I had mentioned many times in my blog since I started writing early last year that the situation is getting from bad to worst in Ministry of Health and soon it will affect the entire healthcare system in the country. Commercialisation of medical education will soon affect all of us. The glut of doctors is getting worst and many of them are being under trained and given “license to kill” . One of the major outpatient clinic in JB use to have only 6-7 doctors before. Now they have 17 doctors running the show and the MA’s are not seeing any cases anymore. A 54-year-old man who is known to be a diabetic for 20 years under follow-up at this OPD has been vomiting for the past 1 month. This was associated with nausea, lethargy, generalised weakness and mild shortness of breath on exertion. He went to this clinic several times and just given meds and told to go back. The moment he walked into my clinic, I knew what is the diagnosis! He is completely sallow looking and even a good medical student should be able to pick it up. His creatinine was 889 and blood urea of 26 mmol/L. Again, I had to refer back this patient to the hospital for dialysis and further management. At one point we were complaining that MAs are running the clinics and screwing up things but unfortunately having doctors does not seem to make any difference either!
The shift system was introduced without proper planning and making the current situation worst. It is going to produce more incompetent and uncaring doctors(as their responsibility is less!). The 2 comments below will sum up what is happening in the hospitals currently:
Comment 1:
The time i enjoyed most was when i was a houseman. Because i don’t have any responsibility.What i did, just following orders from MO/specialist. i don’t mind came early as 5.50 am and went back at night everyday. Tried to learn their management and makes a notes. I hate most when i a MO at district officer. I was alone, no guidance, a lot of responsibility.
Now i am a specialist taking care of HO in my department for almost a 2 years. i have minimum of 30 and max of 60 HO. i tried to remember their names. My department used to receice all the first poster HO. From there i have seen many HO with different attitude, knowledge, missing in action, taking EL, we ask something else then they write something else ; from different University all over the world.
What can i say is, if they committed, make their own effort to learn/ask, be nice to their colleague/staffnurse/JM/attendant in the ward, follow orders that has been ordered; they will be a good doctor. BUt..if they are just standing there like a consultant and quite, have to ask then only they move..BIG problems!.
However…since we are ‘forced’ to start shift system, everything is haywire. i don’t know which patient is being taken care by which HO. 3 shift means 3 HO, MO..not always in the ward because number of MO less than number of specialist. Patient also does’t know which doctor they want to speak to after ward round, staffnurse also does not know which HO to call.
If we do teaching during rounds, next day we asked the same question. No body can answer because, it was a different HO. so..
To all HO, don’t think that you are overwork or asking why you have to do all ‘clerk’ job. You have to know the basic how to trace result, how to get appt, putting IV line/taking blood, that will make you as a doctor. All this will connect you to other people in other department. This will make your job easy in the future. You will realize that once you become MO/specialist.
Comment 2:
Having read all these comments, I am prompted to write about my recent experience.
I am a medical officer in OBGYN for the past 5 years, currently a postgraduate trainee.
I have always treated my house officers as juniors, in fact I treat them like my brothers/sisters
for 5 years, I have never shouted at anyone, never discriminated against any particular grad, and I have never made any judgements on where they have graduated from. This is mostly due to the fact that I was being traumatised an awful lot during housemanship and I don’t like to impose the same to my fellow juniors.
I printed out handouts, notes that I have made, so that they could learn during spare time. I have even printed out materials multiple times and tried to teach them whatever I can recall after studying the previous day.They never read it even though I was spoonfeeding them.
I got scoldings from my Head of Department because they can’t finish doing rounds, or sometimes they cant even fill in the proper names or details in the particular operating notes. I have written all the operating details and all they had to do is help me fill in the time our surgery starts, because I was being called elsewhere for an emergency, I had to leave that to them. Something this simple that even a primary school student can do, they failed to do it. Next thing I know, I got penalised again.
Still, I tolerated all this, I have even offended some senior specialists because I tried to cover for the house officers when they made a mistake.
but few days ago I decided enough was enough. Houseman A was working 7am to 6PM shift. He is supposed to finish his afternoon rounds of 30 patients before going back at 6PM. The MO has already done his rounds on the same day and plans have been made for the patients.There were no bloods to be taken. This HO did “half rounds” till bed 15 and then told the nurse that he is going home sharp at 6PM. He expects his poor colleague who clocks in at 6PM to cover 3 other wards and also finish his rounds. There was a 29 weeks pregnant lady with sepsis and URTI in Bed 16. The nurse told him to check out the patient, but he refused since the “next guy is already coming”.The poor patient spiked temperature 2 times, 39 degrees and 39.5 degrees. I was busy attending to all new cases in the delivery suite. I went to all the wards and checked on all the patients and by the time I reached the 92nd patient I noticed this neglected lady. Nobody bothered to inform me about this patient, and nobody did anything for her. Best part is they actualy tagged the patient’s case sheet” MO TO review”. This same patient has problem conceiving and she had 2 miscarriages before.
I called up HO A :
Me:are you married?
HO:no
Me:If you have a wife who is pregnant, do you want a responsible doctor to see her or an irresponsible one?
HO: of course I want the responsible one
Me: DO you think you are responsible?
HO: silence
then for the 1st time in my career I shouted,yelled and warned him then asked him to write an explanation letter to my head of department.
