Advertisements
Feeds:
Posts
Comments

I wrote my last article on 29/10/2019, throwing a question whether our junior doctors are facing a tragedy or a comedy. I modified the sentence, from the highest grossing R-Rated movie of all time, currently playing in cinemas: JOKER. “I use to think that my life was a tragedy, but now I realised it’s a comedy”.  In that article I explained the letter issued by MOH dated 30/09/2019 on the status of floating doctors. I said, those who receive an extension of contract will likely see their final journey in civil service. The end of that contract will be their end of a job in civil service. It looks like my interpretation of the letter was subsequently confirmed by our Health Minister in the Parliament, just 2 days later, on 31/10/2019:

 

 

 

He has also quoted some interesting figures during his answer in Parliament. As of 31/08/2019, we have 15 246 contract officers! In 2019 alone, we have 4 202 new contract officers and 2 515 are waiting to be appointed between November 2019 to February 2020. This figures are nothing unexpected. Since I started this blog, I had warned that this is going to happen. I first raised this issue in 2006 when I wrote an article to MMA Magazine . The mushrooming of medical schools without proper human resource planning will only lead to disaster. I have spoken about this for umpteenth years and thus I would not go into it again. We are producing about 4-5 000 graduates per year (35 medical schools locally and from overseas) when we have already reached a doctor: population ratio of 1:580 last year! The peak has not even arrived! The idea of contract post has a 2 prong strategy. Firstly, you can kick out those who are not performing and another is to allow you to complete your housemanship and compulsory service. This is similar to any developed country, jobs are never guaranteed but they will provide you with an internship post under contract as it is a statutory requirement to be eligible for full registration. However in Bolehland, transparency has never been in their dictionary. Below is a circular that was issued some time ago on how they expect to evaluate those who will receive permanent post and those who will receive a contract extension. REMEMBER, ultimately it also depends on availability of permanent post, as I wrote in 2016.

 

 

 

In June 2019, the first batch of contract housemen (who completed housemanship in December 2018) received their long awaited letter from KKM…….

 

 

While almost 1000 applied, only about 500 received permanent post and about 50 received extension of contract. In September, I heard another 175 received extension of contract. As per the letter above and my previous article, those who received permanent post got transferred “mengikut keperluan”. The worst is yet to come! Two days ago, I received information via this blog that those who got the extension of contract just received their official contract 2 weeks ago. The contract is extended from 5/12/2019(the day the first 3 years contract ends) to 4/12/2021 which is another 2 years. So, the total contract years will be 5 years. The shocking part, which I never expected was the fact that THIS CONTRACT KEEPS THEM AT THE SAME PAY GRADE AS A HOUSEMEN, WHICH IS U41, contrary to my understanding that it should have been U44 !!!

Yes, before the year 2010, most of us will remain in U41 (or U3 as it was known before 2001) for few years after completing housemanship with just annual increment. But in 2010, under the new promotional prospect for doctors in civil service (which I personally wrote during a SCHOMOS forum with KKM in 2006) , all those who complete housemanship will be promoted to U44 from the day of receiving full registration. While those who received permanent post got promoted to U44, those who receive contract extension seem to be “dianak tirikan ” ……………..

 

 

 

I find this totally atrocious! If a person is going to work as a medical officer and doing the same job as another permanent U44 officer, they should receive the same pay! Yes, they should thank their lucky stars that they have a job but we should never discriminate them by paying them lower than the rest. Unless you are transparent enough to say publicly than these guys had such a poor performance that they are not fit to hold a U44 post( that we are just doing a charity work by extending their contract to complete their compulsory service), everyone should be treated the same. Under labour law, can this be considered “forced labour”? BTW, our country’s international standing in labour law is not that great either.

For those who are unaware, SPA/JPA has been requesting to remove compulsory service over the past few years as they know they can’t provide jobs to everyone. However, it will be a disaster to do so, with many having a license to kill, out there. Completing housemanship do not make you competent enough to manage patients without any supervision. MMC has refused to comply to their request as it affects public safety. MMC’s motto is ” safeguarding patients and guiding doctors”. That’s why compulsory service is important, not just to comply with legal requirement but also to make you competent enough to practise on your own.

Whatever said, we should accept the fact that no job is guaranteed. No government guarantees you a job either. People should not assume that just because they are spending RM 500K to make their child a doctor, your investment is going to produce a guaranteed job and tons of money/return. Those eras are gone for good. However, these poor souls became a victim of poor human resource planning (which does not exist in Bolehland dictionary) and a capitalist world where commercialisation of medical education became a money making business!

I was also informed that from now onwards, the number of floating doctors who will receive permanent post will further decline due to availability of post. Remember, 15K is waiting in line! BTW, please be informed that compulsory service is only for 4 years ( 2 years HO and 2 years Mo), so you can leave before you finish your 5 years (after a total of 4 years). The question is : to where? Some can consider university hospitals but they too have their limits. Not to mention that contract officers are not entitled for Master’s program and banks will think twice before giving you a loan.

Basically, those who are being extended under contract will be paid under U41 salary but will end up doing the same job as a U44 MO, with their life in civil service ending in 2 more years. Again……..

IS THIS A TRAGEDY OR A COMEDY……………..

 

 

 

Advertisements

Since my last article in June 2019, there has been a lot of happenings in our country, as well as in other parts of the world. Is it for better or worst, only time will tell. The tragedy that is affecting our young graduates is something I predicted almost 15 years ago. As usual, our suggestions and warning to MOH was just for filing purposes with no definitive action or plan. It was all about money and how much you can make out of our society’s ignorance and demand. Over the last few months, I have been watching and reading numerous articles in the newspaper in regards to housemanship waiting period and what is happening to those who have completed housemanship and floating around while waiting for MOH/SPA to make a decision whether, you are going to be absorbed permanently into civil service or just an extension of the contract. The frustration among the doctors is palpable but trust me, it will not just end there!

