to get any lecturer from Malaysia to go to Ukraine to teach these students. Basically, they will use the same lecturers from the Ukraine universities to teach part-time in their offshore campus. And woolah, you get a LUC degree which is recognised in Malaysia!! Brilliant and genius move. The title of the article below is spot on : Something is not right with MMC!!

Have you noticed that these issue never appeared in the mainstream newspaper? I am sure you know the answer. I have a feeling that MMC hands are tied and this arrangement is probably done by MOHE and it is a political arrangement. Similarly, MQA has recognised almost 146 universities in China today : http://www.hmetro.com.my/articles/146universitiChinakinidiiktirafKementerianPengajianTinggi/Article

I received at least 2 emails asking me whether this recognises the medical schools from these universities in China. As far as I am concerned, this recognition DOES NOT mean MMC will recognise the medical degree. You just have to wait and watch. Knowing MMC, I will not be surprised if they follow MQA!! I just hope I am wrong! A common entry exam would have been a better idea!

Also remember that 300 seats were approved to LUC to conduct this course and they have also managed to get license to start a 5 years local programme as well. This means that they will produce 400 graduates annually!! Malaysia boleh mah………………..

 

Something not right with MMC

B Nantha Kumar

 
March 16, 2012

Why has the MMC given Lincoln University College the greenlight to run offshore programme in a Ukraine university when PSD had rejected the latter’s direct application in 2003?

KUALA LUMPUR: One of the three Ukrainian universities, Ternopil State Medical University (TSMU), which the Malaysian Medical Council (MMC) approved as an offshore campus for medical degrees, was embroiled in legal tussle in 2007 involving a recruitment agency – Bluegemm (M) Sdn Bhd.

TSMU is a currently not recognised by the Malaysian government and students who graduate from the campus in Ukraine have to sit for the Medical Qualifications Examination (MQE).

TSMU and two other Ukraine-based universities – Danylo Halytsky Lviv National Medical University and Ivano Frankivsk National Medical University – are offering off-shore medical courses through Lincoln University College (LUC).

A former medical student from Ukraine told FMT that in 2004, student recruitment agency Bluegemm issued a letter from the Public Service Department (PSD) claiming that the government had scheduled TSMU as a “recognised university”.

Based on this claim, many Malaysian students were enrolled in TSMU believing the course to be recognised by MMC and PSD.

“These students were cheated into enrolling in TSMU, an unrecognised medical university,”said the student who declined to be named.

He added that in 2007, one of the affected students brought the false claims to Malaysian Consumer Claims Tribunal. The student won the case against Blugemm.

“There has been a series of track records over the years that TSMU’s representative has been cheating Malaysian students under the pretext of being recognised.”

“Many Malaysians have been affected and some have not graduated from TSMU due to financial constraints after being cheated.

“So, we want a clarification from MMC. Why has the council approved LUC to run offshore programme in TSMU when PSD had rejected the university’s direct application in 2003 to the Malaysian government for recognition?” he asked.

He alleged improper administration within the MMC and urged Prime Minister Najib Tun Razak to step in and resolve the issue.

Why issue LUC certificate?

Meanwhile, doubts have arisen over LUC’s credibility and its physical presence in TSMU in Ukraine.

LUC has claimed that they will be using TSMU’s facilities and Malaysian students will be studying in TSMU campus.

However, the Malaysian students will be separately taught by LUC-hired lecturers.

However, a check by FMT showed that all of LUC’s “lecturers” are in fact employees of TSMU, which is a national university in Ukraine.

According to LUC’s marketing manager Murtado Alao, the students, upon graduating, will get their medical degrees from LUC and not the Ukrainian universities.

Another issue of concern is the duration of the LUC offshore courses which stretch to six years instead of five years as commonly practised by twinning programme operators in Malaysia.

Both these issues have raised questions over LUC’s actual intentions and MMC’s wisdom in issuing the approvals to run these offshore courses.