I know I shouldn’t have shouted, but yes, I just can’t hold back any longer,
…………………………………………………………………………………………………………………
Then I read the following letters in the Star over the last few days. One of it were complaining that the shift duties is actually making the housemen to work even longer with less rest and both mentioned about the post-graduate opportunities and new rules that has been introduced. Almost a year ago I mentioned that postgraduate education is not going to cope with the glut of doctors that we are producing. At this moment, there are only 800 seats for Master’s programme , all disciplines included. It is expected to increase to 1000 by 2015. However, by then we will be producing close to 8000-10000 new doctors /year!! Only 10% is going to get a place into Master’s programme. For surgical fields, Master’s is the only way unlike Internal Medicine/pediatrics and O&G where you can still sit for MRCP/MRCPCH and MRCOG. The new rule mentioned in the letter below will only make the situation worst and many are going to get frustrated. Well, I had written about all these before but some refuse to believe what I said and insist that the situation will not be that bad!
Latest rumour: housemanship may be given on contract basis and then you need to apply for a job! No job in civil service means , no postgraduate training ! Opening clinic after housemanship means “license to kill”! God save this country!
Hold on to our young doctors
I REFER to the letter “Clarify housemen’s flexi schedule” (The Star, Oct 18) and “Accord housemen shift work benefits” (The Star, Oct 19).
While I applaud the move by the Government to ease the burden of house officers by reducing their working hours, the Government has not considered the effects this would have on current medical officers in hospitals who do not have enough house officers, especially in east Malaysia.
Since the implementation of the shift system, many medical officers are left with only one house officer to run the entire ward during the day and another for night.
As a result, the medical officer has to also take over the houseman’s role on top of their clinic work, interventional procedures and ward duties.
It is no surprise that many medical officers refuse to stay in government service after being treated poorly and paid miserably.
Thirty-six hours of ‘on call’ for a mere RM150 is laughable.
Also, recently the Health Ministry mandated candidates, who have recognised post graduate degrees such as Membership of the Royal College of Physicians (MRCP UK), to have a total of 8 ½ years of experience in order to apply for further specialty training of four years. (This includes working experience of two years of housemanship, three years as medical officer pre MRCP, one year post MRCP, half year of gazettement and the new ruling of an additional two years of waiting before being eligible to apply for a four-year training programme).
Why does the ministry have to impose such a complicated route and impose such a substantial waiting time before enabling our young doctors to apply for training post MRCP as compared to other countries where training is immediate?
These two additional years of waiting after gazettement to enter a four-year training programme frustrates our local young physicians, with many moving to neighbouring countries who willingly accept them.
What is the point of TalentCorp and talks about preventing brain drain when all the new policies are aimed at prolonging the duration to wait for further training instead of encouraging doctors to improve themselves and serve the country as specialists.
Doctors in other countries such as Britain and Singapore pass the Membership exam at a young age of 25 or 26 and are immediately eligible to enter further specialty training. Many become senior registrars or associate consultants at the age of 31 or 32.
Instead of retaining our bright local talents, we prefer to hire specialists from overseas and complain that there are not enough specialists in the country.
Worse still, we compensate by hiring foreigners whose specialisation may not suit the local settings and whose quality may be questionable.
Why are we not offering attractive training paths to our Malaysian-made physicians? Nothing is being offered in terms of training to retain our local talents with post graduate degrees.
I hope the DG of Health can clarify this latest move and prevent our local talented doctors from being driven away.
Retain our talented professionals by providing appropriate and intensive training.
By fine tuning a training path for the doctors with MRCP qualification and offering immediate training post MRCP, without unnecessary waiting, not only helps reduce the current shortage of specialists but enables our home-grown physicians to have a great sense of purpose to stay and serve the country in the long run.
STUCK IN BETWEEN,
Kuching.
Bitter pill for young docs
I REFER to the letter “Hold on to our young doctors” (The Star, Nov 3).
I agree with the writer’s observations and comments on the crazy, demeaning and unresaonable hurdles that our young physicians face in their quest towards career development and excellence.
Instead of encouraging and motivating them to specialise and sub-specialise, the Health Ministry keeps on adding more hurdles which do not make sense at all.
Doctors have to undergo a mandatory two-year internship and a further two years of compulsory national service before they are eligible to apply to do their Masters programme at local universities.
The annual allocation for the programme is about 400 places and there are thousands waiting for years to get into it.
The only alternative and shorter route (and tougher one too) is for the doctors to sit for the external MRCP, MRCOG and other specialist examinations offered by countries like Britain, Australia and New Zealand.
On the issue of housemen’s flexi -schedule raised by the writer, everyone knows that it is actually shift work because the roster is pre-determined by the hospital administrators without any consultation with the housemen.
The Health Director-General claims that the housemen are required to work an average of only 60 hours a week and they are entitled to two rest days as enjoyed by other civil servants.
In reality, they work 84 hours a week and do not get any rest days, let alone two days.
My cousin is a houseman at a hospital in Klang Valley. He worked from 11am to 11pm last Monday and Tuesday, on Wednesday and Thursday from 7am to 7pm; and on Friday and Saturday, he was rostered to work from 11pm to 11am, finishing at 11am on Sunday.
On Monday, he worked from 11am to 11pm. And from Tuesday, the same pattern was repeated.
It frustrates me that some people in authority are completely unaware of what is happening on the ground.
I hope and pray that the Chief Secretary to the Government Tan Sri Sidek Hassan will seriously look into these issues urgently.
The concerns are downright frustrating and demoralising to our doctors and young physicians.
DISAPPOINTED TAXPAYER,
SEREMBAN
Pagalavan's Avatar 
Run to Singapore if you can my dear young Housemen!
This alternative strategy may soon cease to exist, so those keen on it better take it if and while they still can! How many Malaysian junior doctors can Singapore absorb I wonder…
its too long,so i lazy to read..anyway thanx for putting some of your valueable time to write about this blog…you are so free
Doctors cannot be lazy to read. You read life long. You find time for everything!