Early this month, there was a circular from MOH:

whatsapp-image-2019-10-29-at-7.06.44-pm.jpeg

WhatsApp Image 2019-10-29 at 7.07.01 PM

I find this circular very interesting. As I wrote in my article dated 15/04/2019, the first batch which started their contract housemanship in December 2016, most completed their housemanship end of last year and eligible to apply for a permanent post. Unfortunately, they were waiting for months. While they were waiting, they were kept in the same hospital as a floating medical officer with the same salary as a housemen. As long as the contract is not renewed, they will not receive the U44 promotion. They will remain in U41 as per the earlier contract. The first contract was for 3 years, to cater for any extension of housemanship. That’s the reason the contract has to be renewed after you receive the full registration as only then you can receive a U44 salary. Fortunately, the bright side is the fact that you still have a job till the contract expires.

In June 2019, I was informed that almost 500 of them were absorbed into permanent civil service and only about 50 were given extended contract to complete their compulsory service. Those who were given permanent post were mostly transferred out to where the post is available. A lot of them ended up in Sabah and Sarawak. Either you take it or leave it! There were actually more than 1000 doctors who had applied, following completion of housemanship, end of 2018. What happened to the rest? From my understanding, till September 2019, there were no news about the rest. While waiting, the number of applicants has been increasing as subsequent batches of contract officers began to complete their housemanship. What a mess we are in!

Then, out of no where, the circular above was issued by MOH, dated 30/09/2019. The circular basically says that while waiting for the decision, you can now be transferred to another hospital, klinik kesihatan aka anywhere!. You will not be in the same hospital as a floating officer. It also says that you will be notified of the decision of your application 3 months before your 1st contract ends (which is 3 years from your date of starting housemanship). Basically it just confirms that you will remain a floating medical officer till about 9 months after completing your housemanship (assuming you complete in 2 years on the dot) but in a different location!

The most interesting part of the letter is the fact that, if you manage to secure a permanent post, you will likely be transferred yet again to another location depending on availability of the vacant post that you are being given! Basically means, you will be transferred again within a year to another location! Is this a tragedy or a comedy? The best is yet to come: those who receive extension of contract can remain at the same place where they were transferred as a floating officer! In another word (the way I interpret this), your life in civil service ends there within another year aka completing 4 years of compulsory service. It’s just a diplomatic way of putting it !

All these just points to a simple fact: medicine is not a guaranteed job anymore. The market will be flooded with doctors and no one is going to be bothered whether you have a job or not. How many of them, who did not get a permanent post (can be about 2-3000/year) going to end up opening a clinic? As per my last article in June 2019, the GPs are already struggling to survive!

This is not something that is happening in Malaysia alone. In August 2019, Singapore Medical Council  announced that the number of recognised medical schools will be reduced from 160 to 103, effective January 2020. Many universities in Australia, India, Ireland and Canada were de-recognised. Singapore believes that they are now producing enough graduates of their own to fill the vacancies. Only UM and UKM degrees are recognised in Singapore and I heard that many who applied for a job in Singapore are not receiving favourable response compared to 10 years ago.

Similarly, as I have written in April 2019, Australia is also reducing their dependency on foreign doctors. In April 2019, I wrote that effective March 2019, Australia has introduced a new rule for employers who are recruiting foreign doctors to be a GP in Australia. They must first apply and receive a certification from Rural Work force agency confirming a genuine need to fill the position. In July 2019, Department of Health has reclassified areas which can recruit an International Medical Graduate (IMG). What use to be known as DWS (District of workforce shortage) area is now being replaced by DPA (Distribution Priority Area). These are the areas where an employer can recruit an IMG as you will not be given a medicare provider number(for medicare billing) if you are not working in these areas. Interestingly, many of the areas which use to be DWS areas till June 2019 are now non-DPA areas. DPA now only covers rural and remote areas. For example, in Western Australia, the entire Perth up to Mandurah and even small suburbs like Bunbury and Geraldton are considered non-DPA areas. And you have to work in DPA area for at-least 10 years (the 10 year moratorium) even if you become a PR. The whole idea is to cut down the number of foreign doctors. Furthermore, you can only work in Australia after passing both your AMC Part 1 &2 exams (except Monash Malaysia), where the passing rate is as low as below 20%. As for FRACGP, as mentioned in my April article, those who enter the program in Malaysia from January 2019 will not be receiving FRACGP and will not be able to work in Australia directly. Everyone works under contract in Australia and there are many specialist in Australia who can’t find a full time job. Many work on part-time or sessional basis. There is no such thing as automatic job for a specialist in Australia, upon completing their fellowship. So, don’t assume that doctors are guaranteed a job anywhere in this world!

This interesting letter from a doctor is worth reading, ” Medical Profession is no longer lucrative”.  It is well written, not to mention the increasing litigation and patient demands. Do medicine only if you are determined to overcome all the obstacles. Reading my blog/books will inform you the real life of a doctor and not what the public wants you to believe. It is never as simple and cosy as what the public tells you. Till today, when I look at the comments in social media, the public still believe that doctors can work anywhere in the world. They got NO idea that a doctor cannot work in another country unless his/her degree is recognised in that particular country. They got NO idea that you need to sit and pass an entrance exam which can cost thousands of ringgit without a guarantee of a job! They got NO idea that there are jobless doctors in many countries, Malaysia is on the way to join those countries………

Happy Delayed Deepavali 2019 greetings.

 

IS THIS A TRAGEDY OR A COMEDY…………………..

images

 

 

11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved drug price control and currently under review for implementation. This triggered an uproar among the GPs whose consultation fee is already regulated and capped under Private Healthcare Facilities and Services Act (PHFSA) 1998. Schedule 7 which controls consultation fee for GPs has capped the maximum price at Rm 35! This has been as such since 1998 but the act came into force in 2006. The hospital doctors on the other hand had a review in 2013 and Schedule 13th was amended with roughly 15% increment, starting 2014.