MMC president Dr Hasan Abdul Rahman could not be contacted for comment.

Posted in Education | 13 Comments »

Doctors could face GMC action for ignoring poor care

March 13, 2012 by Pagalavan Letchumanan

 I received this interesting link today: http://www.telegraph.co.uk/health/healthnews/9138415/Doctors-could-face-GMC-action-for-ignoring-poor-care.html. If this were to be implemented here, many doctors may be jobless! I see mismanagement and misdiagnosis on a daily basis , both from public and private sector. I am not saying that doctors don’t make mistakes but a poor care to any patient can be penalised. According to this regulation implemented by GMC today, any doctor who witness poor management of case by another doctor should report it to GMC. If not, you will get into trouble as well for compromising patient safety.

Unfortunately our MMC is not as effective as GMC. One of the reasons could be the fact that MMC comes under Ministry of Health and the DG automatically becomes the chairman. If you visit MMC website http://mmc.gov.my, you will hardly find actions being taken to doctors ( there are a few but mainly due to falsification of documents). It could be due to the fact that not many patients or doctors complain about another doctor. When the new amended Medical Act is tabled in the Parliment(hopefully soon), MMC will be corporatised and I hope it will become more effective.

We also do not have a compulsory Specialist Register. Even though National Specialist register(NSR) www.nsr.gov.my was launched in 2006, it was not made compulsory yet as the the Medical Act need to be amended. Unfortunately, even before all this monitoring mechanism is in place, the government has allowed doctors who have been in service for more than 10 years overseas to return without the need for compulsory service. Thus, these doctors can go straight to private sector! I am now hearing news of some private hospitals recruiting “so-called” specialist ”trained” in a particular country and credentialing them as specialist/consultants to make money. These private hospitals do not make any attempt to make sure whether these ” specialist” are really what they claim to be. I am already hearing horror stories from these hospitals but yet the management of these hospitals are not bothered as money comes first! Imagine doing FESS surgery for 4 hours! They seem to claim that they can do all sort of surgeries etc but in reality it’s all talk but no action! The management of the hospital even got a cheek to say that NSR registration is not compulsory! I was informed that MOH is aware but no action so far as patients did not make any complain.

I just hope MMC will implement more drastic measures to monitor quality of doctors in this country, have more teeth and not to succumb to political pressures. The NSR should be made compulsory for private hospital’s consultants till the medical act is amended.

 Doctors could face GMC action for ignoring poor care

Doctors could face disciplinary action if they “walk by” and ignore poor patient care by other doctors or health professionals, under new General Medical Council guidelines coming into force today.

Doctors could face disciplinary action if they “walk by” and ignore poor patient care by other doctors or health professionals Photo: ALAMY

1:33PM GMT 12 Mar 2012

The new rules mean they may be held to account for failing to raise concerns about sub-standard treatment even if they are not involved. Doctors will be seen as responsible for the “entire welfare” of patients.

Chief executive Niall Dickson said it followed examples such as the scandal at Mid Staffordshire NHS Foundation Trust, where up to 1,200 “excess deaths” occurred due to poor care.

While some doctors did report their concerns, others “walked by on the other side of the ward”, he said.

“Doctors have an obligation to raise these concerns when they see things are going wrong,” Mr Dickson added.

He said the new rules were intended to foster a “culture of openness” in which raising concerns was not just a matter of “heroic” whistleblowing but should be an every day part of working in the health service.

Mr Dickson told BBC Radio 4′s Today programme the guidance was meant to be “more carrot than stick” but that it was “guidance with teeth”.

“Doctors who persistently and seriously depart from this guidance will find themselves possibly with their careers at risk.”

He added: “You can look at examples at the Mid Staffs inquiry, where although some doctors did raise concerns, it is also clear that many doctors didn’t raise concerns, that in a sense they walked by on the other side of the ward.

“That’s not to say that the medical care itself may have been bad, it may have been bad care by other care professionals, but our advice is that doctors have a wider responsibility.