What type of doctor are you, if you are one!. Dr Paga as a responsible citizen taking all the trouble to bring about changes in our system. You just sit back comment and hopping god to change our system or worst still run away from the problem by migrating! sheeze! We dont need doctors like you!
I have saw in Hosp Sg Buloh where they overlapped their shift period so that both HOs can passover within that time frame, in 1hr I believe..I personally believe the shift system would be the best choice on paper, but the implementation must be done more carefully and considerably. Of course, it comes down to each drs attitude toward their pts and work.
There is nothing wrong with a shift system if things are done sensibly.
Two shifts during the day (8am-3pm, 3pm-10pm) and a skeleton staff at night (10pm-8am) is usually enough. Only the morning and afternoon teams need to do rounds. A consultant or senior reg in the morning team makes sure plans are done right.
That’s actually where the problem begins. That system will include 3 hand over everyday.out of 24 hour you will waste close to 3 hours a day. practically each shift is 5hours of patient care (7 hours – 2 hours hand off). If that system works that does that mean that there will be 3 rounds a day?who will be in charge of teaching of night team?
I am not against shift system but so far the only thing I heard from friends in Malaysia is that it feels like holiday even when they are working. If those time can be used for studying that will be great but…not everyone will do so.
Shift system is still not a bad idea if education and experience of interns/HO are balanced. Prolonging housemanship (which i think it was mention previously) will only make current situation where doctors are overloaded worse than ever. I have heard that they may even cancel housemanship/compulsory service from some source in Malaysia but I hope that is not true. IF that is going to happen, private clinic will be easier to find than mamak store.
If housemanship is cancelled, then the individual is unable to registered in MMC so they can’t open clinic as well.
Well interns should not be made to work nights, period – unless in ED/OnG.
In the normal wards, a skeleton night crew to look after a large number of patients is usually enough. You dont need to make plans three times a day.
“I am not against shift system but so far the only thing I heard from friends in Malaysia is that it feels like holiday even when they are working. “
– care to elaborate?
I have friends currently serving in Malaysia and after they change to shift system the overloaded ward has even lesser work to do. They get to go home earlier – probably happens more commonly with a place that has tons of houseman.
To the ‘stuck in between’.
His/Her statement :
‘Since the implementation of the shift system, many medical officers are left with only one house officer to run the entire ward during the day and another for night.’
I’m wondering we are having houseman glut and how come only one HO is left to run the ward????
and
‘Doctors in other countries such as Britain and Singapore pass the Membership exam at a young age of 25 or 26 and are immediately eligible to enter further specialty training. Many become senior registrars or associate consultants at the age of 31 or 32.’
I guess we can’t compare our system in Malaysia with Britain and Singapore. From my experience, the faster a MO become specialist and further sub-specialize, the respective specialist will leave the government faster and join the private. So the above measurement just inhibit him from getting master/sub-specialization. So indirect he stays in the government sector for a longer time and serves the people. At least some of my friends, almost all of them leave government as soon as they got what they want and none of them choose to stay. So, isn’t this is another kind of brain drain?
‘Hiring foreigners whose specialization may not suit the local settings and whose quality may be questionable.’
I think the government is looking from the perspective as employer, they hire them as contractual worker so they are free to terminate them and employ others.
Therefor the above reasons doesn’t seem very convincing to me at least. All he wants is just become specialist and GET OUT from the GOVERNMENT ASAP and go for private. Isn’t it?
—————————————————————————————-
As for the feedback from the Tax payer. I feel that he is complaining too much. What is wrong with working 11am to 11pm for 12 hours? You can take the opportunity to learn cases from the ward. You are not going to work forever like this. There are many things to learn in the ward. Currently the younger generation of doctors prefer:
1. Short and Fixed working hour
2. Can’t be scolded, must talk softly and be pampered
3. Must teach me what you know, if you dun teach me, you are bad senior dr
4. Must have plenty holidays
5. Better not come to work on weekend
6. Must have high salary
7. Make sure I have breakfast before work.
8….
9….
The latest news shows that pharmacist already had reduced compulsory service from 3 year to 1 year. The second storm for them (government pharmacist) is here – the pharmacist is having pay cut now in government sector.
In few years time, wait until doctor no more job. Would you still complaining like today? That time, you will be lucky if you got job. Time has changed, my friend.
Just an add on the issues with pharmacist
I have heard private pharmacies are reducing the salary of new licensed pharmacist because of the overloaded volume.Some pharmacy actually pay almost 1k lower than government. Simple rule of supply over demand.
To reply your question “I’m wondering we are having houseman glut and how come only one HO is left to run the ward????”
We have glut of houseman but there is inappropriate distribution of numbers in hospitals. Those gluts is usually seen in hospital in Klang valleys, and big hospitals, where they have minimum of 50 HO per department. Sadly, for smaller hospital, the average number can be 15-20+. In one of the hospitals in Perak, when shift system implemented, there is only ONE HO in each ward (30-40 pt). When the HO goes to take radiology appt/clinic, it will left with 1 MO clerking new case, doing procedures, tracing results and taking blood.
With lesser amount of HO during shift system (as HO is already less in the hospital), HO is only busy finishing up the ward work, without having time to learn. Although it is stated that shift system work 12 hours, but tell you, they usually work 14-16 hours. Eg, 7am – 7pm. But go home at 9-11pm. Everyday! And this is tiring, just like those houseman old working days.