What are my views and take on these issues? Well, my comments, even in the past, had created a lot of negative feedbacks from fellow doctors. But as I had always said, I call a spade , a spade! Just look at the public feedback in Facebook etc when the above town hall meeting was reported. Videos of our GP colleagues venting their frustration was shown live and recorded by various media. Did you really expect the public to show sympathy? The answer is a BIG NO! For the public, doctors are sitting in a cozy air-conditioned room and earning tonnes of money! Only when their own kid ventures into becoming a doctor, hoping to live a glamorous life, they realise the actual life as a doctor! The hours of work, training, exams, risk taken, litigation etc before you can even think of earning a decent living.

Having said that, generally a doctor can still earn a living as long as they can get an internship post and complete their training. However, the era of earning tonnes of money and being “rich” is gone and going…….Our income will be similar to any other profession, allowing us to live a life. If you are still thinking that spending RM 500 000 to RM 1 million to be a doctor is going to give you a luxury life, think again! Jobless scenario is already happening in many countries.

Now, coming back to GPs. The day you open a private clinic, it is a business, period!Same goes to private specialist. In any business, there are gains and there are loss. Some businesses closes down and some businesses thrive and even become global players. Business is a business, nothing differentiates you than anyone else. Unfortunately , health is an essential service. Health and Education are 2 components in any country which should be the government’s responsibility. I have said and maintained this statement since I started this blog. Many may not know that the PHFSA 1998 was actually tabled and passed in the Parliament in anticipation of corporatisation of health care in this country. The corporatisation of healthcare aka National Health Financing Scheme was suppose to be implemented in 1999 as the last corporatisation exercise of Dr M! Everything was ready on paper.Unfortunately, the sacking of Anwar Ibrahim and subsequent reformasi etc totally shut down the plan till today.

Frankly I don’t agree with controlling of consultation fee. Let the market force decide. BUT healthcare is an essential service and thus the government need to be responsible. Thus, in Malaysia, they control it via the Malaysia Boleh way! Same goes in any other country as well. You may think that in other countries, the government do not control the consultation fee. On paper , yes but they do control it in another voluntary way. Their National Health Financing Scheme(NHFS) that pays for all the consultation/procedure fee do have a limit and standardised payment system. Anything more than that, the patient has to pay out of their own pocket. Public being public, obviously they will choose a doctor that only bills what the NHFS pays. NO one will ever want to pay out of their own pocket! In some countries, the doctors can only accept what the NHFS pays which is basically a fee control mechanism where everyone technically is a civil servant. Even in Australia, many patients prefer to visit the “bulk-billing” doctors (accepting Medicare fee) rather than cash billing doctors.

The GPs were arguing that they are only allowed to charge a maximum of RM35 for the last 21 years. Now, just look at the comments from the public in FB etc. You, me and all members of the public knows that a simple consultation and medication by a GP will cost RM 50-70 and in some cities, can even reach RM 100! Patients are smarter nowadays. Even my patients will go to a pharmacy and ask for the cost of the medications. Similarly, many cash paying patients would do that and will know the actual cost of the meds given by the GP. So, do you think they believe that you are charging only maximum of RM 35? You may argue all you want about the cost of running the clinic etc, but a business is a business! NO one cares whether you are running at a lost or not. No one believes the notion that you are providing a service to public. Didn’t you become a doctor to help man-kind and provide service (aka free service)?

I found that one of the main issue that was discussed the other day was about TPA (Third Party Administrators). Many were arguing that TPAs are only paying RM 10-15 per consultation and wants the government to make sure that they pay RM35 per consultation. Now, let’s go back to my statement above. It is a business! TPA goes around to negotiate the best deal in town. So, the person who is WILLING to take the offer will sign an agreement with the TPA. A business deal! So why are we complaining? You signed it and agreed to it but complain later? We all know that many GPs are dependent on TPAs. Almost 60-70% of a GP’s income comes from TPAs. Without TPA, many more GPs will close shop. This is similar to private hospitals. 95% of hospital admissions are medical card holders. If insurance companies go bankrupt, all private specialist will be out of jobs! That is the fact. So, TPAs can “tarik-harga” . Unless the GPs can unite and state their demands, no TPA is going to entertain your request. By 2021, the market is going to be flooded by GPs when 50-60% of doctors(roughly about 2000-3000 per year) completing their compulsory service not going to be absorbed into civil service. You think the TPA is going to symphatise you? They will be having a jolly good time of GP shopping! And don’t forget the “uberisation” of healthcare where even those who are waiting for housemanship seem to be giving “online” or phone advise!

Even if the government removes the fee schedule, how much do you think you can charge a patient? How much a patient is willing to pay out of his/her pocket? Under-cutting and bad-mouthing is going to be rampant and again TPAs will have the same modus operandi. They will continue to negotiate a deal for the cheapest possible GP. That is business and everyone wants to make the maximum profit.So, if you agreed and signed for it, you have no basis to complain. The government is not going to interfere with that.

I really felt that most of the arguments that were forwarded during the town hall meeting were emotional in nature. I was watching it live on FB and was putting myself as a member of the public. What I saw was just doctors arguing to make more money! And that was exactly how the public felt as seen in many comments on FB etc. Bringing politics into the picture made it even worst! Whatever political ideology we have, we should keep it among ourselves and should not display it publicly, as we are dealing with members of the public who may have different political ideology. Even more shocking and surprising for me was when one of the speakers rejected Universal Health Care! Lucky the MMA president came with a statement 2 days ago that MMA and all medical associations had signed Declaration Titiwangsa in support of Universal Health Care.