“They have a responsibility not just for the care they give, themselves, but also for ensuring the entire welfare of patients and that includes care provided by other doctors but also care provided by other professionals

“They have an obligation to raise concerns when they have them, and doctors who are in management positions also have a responsibility to act when those concerns are raised.”

The new guidance also bans doctors from signing contracts with gagging clauses that attempt to prevent them from reporting problems to the GMC or other regulators such as the Care Quality Commission.

Mr Dickson said there were “odd” examples of such contracts which appeared to have resulted when “HR departments get some advice from lawyers” to “absolutely seal this thing up”.

He added: “What we want to encourage across the health service and indeed the private sector is a culture of openness where people feel that raising concerns is not just about whistleblowing.

“It is not just about an heroic act, it should be part of every day culture. That’s the only way in which patients will be protected.”

Posted in Education | 2 Comments »

For Future Doctors: Housemen Overworked ? Part 2

March 10, 2012 by Pagalavan Letchumanan

Two days ago, someone by the name of ThiruKCS wrote a letter to at least 3 medias, namely theStar http://thestar.com.my/news/story.asp?file=%2F2012%2F3%2F8%2Ffocus%2F10874444&sec=focus, Malaysiakini http://www.malaysiakini.com/letters/191405 and FreeMalaysiaToday http://www.freemalaysiatoday.com/2012/03/08/the-darker-shades-of-a-houseman%e2%80%99s-life/. I got no idea what he is trying to say and what is his intention but he sounds desperate!

I will say this again that if you want good, nonstressfull life, then go and find another job! Being a doctor needs a lot of commitment and stress management as life’s are at stake. If you can’t handle that, you can always quit and find another less stressful job. The last I can remember, housemen are doing shift duties now! so, if even shift duties are still stressful, then what does this guy wants? Does he really think that other jobs are less stressful and have better life? No doubt that the others may not be dealing with life but do you know how many hours an accountant spends doing accounts, a lawyer spends in preparing a case etc etc? Every job has it’s stress but medicine is different in the sense that it deals with life and since you chose this job voluntarily (hopefully by knowing all these before), you just have to go with it and learn how to cope.

There is no such thing as “office hour” job for a doctor. You need to make sure that every of your patient is well and properly managed before you leave the ward! That what makes you a good doctor. Of course, I am not saying that you should work 36 hours straight but working shift hours does not mean your responsibility is less! The stress of doctors only increases as you go higher in hierarchy as the responsibility increases. And don’t forget the litigation rate and lawyers ever waiting to sue you. BTW, where did he get the figure that 60% of housemen are having psychiatry disorder? That means 6 out of 10 housemen are mentally ill!! That’s scary. Are these the people who are going to treat us/public in the future?

BTW, this guy has just come up with a new theory for a cause of Cushing’s syndrome: Housemanship. So, medical students can now put this as a differential diagnosis. “Medical studies have determined that stress causes our bodies to produce more Cortisol. This “stress hormone” is normally only released into our bloodstreams in emergency situations. When we become scared or excited, Cortisol is flooded into our bodies to help us deal efficiently with the situation. Too much of this hormone in our bloodstreams can and does cause adverse health conditions. These conditions can include, but are not limited to, cardiac problems, strokes, obesity, a lower immunity system, and insomnia”  WTH!!

So, for those who intend to do medicine and expect a good job, good life, good future and good money, please think again. It is people who have this perception who end up writing these sort of articles to newspaper and making a fool out of themselves. This was one of the purpose of this blog, to educate the youngsters about medicine and being a doctor.

THis was one of the comment that I just received in my blog yesterday, by a housemen: ”I realize that quality of doctor are dropping. Compare to senior 2-3 year older than me, i can see huge different between us. For example, during their HO time, maybe just 2 HO allocated in one 30- 40 patient ward,during my time it is 15 HO per ward. So, training is lacking.