2. To reply your 2nd doubt “‘Doctors in other countries such as Britain and Singapore pass the Membership exam at a young age of 25 or 26 and are immediately eligible to enter further specialty training.’ I guess we can’t compare our system in Malaysia with Britain and Singapore. ”
You mentioned that if those young doctors get specialisation early, they will leave government sector. Why will they leave government sector? Because for better pay, better respect. However, with current government new policy which thought will tie up more doctors, these will seriously produce brain drain as their effort is not appreciated, and soon, they will go abroad for further studies.
We are actually comparing our system in Malaysia with UK, hence having SHIFT system implemented! If want to compare, why don’t they also look into salary and specialisation; and NOT merely the working time.
1. ‘Stuck in between’ is in kuching, Sarawak not Perak. Pls tell me which hospital in Perak is it? I try to inform my friend in Putrajaya about this matter. I think the solo HO in Perak is very lucky as he got plenty of opportunity to learn and get his ability tested compare to the urban HO who they just passing their time. I would be happy to be this kind of HO. In fact, one of my friends in the ED like to see all complicated cases and he attended most of the difficult cases and now make him a very good ED physician.
2. You mention ‘Why will they leave government sector? Because for better pay, better respect. However, with current government new policy which thought will tie up more doctors, these will seriously produce brain drain as their effort is not appreciated, and soon, they will go abroad for further studies.’
How will new policy that which tie up more doctor will produce brain drain since they work in the government sector longer? I don’t get it since the Caucasian countries are closing their door to the foreigner.
I think as a doctor, we should not put money as first priority (money also important as well). I rather get respect from the patient rather than from my college.
In private sector, it is not as easy as you think. Due to the pressure from your management and life, you will start to let go your principle and become a normal ‘money making’ machine and start selling yourself. Overtime, you will throw away your school of teaching –
1. Give unnecessary drugs (my experience, 12 medicine for simple low back pain, so pt take 16 tabs med 3 times a day)
2. Do unnecessary lab test and others (e.g. MSCT angiogram for low CAC) – common in medical center
3. Do unnecessary LSCS (despite pt can deliver per vagina) – high LSCS in private but not in government.
4. Do unnecessary operation as well.
In government, a doctor will try not to do thing (test, procedure and intervention etc)
In private, a doctor will try to do everything (test, procedure and intervention etc) and some even repeat what you have done.
My friend as physician in the government is enjoying her life. Go overseas vacation at least 4 times/year (own one) and able to attend many courses sponsored by the government. Despite not earning as much as the private, but she get very much satisfaction in her career.
who wants to be in government forever? by working in such environment ,many of us feel unappreciated ,it is not bcos of the lower income only.But also the attitude of our hospital management and MOH.
i got a lots of friends ,as soon as passing their mrcp,they choose to go sg .But do u think it is bcos they think sg is far better than malaysia.No,they still love malaysia where they grew up and live for more than 20 years.
What’s wrong if we want to become consultants with subspeciality faster?
Government ,if it is able to produce more and more subspecialities ,i believe soon the private sector will full of subspecialities and it will help to retain doctors in governemenrt sector too!
Private :How will new policy that which tie up more doctor will produce brain drain since they work in the government sector longer? I don’t get it since the Caucasian countries are closing their door to the foreigner.
Funny.Yes some of the caucasian countries are closing their door to the foreigner.But there are countries like SG ,HK and Aus.Many of my friends went to sg right after their MRCP OR MRCS bcos sg provide chances of subspeclialities.One of my friend with MRCS went to HK and hoping to enter their neurosurgery training.Many of my friends sat for AMC exam once they passed and they also choose to leave!
Many doctors are leaving bcos we feel gov are treating us like DOG .
ya ,u are right.Soon our country ,will be full of doctors and we can demand for more like now .But mind you,our country are only going to have inexperienced doctors everywhere.
Our government dun provide more training opportunities to young doctors .They try to impose unfriendly rules and hoping to keep those with mrcs or mrcp in the service.This is definitely push many of them to our neighbours.Our government fails to create an work environment which is attractive to specialists and consultants and keep them in the gov sector to provide a better and higher quality healthcare to malaysian!
Yes. Your reasons are absolutely ‘realistic’. However, it is because many of the best brains like you and your friends are leaving to other countries for the reason of sub-specialisation. And from my experience, none of them come back to work in the government. If so, only short period and pending vacancy from the private. So, how you can expect the system to change?
You said you love Malaysia but many of you choose to stay in other countries and become PR after got what you want. There is no wrong to become consultant with subspeciality faster. But it is very wrong that the government train you up and later you resign and leave the government sector. I would say this is self-centered (At least must finish up the compulsory service).
It is like when you are the boss, and after training your staff to specialist and the specialist just leave after completion. So, would you appreciate this kind of staff??? Of course NOT. I will also treat him like dog as well.
By the way, beside your best brain, there are other factors that make what you are today. The most important one is your patient.
How many patients you have treated so far?
How many patients risked their life to be treated by you?
How many patients you killed so far?
And others…
You are what you are now because of your patients not yourself only.
Like what Tan Sri Tengku Razaleigh said in ‘Undilah’ :
Negara ini memang ada macam-macam masalah, tetapi ingat, Malaysia tetap negara anda.
in the first place,who will willing to come back to serve in the government sector again after he/she left for other countries to become subspecialists ? The answer is NO. As i mentioned ,bcos we feel the G does not appreciate our effort at all.Despite of this,they imposes all kind of funny and unreasonable rules to control us.Dont forget,besides the G provides us the training as HO and MO ,we also provide our service to the G and the people.Many of my friends left for sg after they completed the compulsory service.I think This is Fair enough.
it’s not i want the system to change.But the system need to be changed,Especially the mindset of the people in the management level and MOH.Yes we r doctor but we are not slaves.i think we can always accept the better offer in our life.