When 1Care was mooted in 2012, the GPs went against it as well, mainly because of dispensing separation. It was scheduled to be implemented in 2014 but the 2013 election results made it to be shelved indefinitely. We have to admit that it is the dispensing rights that the GPs have which is giving them the survival. With limited consultation fee, they make profit from dispensing medications. IF this is removed, more GPs will close shop and become unemployed. This was the reason why GPs were shocked and reacted when the Minister announced last month that drug price control mechanism will be implemented. To me, I support the drug price control mechanism. We have to look at the public and see what benefits them. Working in a private hospital, I very well know how the hospital mark-up the medication prices. Some are up to 100% mark-up, especially for inpatients. That’s the reason I don’t like to give generic medications to patients as the organisation that makes the most profit will be the hospital. The cheaper the drug, the higher the mark-up. I rather ask the patient to buy from a pharmacy via a prescription slip from me. As for a GP, having a price written at the box may reduce their overall charge.

Now, let’s come to the solution! WE have to change and move forward. We can’t be harping on the same model that we have been doing since the 1960s! The world is changing and many countries have moved on to new models. Whether these new models are better or worst is something to be decided later. We have to move to a win-win situation, for the GPs, doctors in general, government and the public. Our healthcare system is not sustainable. I have said this many times before. Two parallel system running concurrently, competing against each other for an essential service is doomed to fail. We have a public system totally funded by tax payers and a private system almost 80% funded by insurance (aka out of pocket). The insurance companies are also bleeding in billions and the only reason they are still providing medical cards is because it is mandatory under Bank Negara rules. If not, which company wants to continue a loss making business?

The way forward for a GP to have a lifeline is to have a National Health Financing Scheme which will integrate  public and private healthcare system. This is the only way you are going to survive and have a decent living. You may not make tonnes of money but at least you can earn a living. With the NHFS, GPs will be paid by the scheme with an agreed fee. GPs can charge extra with removal of fee capping but how many patients will be willing to pay out of pocket is something we need wait and see. Eventually, most GPs will do bulk billing! It will come with a price. Dispensing separation will become inevitable with NHFS, where subsidised or fully funded medications by the NHFS will have to go through a dedicated pharmacy. But the overall cost of running a clinic will drop as you do not need to employ staffs to dispense or to run an in-house pharmacy. GPs have to form group practices like in many other countries. The NHFS may have to pay higher fees for a specialist GP which will make more GPs to upgrade themselves. Sometimes I feel very sad when I attend CME talks to see the same GP’s faces all the time! And guess what, most of them are senior GPs! The younger ones are hardly seen as they are busy trying to run their clinic.

With the NHFS paying the consultation, procedure fee and medications, there are bound to be audits. Again, this is nothing new as most countries with NHFS do such audits. You will have feedback audits, prescription practise audits and even average consultation fee audits. The number of patients you can see a day may be limited in the context of quality care. Prescription of certain drugs like opiates, steroids , antibiotics etc will be monitored. At the moment, these are never audited and the GPs can do whatever they want. Do we even have the data of total usage of antibiotics by GPs in Malaysia? We do have data from KKM and private hospitals but not from GPs as there are no laws to mandate GPs to be audited for such usage. IN any system there should be check and balance and doctors are not or should not be exempted. Unethical practices will rise if these issues are not kept in check, as what is happening increasingly in private hospitals.

There is no point arguing with the government when it comes to essential services. A government’s duty is to provide such service to public. Just see what happened when education was privatised! We made someone rich by making the public to go into debts!While the NHFS will have to get the money from the public in the form of premiums plus funding from the government, at least it will distribute the health service to a united system. Patients can go anywhere without paying anything and the GPs will be able to get the load with lower overhead cost, enough to have a job to survive.

Either we change to live a reasonable decent life or we die a slow death……. it’s our choice.

 

Lately I have been slow in updating my blog as I have been extremely busy and travelling overseas quite frequently. As our children start to begin their university lives, our life changes as well! Yesterday I saw an interesting article in The Star which quoted Prof Adeeba, the Dean of UM Medical Faculty as saying that medical graduates are not prepared for their job. The same article quoted that 30% of housemen do not complete their Housemanship in 2 years, according to Health Minister. Don’t these sound very familiar?

I have been talking about this for almost 10 years now, in fact longer than that, if you have read my MMA articles as way back as 2004. The above statement was made during the UM’s MEDxUM conference held in UM last weekend. I was actually invited to give a talk on bullying and harassment but unfortunately, the notice came late and I was not in the country last weekend.

For years I have been saying that medicine is not a “glamorous”, easy life and good money job! The public would like to think as such until they see their own child “suffering” after graduating. Then they blame everyone else except themselves. I am not saying that the system has no issues but every system in the world has issues. BUT being a doctor means you have to work and work to gain experience and further our studies. Our education do NOT stop after the 5 years MBBS degree. It goes on and on, till you go 6 feet underground, not to mention the number of exams we need to sit etc. It is a life long learning and our teachers are our patients.

Last week, our Minister said that Housemen can be called at any time to help out. Currently housemen working hours have been reduced to 60hrs per week compared to 70 hours before. Shift duties have been going on for few years now. But each hospital would have their own problems and as such every hospital would have their own rules and regulation. The priority is that, the service must run. Many people were unhappy with what the minister had said BUT service comes first. This rule does not apply for doctors alone. It applies to every single civil servant. Any civil servant can be called to duty at any time. During disasters etc, not only doctors are called but also police, bomba, welfare department etc. It is the duty of the government to make sure that the rakyat is taken care. That’s why you are called civil “servant”. You are a servant to the government and the people. The government(aka the people) pays you to take care of the “rakyat”. As a doctor, which you chose to be, your duty is to serve mankind. Isn’t that what most budding medical student would say during interview? Furthermore, the word “Houseofficer” actually means that the doctor stays IN THE HOUSE and is available at all times! That’s the reason it was mandatory for us to stay within the hospital compound during those days. Unfortunately, with increasing graduates, hospitals could not provide the necessary accomodation to all housemen and allowed them to stay elsewhere/home.

If you have pure passion for a profession, you will even do it for FREE! Unfortunately, along the way you will realise that life is more than that. You need to earn a living. You will need to serve your loan, children etc. When you are a student, all these are taken care by your parents and thus you are “stress free”. Reality hits you much later. As a doctor, you need to sacrifice a lot. Hours of work, spending little time with family and even “neglect” family members. The public do not understand all these till they have their own child in the system. Then they go on writing complain letters to the newspaper for their “adult” child who by right, should be able to take care of themselves!