Then, we also realize that our future was really unpredictable. After you complete your housemanship, where will you choice to go? I also find out that majority of the doctor will choose field which had relax life, they don’t mind to be a chronic MO, such as at KK, district hospital, or some posting with no active call like ENT, radiology, pathology, opthalmology, psychiatry. So, these posting become hot posting when it come to the time to apply as a medical officer there. When these posting are full of the chronic MO, then, it was a bit unfair for those who really had interest in the field and plan to be specialist there, because when a department is full, you will had to go to other department which you don’t really like.”

Asta Levista babe……………………………

The darker shades of a houseman’s life

<!–

March 8, 2012

–>March 8, 2012

FMT LETTER: From Thiru KCS, via e-mail

Lately, there has been a lot of discussion on the plight of medical house officers in our country who are compelled to work long hours uninterruptedly. The most important asset of a country is not its natural resources, but rather its human resources. This is especially true in a knowledge-based economy, which, of course, will be the trend in the future if not already the trend in most of the Western countries. When noble professions are ever discussed, the first that comes to mind is none other than medical doctors. The big unsolved question is that are we giving enough importance to this profession?

Stress and burnout are concepts that have sustained the interest of house officers and researchers for several decades. These concepts are highly relevant to the workforce in general and house officers in particular. Despite this interest and relevance, the effect of stress and burnout on patient outcomes, patient safety, and quality care is still at the tip of the iceberg when it comes to solutions and action plans.

The Employment Act 1955 (EA) mandates that overtime pay at double the normal wage-rate and triple the normal wage-rate must be paid when employees work on rest days and public holidays, respectively. I’m aware that civil servants do not come under the purview of the EA; and doctors, housemen and the medical fraternity in government service are specifically excluded due to “work, the performance of which is essential to the life of the community” [EA Section 60A (2)(b)]. It’s almost absurd when authorities are convinced that they have looked into the matter by comparing the improvements introduced from a decade back. The issue that crucially awaits justice is what could be done to further improve the lifestyles of these house officers.

The utmost important issue to be addressed over here, apart from the payments and incentives which has always been debated despite the rise in the cost of living is the quality of life that these house officers lead in their daily lives. As the flow of life force energy moves through the physical and emotional bodies, it can become imbalanced or blocked. Although the hazards associated with the prolonged hours worked by resident physicians and house officers have been documented in numerous studies, limited attention has been paid from the administrative point of view on how to curb this issue. It’s distressing looking at the rates of house officers that seeks for psychiatry consultation at an alarming 60% in total at year 2008. Is this the kind of situation that we anticipate being healthy for these group of professionals? I can safely call this a crisis that screams for immediate remedy!

The development of trust in the physician leads to a proper patient-doctor relationship and is part of the healing process. A major element necessary for patient trust is with an individual whom is able to respond to the patient with focus and diligently gather information from the slightest reactions exhibited by the patients; and this in no doubt is only possible when your mind and body is in synch. How would you even try to develop this professional relationship with your patients with these factors; red, puffy eyes and a haggard appearance, lack of mental clarity not mentioning your aching physical body!

Medical studies have determined that stress causes our bodies to produce more Cortisol. This “stress hormone” is normally only released into our bloodstreams in emergency situations. When we become scared or excited, Cortisol is flooded into our bodies to help us deal efficiently with the situation. Too much of this hormone in our bloodstreams can and does cause adverse health conditions. These conditions can include, but are not limited to, cardiac problems, strokes, obesity, a lower immunity system, and insomnia. An overworked house officer is prone to make unavoidable mistakes that would simply cause the lives of their patient not forgetting a huge blow to their career.

Based on current empirical evidence on stress and burnout in house officers, it is highly recommended that these issues are looked into precisely to enhance patient safety. May the relevant authority ensure that these public service doctors are happy and capable of providing the best service to the nation. So to the powers that be, wake up and smell the coffee.

Posted in Uncategorized | 57 Comments »

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