And you said “It is like when you are the boss, and after training your staff to specialist and the specialist just leave after completion. So, would you appreciate this kind of staff??? Of course NOT. I will also treat him like dog as well.”
I guess this is the exact mindset of our government and MOH,That’s why they fail to solve the Brain drain issue .
One thing ,It is so stupid to hire those foreign doctors with some doubtful qualifications to treat our own people.I do have foreign doctors as colleagues in malaysia previously.But sadly,ONLY ONE i know can speak fluent malay,haha but the only one also left to australia once she passed the MRCP.I saw many patients in the ward show no confidence in the foreign doctors’ management even though these doctors are specialists because they dont have the communication skill to handle the patients.
that pianism character is an idiot. Dr page I’m starting to think whether BN cybertroopers have descended on ur blog.
Anyway, back to the issue at hand.
I once met a senior partner of a Malaysian medical group practice who said
“Doctors (gp’s) these days want to join established private practice, work 8-5 and earn 10k minimum. They have no experience in family medicine and take no risks. They forget that when we first set up our clinics, we used to sit there the whole week, treating patients. Yes we made our money, but only because we took risks and invested savings into a practice”
– i remember the statement coz i wrote it down in my journal 🙂 –
So that sums up our problem. All junior doctors want to take the SAFE way out, work MINIMUM hours, and earn MAXIMUM pay.
Cannot la….
let’s talk solution shall we,
1. Problem- Houseman Glut
Since in Malaysia everyone wants to become doctor and you can open up medical school even at your own backyard. The only solution is to have a common qualifiying exam for everyone. The problem with that is unless we have an international standard or external body to govern this, the exam will just be another “SPM” where the government decides the passing rate.
But if we employ international standards then if might open another can of worms since the quality of training in some of the local medical schools is second to crap. Comments will be made about the quality of education in Malaysia.
2. Internship training
I believe in Malaysia is to make a generalist out of our junior doctors due to staffing issues in the rural areas. I think given the current situation, it is just a matter of time where we have glut of MOs with poor generalist skills manning the rural hospitals/centres.
Why not streamline the training from the beginning? If we look at postgraduate year 1 in Uk/NZ/OZ, only core runs are compulsory i.e medical, surgical, ed. Maybe in Malaysia you could argue ortho/trauma as one of the core ones. Leave paeds and OnG to those who wish to be a generalist or specialize in these spec.
3. Specialist training
We dont have enough specialist in the public system to train etc…because they are all in private practice. Only the dinosaurs with their JUSA dream and political ambition/connection stay on and become HOD. Possible solution for this is to take out MOH out of the civil service and corporatize the healtcare service. Appointment based on merit and contracts.
I’m sure these ideas have been toyed around. I know the reality is….these are utopian dreams.
I think we seriously need to think of a solution to our unique problem.
I do agree…most of our problems stem from affirmative action gone wrong and reset is the only way to go. Bloated civil service, poor education system, healthcare in shambles, racist politics..bla2 since our very own doctor took over the country.
Damage is already done. Are we gonna abandon ship or shall we captain this ship to shore in this troubled times?
http://www.malaysia-today.net/mtcolumns/newscommentaries/44780-sub-standard-housemen
I think shift system works well if the system is well planned. As mint berry crunch suggested only do round in the morning and cover staff at night.
Most hospitals in Australia have shift system with the home teams- the actual treating team of consultants, MO/regs and HOs do their rounds every morning/afternoon and come up with plans and implement them while the cover HO/residents who work in the evening and night would review only SICK patients and sort out any acute issues (and occasionally chase up any results and implement any plans that are not able to be done earlier with clearly documented plans from the home team) under supervision of MO/reg who is on site all night. I am not sure whether in Malaysia there is an MO/registrar who is on site in the hospital at night to supervise and review patients or he/she is on call.
I am not sure what is the ratio of HO/MO during day and night for the shift system in Malaysia but in Australia there are more day shift HOs in a team-a busy general med/surg unit can have 2/3 HOs during the day so they can divide the number of patients they have and normally only 1/2 covering HO/resident for evening and night that cover a few teams. This would ensure that there is equal workload and things that should be done during the day are done such as ordering investigations- ultrasound or MRI and referral to other specialties. The home or day team is still responsible for the patients management but if any acute issues not sorted out at night then the night HO + MO/reg have to take the rap.
The night HOs do learn quite a lot from managing and reviewing sick patients during their cover shifts because they have to come out with initial plans to stabilise patients often without much investigations -very diificult to get imaging done at night, before consulting the MO/consultant.
Tsunamihastostop, good try… some pretty innovative suggestions.
The first thing is, corporatizing healthcare is very difficult simply because of the infancy of healthcare management as a science. Performance and operations management in healthcare is still evolving, as opposed to say the aviation industry where back in the 1970s Boeing was already implementing Enterprise Resource Planning to build planes spanning across the entire States. Privatizing healthcare is simply not possible as its essentially a public good which cannot be produced efficiently at high volumes (yet).
The second thing is, we cannot simply apply UK/Aussie’s “super specialize” everyone including the GP’s. Look at the Americans, where has it go them? Yes we want specialists to treat difficult problems, yet, specialists cost money. And cost control is the next hidden healthcare ‘epidemic’. The concept of health systems performance varies from country to country, depending on its environment, economy, culture, among other things.
We need localized solutions, using globalized tools and techniques.
I’ll give you a solution.
1. Break the two-tier system this country is having. A public private dichotomy is poisonous. It’s not like the private specialists in Malaysia are so damn conscious about innovation that we need a ‘happening’ market economy driving this sector. Take the huge money these people are making treating patients who have relatively simple problems.