More than 10 years ago I predicted that the time will come when doctors will have to wait in a “Q” for Housemanship, it will likely be given under contract and majority will eventually would not even get a civil service job. All these had surely and slowly come true. Many had emailed, messaged and even called me to say that all my prediction has come true. I have also met some junior doctors, Housemen who came to see me and had read my blog when they were students. They all admitted that every single word that I said about the system, life as a doctor, predictions were all on the dot! Some of them regretted doing medicine.

Next year will be another year to watch, as the first batch of contract doctors/housemen would be finishing their contract. Their contract started in December 2016 and would be completing their 3 years contract this year-end. Majority who had completed their housemanship had applied for a permanent post early this year but I was made to understand that they are yet to get any reply. Their contract can be extended for a maximum of 4 years to complete the compulsory service. Thus, by end of next year, we will know how many will still continue as a civil servant and how many would be left in the limbo. The 1st batch of Pharmacists contract ended end of last year and many were left without a job. Suddenly my hospital received tons of application for pharmacist when we only had 1 post to offer. The rough figure I was quoted was that only 30-50% of the doctors will be absorbed into civil service permanent post. These percentage would gradually decline later as more and more doctors are produced. Even those who get a government job, you can be sent anywhere in Malaysia. Either you take it or leave it! So, what will the rest do? Those from well to do family may end up opening a clinic. You may see a clinic in every other shop-lot by 2020, Wawasan 2020 achieved!

For those who are complaining, you should thank your lucky stars that you even have a job (under contract). Just bite the bullet and do it. Life is never easy and the world do not wait for you. The world is moving and changing daily. I even had some who are planning to return back to Malaysia from UK. They were told that ” tiada urusan pengambilan pada masa ini“. The problem is the fact that MOH do not even have enough post for those who are finishing housemanship in Malaysia, how are they going to provide a job for those who are returning from overseas? Obviously you will be at the bottom of their list and not their main problem. The MMC circular 2 years ago had already given a guideline for those who are returning from overseas. I had posted it in my blog in 2017.

I still have parents who believe that their child can work anywhere in the world with their local medical degree! I find it rather annoying at times. They just refuse to read or take advise and blame the system. Medicine is the most regulated profession in the world. Some countries still practice the “recognised degree” list and some have moved on to “common entry exam” format. MMC still uses the former. If your degree is not recognised in the country where you intend to practise, you need to sit and pass the entrance exam. These exams are not cheap and majority do not pass on 1st try. After spending huge amount of money, there is no guarantee that you will even get a job. Most who do get a job end up working in a rural/remote areas under a “non-training” post. Even Australia has closed their doors to foreign doctors who passed AMC exams. They do not provide internship anymore as they do not have enough post for their own graduates. However, if you have some years of working experience from your home country/elsewhere, you can try to apply for a supervised GP job. Even that rule is changing starting 11/03/2019 as below:

“Visas for GPs initiative

The Visas for GPs initiative will manage growth in Australia’s medical workforce by regulating the number of doctors entering Australia to work in the primary healthcare sector through the skilled migration program. The Visas for GPs initiative will commence on 11 March 2019.

All employers nominating a position that will be filled by a doctor who needs a visa to work in the Australian and New Zealand Standard Classification of Occupations (ANZSCO), occupations listed below will be required to obtain certification (a Health Workforce Certificate) from a Rural Workforce Agency (RWA). A Health Workforce Certificate is a letter issued by a RWA confirming the genuine need to fill a primary healthcare position at a given location in Australia by a doctor in the following three occupations:

  • General Practitioner (ANZSCO 253111)
  • Resident Medical Officer (ANZSCO 253112)
  • Medical Practitioners not elsewhere classified (ANZSCO 253999).

Employers will be required to attach a Health Workforce Certificate to their nomination application for any of the following employer sponsored visas:

  • Temporary Skill Shortage (subclass 482) visa
  • Employer Nomination Scheme (subclass 186) visa
  • Regional Sponsored Migration Scheme (subclass 187) visa.”

The idea is to reduce the number of overseas trained doctors for GPs by 200 yearly for the next 4 years. It is estimated that if they do not do as such, Australia will have an oversupply of 7000 doctors by 2030. Gone are the days when you can sit for AMC Part 1 and then go to Australia to work as a GP/MO before sitting for Part 2. And for those who think that you can sit for the FRACGP via the Academy of Family Physician of Malaysia and go to Australia to work, please be informed that the rules have changed from January 2019. Those who enrol into the program from 2019 will only receive icFRACGP(International Collaboration) and would NOT be registrable in Australia till you complete further modules. How these further modules will be conducted is not made known at the moment. Must you be employed in Australia under supervision or is it done online? If you need to be employed in Australia under supervision, then the above VISA rule will apply which also makes it more difficult as there would not be any FRACGP holders in remote areas to become your supervisor. Even for people like me who had worked 22 years as doctor and have been a specialist for 15 years, I cannot work in Australia as a specialist as my degree is not recognised! Even if I am assessed as “substantially comparable” by the Royal College of Physician of Australia, I need to find a job which can provide me with 2 peer reviewers to peer review me for 12 months before even being considered for specialist registration. To find such a job is almost impossible and you need to find it within 2 years of the assessment. Not to mention the amount of money you need to pay to do all the assessment!

So, for those who feel that spending Rm 300-500K locally would give them a job anywhere in the world, please understand that the world is changing rapidly. Even Singapore has reduced the number of intakes of foreign medical graduates since the last 2 years as they have their 3rd medical school producing graduates since 2017. Only UM and UKM degrees are recognised in Singapore and I heard many who applied the last 2 years never received an offer unlike 10 years ago when Singapore first recognised these degrees. BREXIT may also change some rules in UK.

I started with ” The Storm is coming…..” in 2011 and upgraded it to “Hurricane is coming…..” in 2012. The Hurricane is now sweeping through the nation and the world…………

It has been a while since I last updated this blog. In my last article, I promised that I will be writing a series of article in relation to the changing world of medicine but unfortunately I met with a small accident in September while going to work. While I was OK and only hit a divider on the highway, my car was damaged and currently still in workshop. It is really frustrating when you don’t have your own car to travel around. This entire fiasco kept me busy for the last 3 months with Deepavali early this month and some travelling to do.

Medicine is or “was” a noble profession. It started as a science to help humans, to discover diseases and ways to treat them. Early doctors were trained purely by apprenticeship with no formal training or degrees. They did their own research at the back yard and came up with new techniques, findings and even treatments. In the 19th century, our ancestors believed that doctors need some form of self regulation and proper training modules. Thus, registration and regulation of doctors started. General Medical Council began in 1858.

Doctors are the only people on the planet given the rights to collect and record clinical history and confidential informations of a person. It is the only profession which can take detail information about a person which include certain intimate or sensitive details and social circumstances. You need to know every detail about a patient, from travelling history, problems at home, social history, sexual history etc etc. Only then we can formulate a diagnosis and provide treatment plans. The patient trust us to keep these informations as tight as possible and not to release the information to a 3rd party or even to his/her relatives which may even include his/her partner without the patient’s consent. This is where medical records safe keeping and confidentiality comes into the picture. Every medical council in the world has guidelines on these issues. Every doctor should read and understand these guidelines as not to breach ethical and professional bounderies.

Doctor-patient relationship is a unique relationship. We should keep professional boundaries at all times. This is the main reason why we should not be treating our own family members and close friends. Emotion would not allow us to provide the best standard of care to our loved ones. We will be in denial and would not give the best advise. On the other end, patients can become a vulnerable victim to a doctor. Only a doctor knows sensitive information of a patient and thus can easily be blackmailed by a doctor. This is one of the reason why professional boundaries are important to be maintained. This is also the reason why we must be regulated!

The advent of social media has created a totally new set of problems. Many doctors do not realise that social media can blur their professional boundaries. Facebook, Twitter, WhatsApp and many other messaging platforms have created new problems in the medical profession. Let’s look at WhatsApp. Doctors nowadays easily give their phone numbers to their patients, send confidential informations such as blood results etc via WhatsApp to the patient and even discuss their problems via WhatsApp. The doctor believes that he is tying to help the patient but forgets the fact that it can be construed as blurring professional boundaries! Imagine if you message the patient at 11pm at night and the patient is a married lady with some social issues, like problem with her husband etc. Imagine if the patient starts to communicate with you via WhatsApp for her personal matters, presumably seeking advise in relation to her relationship issues etc. This can definitely lead to something more serious like the case over HERE and  HERE. Furthermore any confidential information send via WhatsApp etc can be considered as a breach of confidentiality as it is leaving your premise. You got no idea who can see those messages even though the phone number can be the patient’s. It is always advisable to ask the patient to come back to your clinic for any discussion or issues. Never discuss any issues over the phone or via text messages. In India, a reason court ruling determined that telephonic consultation without seeing a patient that lead to death can be considered as culpable negligence which leads to being charged as culpable homicide!

Another issue is Facebook(FB)! Many doctors have FB profiles and some of us are active on Facebook, posting various personal matters and views. Way back in 2011 , BMA (British Medical Association) had already issued warning in the UK that interacting with patients at social networking sites such as FB can lead to blurring of professional boundaries. WE must, at all times maintain the doctor-patient relationship status. Making a patient a “friend” on FB blurs this boundary. Once you become a friend of a patient on FB, the patient can access many personal information regarding yourself, they can probably see your family members photos, your political and religious inclination and even comments that you might have made regarding a patient that you just saw in your clinic. IN fact, I have seen many doctors posting and discussing patient’s history and details in FB. While you may not mention the patient’s name but if that patient is your friend on FB, he will definitely know who you are talking about. Many Medical councils and boards in the world have produced “social media guidelines” and the common advise has always been ” never friend a patient on social media including FB, Twitter etc”. To my knowledge, MMC is yet to issue any guideline on this. KKM did issue a minor guideline 2 years ago after the labour room picture fiasco. Not only a patient can see the “life” of a doctor but the doctor can also “spy” on the life of his/her patient. In 2017 there was even an uproar in Pakistan when a doctor requested a patient to become a friend in FB! It was deemed as a form of sexual harassment and the doctor lost his job!

Whenever I talk to younger doctors in regards to this, I see a shocking face! Many doctors out there do not even know their own ethical boundaries with patients. Some even attend patient’s personal family function and interact with patients as though they are family friends. Yes, you may think that it is nothing wrong BUT as a doctor treating such patient, you should never cross the line. If the patient becomes your family friend then you should politely decline to be their doctor, to safe-guard the medical profession and doctor-patient relationship. THIS is a good article to read “Unhealthy relationship with patients”. I reproduce one of the excerpt here:

Maintaining professional boundaries

 

Avoid situations that may be misconstrued by the patient – for example:

  • Giving a patient a lift home in the car
  • Seeing patients outside the surgery without a clinical reason
  • Telephoning the patient without a clinical reason
  • Having personal transactions with patients, such as lending money
  • Conducting non-emergency consultations outside normal surgery hours
  • Having conversations with patients of a personal nature.

Medical examinations can be misinterpreted by patients, and they can be left feeling that proper boundaries have been crossed so when conducting examinations:

  • Explain if an intimate examination needs to be conducted and why
  • Explain to the patient what the examination will involve
  • Obtain the patient’s permission before commencing
  • Give the patient privacy to undress and dress
  • Keep discussion relevant and avoid unnecessary personal comments
  • Encourage questions and discussion
  • If you can sense that the patient feels uneasy, offer a chaperone or invite the patient to bring a relative or friend.