2. Once the public and private dichotomy has been broken down, give consultants and senior doctors incentives to lead “teams” where performance incentives are given for them to TEACH and GUIDE the junior doctors no matter how much they suck. That will teach em a lesson to complain. Suddenly, instead of crapping on the younglings, they will group up and suggest how to whip some discipline on them.
3. Engage junior doctors, sign them up early for postgraduate plans and give a career development scheme for them to work on. You will be surprised how many of these so called useless young junior doctors just don’t have motivation to learn due to the ancient system employed in our gov hospitals.
4. Make academic medicine the most lucrative field for Malaysian specialists. Give them incentives for being Professors who will further their field’s original knowledge by conducting RCT’s that make sense, not just plagiarizing other countries research
5. Give generous incentives for private GP’s to open clinics in rural areas. For example, tax breaks or yearly bonus for anyone who opens a clinic in a 30km radius where there is no other clinics. When there is two or more clinics in the same area, give preference to seniority, qualifications and documented performance
I could go on and on. I’m sure all of you can if you put on your thinking cap.
Whatever the MOH is doing right now, (including our Minister and DG and policy maker too); be it for the HO/MO/Specialist (eg. subspecialisation, etc); they are seriously causing severe harm to the system overall. One fine day, everything will crumble and then it will be too late.
You need a clinician to be the administrator (ie. Minister), but it must be a true clinician with clinician and patient’s interest at heart. If you have someone else, it becomes difficult.
I do not know if it is the same elsewhere, the morale of govt specialists and MOs are so low at the moment. Only those non-clinicians and HOs are having fun time.
More news on this:
http://www.thesundaily.my/news/201492
“You need a clinician to be the administrator”
really? why? I don’t agree with that statement simply because you are excluding non-clinicians from becoming excellent healthcare managers based on what evidence?
In fact, so far, the ‘clinician’ administrators are not exactly fantastic. Columbia Asia has a few hospital CEO’s who are finance related. Even Sunway Med’s latest CEO is a finance person. And the fastest turnaround ever made by a hospital in Malaysia, Mount Miriams at Penang, was helmed by a non-clinical CEO.
interesting eh.
well, that just means hospital will do business well =P (but I am not against it). Even in United states the head of admin is always business/finance related. I am pretty sure alot of private hospitals all over the world do not want clinician to be in the admin.
I had the best time of my housemanship training at Hosp Taiping. That was 8 years ago. Yes, we had shortage of HOs but that was never an excuse not being able to cover the whole wards and patients, going to the opd etc. having back to back calls. we learned a lot back then.
I told this to the younger generation of HOs but they bluntly said, “you cannot compare ur time with ours, we dont get enough rest especially when we’re oncalls eventhough there are 6 of us, too many procedures to do, too many patients to clerk yet very little time blah blah blahhh”
complaining and complaining and complaining is what they all do and good at.
too much pampering perhaps…i wonder if a good slap on the face on prn basis would do good.
i now joined the academic field, with the allied health instead of the medical faculty. i’ve came across parents who begged to have their children transferred from the allied health program to medical program (although their kids were not eligible), they would fork through certain strings just to make sure they get what they want.
i think we have to tackle from the root of the problem…the parents mentality. they only see the wonders of being a doctor….when in fact their kids are so lousy at doing their jobs as HOs…
and bear in mind, these are the ‘quack-lified’ doctors graduated from ‘lemon’ universities/colleges who will be seeing and dealing with patients every day.
do we want to have our family members/relative to be seen by them?? it’s like a death sentence to the patients!!
*just sharing my 10cent opinion*
lol well it’s not just the parents i contend.
Seriously, how many 18 yr olds can make mature decisions on things like this.
“I’ve always wanted to become a doctor” has become a stereotype of sorts…nurtured by parents to be regurgitated during the interview.
I dont think any SPM leavers, myself included, truly knows what he/she wants to become in life. The public conception of what it means to be a doctor – sit in clinic, see coughs and colds, discharge and earn 50 bucks easy money – is bullcrap and it’s the root of the problem… parents dont help with that misconception either :p
Health care quality is deteriorating. Houseman nowadays knows nothing about patient. Worst, cannot even take a good history, not to mention about good physical examination and investigation.
God safe this country. I wonder whether the “top levels” are worried about this as they will most probably seek treatment at the private top specialist centre or our near by country.
Please, do something to safe this country!
I even saw once a houseman copying the ETD clerking sheet and not clerking the patient or seeing them. *sigh*
ash you saw that ONLY once?=P I am pretty sure that happens much more than once
when i was a houseman 2 years ago, i worked 0630am-1200midnight, almost daily… even if oncalls 630am till the following day 10pm… and i wonder, why are the new houseman still complaining when they are working 1/4 less the hours i used to… sigh…
totally agree dude!!me too was working my ass off without complain!n learnt as much as possible all the way..n im thankful for that.so stop complaining and just do your bloody job.if u want a simple job then dont study medicine.because medicine is only for awesomme and great people.obviously you are not one of them!
QUESTIONS
How many medical schools that are needed in this country actually?What numbers of medical graduates need to be produced annually?
Should all other unnecessary medical schools closed and which schools?
Lets look at other developed countries, since that is what we aspire to be.
UK pop 62 mil with 33 med schools.
Med school per million people = 0.53
Australia pop 23 mil with 19 med schools.
Med school per million people = 0.82
Malaysia pop 28 mil with 34 med schools.
Med school per million people = 1.21
The numbers above need to be contexted for each country. Aus and UK have well-developed hospital systems, with specialists in smaller district hospitals, unlike Malaysia. It will take 15-20 years and a lot of govt spending to upgrade and expand our district hospitals for all of them to accommodate specialists.
UK relies heavily on foreign-trained doctors. They used to come from the subcontinent, now they come from the EU. Also, they are a densely-populated country. Both these factors mean they train slightly less doctors compared to Aus, whose population is more spread out and traditionally relied less on foreign-trained doctors (until 2004).
Now, we look at Malaysia. Another factor we need to consider is that there are many many Malaysians who study medicine overseas and who almost have to come home to Malaysia to do their housemanship. This is not true for UK and Aus. Malaysians who study in Ukraine, Russia, Indonesia, Bangladesh, Egypt, etc can’t really stay in those countries. MARA sends 1,000 students to Egypt alone each year to do medicine. I would conservatively say another 1,400 students go to these other unis each year. If we regard these 2,400 Malaysians as originating from 12 medical school (200 students per intake per year), Malaysia would have 1.64 medical schools per million people.
Even though UK and Australia also rely on foreign-trained doctors, they are not their own citizens and they can ‘turn the tap off’ anytime without much consequence. Australia was very very difficult to migrate to as a doctor from overseas from the 1980’s to 2004 because they closed their doors when they had enough at the time.
As to how many med schools we need, I would estimate a ratio of 0.8 medical schools per million people. This is my own opinion. That would mean 22-23 med schools instead of the current 34. Yes, our population is growing exponentially – we can rely on some foreign-trained doctors but not as many as currently.
Which local unis to ‘close down’? I would say none – we just need to amalgamate the smaller ones to pool their resources to make them better and more efficient. This will bring down the overall numbers. This will also mean less profit for the owners so I doubt it will happen. The reality is also that private medical schools are the only real avenue for non-Malay students to do medicine because of govt policies (e.g. giving equal standing to matrics vs STPM) – and this is a factor driving the market.
You cannot see medicine from quantity point of view. What is more important is the quality of students who are enrolled into medical schools. WE have too many medical schools with poor quality control. This in turn will produce poor quality doctors who will detriorate the healthcare of the country. Litigation rate will go up and the country will loose a lot of money!
Based on random calculation, we just need about 6000 graduates a year. BY 2015 we will achieve a ratio of 1: 600. However, if the current scenario continue, we will be producing far more than that figure as we should not forget those graduating from overseas.
The government should just stop sponsoring students to study medicine overseas as it is not going to be a critical field anymore.
It is not the number of med schools, but the total numbers of doctors produced, or rather joining the workforce, that is important.
UK and Oz are matured countries with stable doctor/patient ratios.
UK produces about 6300 doctors for a population of 60 million, or about 100/million. However, new registration of doctors in GMC averages 11,000-13,000, indicating a large number of EU and IMG joining the work force. 30% of doctors in UK now are IMG’s.
Oz produces 2100 doctors currently for 21 million population, ie also the same 100/million. However a paper that looks at the actual numbers required to maintain current ratios puts Australia’s requirement at 3000 minimum, to replace retirements, population increase, decreased working time etc. The production numbers will go up to 2500 in a few years, as several new programmes graduate their initial batches. About 1000 IMG gets registration with AMC every year.
Therefore, it would seem that, based on stable needs countries like UK and Oz, about 100-150 new doctors are needed every year per million population.
Extrapolating to Malaysia, with the current population of about 30 million, we will then need 3000-4500 new doctors to keep stable, and to improve the ratio, more than that is needed. So, on the surface, having numbers like 6000, 8000 per year is not excessive.
The problem with Malaysia’s case is, it increased too fast and overtake the ability to train them, both at undergraduate level, and at housemanship, and postgraduate training. In addition, there is poor quality control, and included in this numbers are many poorly trained doctors, and many mediocre students who should NOT have been accepted into med school in the first place.
There is also the question of whether Malaysia, as a mid level developing country can afford the kind of high level care, and the kind of funding required that OECD countries practice. There are many instances of other developing countries with doctor production below western ratios, but still with unemployed doctors, as the economy just cannot not support that many doctors.
.
The forecasted production number of 2500 doctors per year for Australia in 2012 is from the Medical Specialist Training Steering Committee, and only takes into account local students. If you include foreign students, there will be just over 3000 graduates (from a paper produced by the Australian Medical Association).
Also, the number of IMGs registered each year includes a significant number of Brits on a working holiday and only stay for 12 months. Some of course like the work environment in Aus (who wouldn’t, compared to the NHS!) and stay permanently.
Australia’s expansion has also been quite rapid (doubling the number of medical schools in the last 11 years) but not as rapid as Malaysia. Even then, they have had a headache trying to find ways to accommodate these new graduates. Also, the number of postgraduate training places haven’t expanded in tandem – many private hospitals are now being utilised for postgraduate training.
You still have to prove a vacancy cannot be filled by an Australian before you give a foreigner a work permit – expect less IMGs being required in the future and Australia to revert to its closed doors policy as it was before 2004.
So its true that UK/Aus needed foreign doctors over the past 2 decades to fulfill their growth strategies. And countries like US alone has 40% indian migrants. Nothing wrong with seeking a better life.
Maybe the Malaysian gov’s strategy is to create a large pool of Malaysian doctors (quality is secondary) to create an artificial barrier to prevent migration from ASEAN countries (minus singapore) to fill-up our government posts once AFTA kicks in. Thats my theory anyways.