Be aware of your own vulnerabilities:

  • Develop skills in saying ‘no’ whilst maintaining compassion and rapport.
  • Be aware of the impact of isolation and take steps to have as much peer interaction as possible
  • Do not to be seduced by comments that may appeal to your ego ‘you’re the only person who listens to me and understands me.’

Some of the things you need to consider include:

  • Making friends with patients or treating friends as patients can lead to unreasonable patient demands
  • Politely decline invitations from patients to be Facebook ‘friends’
  • Living and working in close rural or cultural communities means you may be invited to social and community events. You don’t need to decline every invitation you receive but do consider the nature of the event before accepting. And, you must always maintain professional boundaries if you choose to attend
  • Accessing patient records for the purpose of making social contact breaches the patient’s right to privacy.

I realise that many junior doctors and even some of my own colleagues do not understand their boundaries. They take it for granted especially doctors in private sector. These doctors feel that it is a form of marketing strategy to be friends with patients in FB, to attend functions organised by patients and make friends with patients as though they are your family friends. Some even question me when I advise them not to do so. It is ethically wrong fo a doctor to breach a doctor-patient relationship. At all times, we should maintain our professionalism and treat a patient as a patient! Never do more than that except in an emergency situation.

I see a very dangerous trend of doctors accepting patients as FB friends etc. Please be VERY careful! It can be harmful in both ways. With increasing medico-legal cases in court, it can only harm you further. We are not any different than judges who have to refrain themselves from many social events.

It has been a busy year for me. I may not be able to update another article within the next 1 month. Thus, I wish everyone a very HAPPY NEW YEAR 2019…………………

Three years ago, I wrote an article with the above title. I thought of revisiting the title again, as there are a lot of negative publicity with the medical profession over the last few weeks. It all started on 29/07/2018 when a front page article was published by the Star.

 

The front page title was followed by an article which supposedly exposed an HOD who has been sexually harassing junior doctors. Currently KKM is conducting an enquiry into this matter and the said HOD has been asked to go on leave. While I do not want to speculate on the truth of the matters raised, I am not totally surprised either. “With Great Power, comes Great Responsibility” but unfortunately, Great Power also comes with great corruption! It is not unusual for someone in great power to abuse their position. It happens in almost every field. Even in Hollywood and Bollywood, actresses have been sexually harassed. The recent expose of Harvey Weinstein sexual harassment scandals rocked Hollywood and subsequently many more exposures came to light. Whenever someone is in a vulnerable position, the superiors with ultimate power tend to take advantage. Have I seen it happening in medical field? If I say NO, I will be a liar. However, most of what I have heard are verbal in nature. Please be also informed that there is a difference between sexual harassment, sexual abuse and assault.

On 9th May 2018, for the first time since independence we saw a change of government. What happened after that? Expose after expose showing how the country’s and the people’s money were misused and abused. I have lost track of all the exposes since 9/05/2018. Why did it happen in the first place? The answer is the same: with great power comes great corruption! Anyone who stays in power for too long will bound to misuse their position. It is human nature. That’s why politicians will never try to give up their seat. The same thing happens in any organisation. When someone becomes the HOD and remains so till retirement, he becomes untouchable. He becomes so powerful that every single thing needs his approval. From approving leaves, giving SKT marks, approval to attend courses, signing for exams, approving claims, signing off housemen etc etc, almost everything needs his/her signature! What a powerful position! On the other hand, the HOD can go missing anytime, hardly does any clinical work, goes overseas conferences under pharma sponsorship etc etc and NO ONE will ever complain or take action against him/her! I have seen HOD’s who only came to work twice a month and was sitting on a JUSA C level! The rest of the days, he/she is contactable at home! I have seen HODs who hardly does any clinical rounds but will appear in the ward everyday when a VIP gets admitted. It really fits into the term ” Makan Gaji BUTA”. How many HODs even put in their leave application forms but yet they are on-leave?

When someone is that powerful, things like sexual harassment etc bound to happen. Many years ago, I wrote in the MMA magazine that HOD’s post should be rotated! When I was doing my attachment in Singapore in 2007, it is the policy of the hospital that HODs can only hold the post for a maximum of 2 terms. One term is 3 years. So, after 6 years, the baton must be passed to the next person. This next person may be a junior to the current HOD by years BUT the rotation will still need to be done. The whole purpose of this policy is to prevent abuse and at the same time, give the junior doctors an exposure to administrative work. Somewhere in the late 2000s, there was a circular from the then DG, Tan Sri Ismail Merican suggesting that the HODs to be rotated every 5 years among the JUSA salary scale. Unfortunately, there were huge objections from the HODs themselves and the suggested plan never materialised. Human nature: power! And absolute power corrupts absolutely!

IN 2014, I wrote an article about bullying. In fact, i had written several times on the issue of bullying and thus, I would not elaborate on that matter in detail again. There is a thin line which differentiates bullying from scolding. We cannot assume that every scolding is a form of bullying. Medicine is about life and death matter. A simple twist of the pen can cause death. Thus, seniors scolding juniors will happen no matter how hard you try to prevent it. However, it should not be done in front of the patients/relatives.Bullying on the other hand has nothing to do with scolding for making mistakes.Bullying includes actions such as making threats, spreading rumours, attacking someone physically or verbally, and excluding someone from a group on purpose. Unfortunately, it looks like now, every scolding is being considered bullying. Medical life is a stressful life, both physically and mentally. When you work in such a stressful situation, scolding bound to happen. However, with increasing number of doctors, shouldn’t it get better? Where did we go wrong? Why despite having increasing number of doctors ( I heard some hospitals have close to 4 MOs in a ward!!), there seem to be worsening situation of “bullying”? BTW, real bullying do occur and it occurs in every profession and in every country. This article talks about bullying in Australia and this in NZ. Nothing unusual but the type of bullying varies from one centre to another. We can never prevent it completely as we are working in a stressful job.

My answer is simple, which I had written since 2004! The quality of graduates had deteriorated! When quality deteriorates and graduates do not even know basic medicine, scolding aka “bullying” will become more rampant. From what I gather, the quality has deteriorated to the extend that sometimes, the consultants do not even bother to ask the HOs anything, as it is pointless! How did someone graduate when they do not even know how to take a history, examine and come to a diagnosis? It is the very basic of medicine that you go to a medical school for. How did someone even passed the final exam? Again, this is what you get when you commercialised medical education. Do you really think that the medical schools are interested in producing the best quality of graduates? All private universities are profit driven. Only profit matters. With such a low entry requirement to enrol into a medical school, we still have almost 100% passing rate! Can anyone beat that? Australia with such a stringent entry criteria, still have about 5-10% drop out rate! UK has almost similar figures. India went through the same phenomenon when they commercialised their medical education in late 1970s. Corruption, lowering entry requirement and high pass rate with dropping standards forced Medical Council of India to introduce a common entry exam! Now, every student who intend to do medicine must sit and achieve certain level of pass marks to be eligible for medical course. Only after that, you can apply to the universities: public and private.

I just hope MMC will seriously look into this matter and introduce some form of either a common entry or exit exam to maintain the standards of medical graduates. If not, we are be going backwards! Many still do not know how medicine has changed and still changing. I will continue these series of articles over the next few months. My next issue under this heading will be “doctor-patient relationship” and professional boundaries. With social media everywhere, do medical students or junior doctors know where their boundaries are?

Happy 61st Merdeka ……………

 

It has been almost 3 months since I last updated my blog. I had to travel a lot during these 3 months and a lot of personal issues to settle. But one thing I never forget or miss, is to vote! I have voted in every election since 1995 except in 1999 where I could not go back as I was on-call(at that time my voting station was in Seremban before I changed to Johor for 2008 election). This year’s election was the mother of all elections and the verdict was something I had never expected. I never expected BN to fall in my life time! The most I expected was to give BN a close simple majority to win. I also never expected Johor to fall and close to winning 2/3 majority by Pakatan. While I stood awake till 4am in the morning of 10/05/2018, i could not resist the tears that flowed through my eyes when I saw the people of Malaysia waking up and voting out a government that has been in power for 61 years.

I had always supported a 2 party system. It is a system that is in place in most western countries or matured democracies. The people have the power to decide which coalition party will rule the country. In any such countries, you will see that the people will change the government every 5-10 years. This will keep the ruling party on their toes and never to underestimate the power of the people. Once they fall, their dirt will be washed in public as what you can see happening right now in Malaysia. So, in the future no party can hide anything for long. It will benefit the people in long run.

So, what are we to expect from this new government. To be frank, I don’t expect much in 5 years. There are a lot of things that need to be corrected over a short period of time. First and foremost, I feel the new government should put a system in place that will prevent any form of power abuse. AG, MACC, EC chairman etc should be elected by Parliament and made answerable to the Parliament. MACC should be given power to prosecute. These people should face the Parliament to answer questions from both side. Prime Minister’s term should be limited and Finance Minister should never be the Prime Minister.

WE should not forget that the mess that this country is in now, and abused to the maximum by the previous PM was created by our current 7th Prime MInister! I had written enough about this in my earlier articles way back in 2010. I had mentioned how DR M’s social engineering and Malay nationalist ideas destroyed the future of this country. However, he did develop this country into an economic power house which benefited many people. Unfortunately, as smart as he is, he never expected or foresee that his very own people will misuse the system that he created. I just hope that in his last few years of life, he had realised his mistakes and do what is necessary. I had always said to many people that GOD will make sure that DR M will live long enough to see the damage that he has done to this country. GOD is great!

Many people asked me whether anything will change to the medical field. Firstly, I don’t think the long waiting period of medical graduates for employment will change anytime soon. With the current financial situation of the country, it is unlikely that the new government can create more post or even build more hospitals. With increasing number of graduates from this year( where all medical schools will be producing graduates), the waiting period will only get longer. However, one thing that the new Education Minister can do is to tighten the entry qualification into the medical program. By doing this and making the accreditation process tougher, many medical schools (especially the smaller “shop-lot” ones) will undergo slow death due to lack of enrolment. Over the last 2 -3 years, many medical schools already struggling to meet the required number of students.Imagine increasing the entry criteria to 5A’s in SPM with higher CGPA in Pre-U courses. Hopefully, this measure will slowly reverse the current situation over the next 5-10 years. Remember, the mess that we are in now was created almost 14 years ago!

If even the Ministers’ have to take pay-cuts, I don’t expect any pay rise to civil servants in near future. Probably once the country’s economic status is better, we can expect some pay rise. What I would like to see is a complete restructuring of the Malaysian Healthcare System. The current system of having public and private healthcare system running parallel to each other is not sustainable in long run. The government would not be able to sustain the increasing healthcare cost and maintaining an almost free healthcare system. On the other hand, the private health insurance companies would not be able to sustain the private health sector. Our private health sector is almost 90% funded by the private health insurance. I use to tell my friends that if the private health insurance collapses, I will become jobless!

I would really like to see a proper integration of public and private healthcare sector via a National Health Financing Scheme. This should include the GPs, private hospitals, KKs and public hospitals. WE have enough doctors but maldistribution is the issue. BY having such a system, maldistribution between private and public sector can be reduced. Eventually, this will also reduce the maldistribution between urban and rural areas.

With all the euphoria that we are having now, it is just too early to say how this new government will perform. Statistic shows that Pakatan only received 48% of the votes with BN & PAS taking 52% of the votes. Pakatan won in many areas due to split votes. PAS benefited from split votes in Kelantan and Terengganu. Personally, I feel that the Pakatan government is not really in a very stable situation. Tides can change by next election if they do not outperform the previous government by leaps and bounds.

Whatever said, politics in Malaysia will NEVER be the same anymore………

 

SELAMAT HARI RAYA 2018 TO EVERYONE………