In other words, I rather have poor quality Malaysian doctors then poor quality non-Malaysian doctors??? (assuming the other non Singaporean ASEAN nations are also producing sub-par doctors)
*disclaimer – i generally reserve my comments about the quality of young doctors
*disclaimer 2 – i am allright with migration (in case Ramu and wtv make a comeback)
*40% indian migrants as doctors
Maybe the Malaysian gov’s strategy is to create a large pool of Malaysian doctors (quality is secondary) to create an artificial barrier to prevent migration from ASEAN countries (minus singapore) to fill-up our government posts once AFTA kicks in. Thats my theory anyways.
Certainly possible, but a much easier way would simply for the ministry to recognize a select number of universities and automatically disqualify the grads from coming in. Those from unrecognized unis would then have to climb a mountain of red tape and exams to make it impractical to work in malaysia.
Creating a large pool of doctors seems like the much more difficult, expensive way to solve the potential problem.
But thats not possible as under AFTA rules, if a doctor is recognized by his country to be a medically qualified practitioner, under non-discriminatory rules Malaysia would have to recognize them as well. Thats why there is a certain brouhaha to get the National Specialist Register up to mark before AFTA so that Tom, Dick and Harry cannot claim to be a hepatobiliary surgeon and operate on anyone the ‘unethical’ hospital plans to admit.
It get a bit more complicated under the WTO-AFTA rules..
Mahathir once said ” we will flood the market with doctors” . This will bring down the cost of healthcare as more competition among doctors.. Doctors will start giving discounts like Giant/Carrefour and Kedai 1Malaysia to stay alive and earn a decent living.
Well, competition is not a problem Dr Paga. Competition breeds innovation and quality follows through.
Adam Smith’s ‘invisible hand’ will ensure the poor quality doctors are left lagging in the race. The market will decide what they want in a doctor and choose appropriately. At least this is true for the private market.
the problem will be, once the public sector is filled with inefficient medical practitioners, then we will have a situation where health amongst the middle and low class malaysians will simply deteriorate (unless technology disrupts this paradigm like how everyone know owns a smartphone and is suddenly knowledgeable about everything and anything)
Actually, competition in this context is a problem because of an uneven playing field. Current govt policies will favour doctors of a certain race and the companies they own. Quality does not come into the equation. Even many private hospitals hire by race these days.
Also, the ‘market’ in Malaysia, i.e. the patients, don’t really know how to judge for themselves the quality of the doctor. The average Malaysian patient thinks a good GP is one who gives them medicine for everything. If a GP tells them they just have a common cold and it will go away on its own without antibiotics, the patient will leave the clinic and tell everyone that this GP is lousy and go to another GP to get antibiotics.
Our watchdog (the MMC) also rarely takes action against any doctors who commit major negligence so this keeps the incompetent ones in the system.
Don’t get me wrong, I agree in competition as a principle when it comes to entry to medical school, entry to postgraduate training, hiring for jobs, etc – but there needs to be a level playing field.
And don’t forget, there are a finite number of jobs out there so even if were had an ideal competition model, the sheer numbers being produced will result in a generation of wasted resource. These students and their parents might have been better off spending their money on another degree and contribute to the economy in another way. But then you have politicians telling them now that everything is ok and we still need lots of doctors – so we’re in this current situation.
thanks nav… good stuff
if we don’t start controlling the quality of doctors in Malaysia, in the future, ALL the doctor trained in Malaysia will be branded as of lesser quality, no matter how much we are well-trained.
Anyone have inputs on singapore’s houseman training program? Their hours, training etc. a lot of parents are of the view that if they get their degree in UK but they could not train in UK, they can always go to Singapore
If your degree is recognised in Singapore, you can apply for a post in singapore. However, singapore is changing their sytem to residency system like US. So, alot of things are changing as well.
[…] them are being under-trained,” wrote Dr Pagalavan Letchumanan, a consultant rheumatologist and prolific blogger on crucial issues in health […]
[…] them are being under-trained,” wrote Dr Pagalavan Letchumanan, a consultant rheumatologist and prolific blogger on crucial issues in health […]
[…] them are being under-trained,” wrote Dr Pagalavan Letchumanan, a consultant rheumatologist and prolific blogger on crucial issues in health […]
Thank you for the very lengthy post. It is a good read.
There is too many medical grads a year. We (the specialist/hospital) just cannot cope. In some places there are not enough patients to HO ratio. Previous system that harrasses us and made us work unbelievable hours perhaps is not idealistic but we did learn from the volume of patients we were exposed to. The shift system is ok if only it is studied and implemented properly. But as usual in Malaysia no proper study in ever conducted before implementing any MAJOR changes to a system… it is a universal Malaysian malady and no one ever consults the doctors themselves.
My belief is that it is better that majority of HOs work normal hours (perhaps 7 to 7) and a few (3-4 if needed) do the night shift. The normal hours they will learn a lot of things and the specialists are around to teach and supervise. Night shifts are needed asHOs need to be exposed to this situation as they are working and needed to be trained to be MOs in the future. I hope in the future they can implement shift work for MOs and perhaps some specialists (esp those staying in specialities) too so many will have a better QOL.
* I am a specialist in goverment service and i am frustrated that n one asks us of our views prior implementation of this new changes. I am frustrated that I now cannot teach my HOs like I used to previously- because I rarely see them. I am frustrated that many junior doctors have poor work ethics and poor attitude hence compromising pt care. I still try to teach but i have decided to not force feed the juniors. I have seen a few bright sparks but the are too few…but i am still optimistic
You are absolutely correct, this is what that frustrates people in government service. Your are a servant to the government!
what is this all about.im not a doctor,i used to be a patient in one of gov hospital, but what i see,medical officer,specialist and nurses work lesser than the housemen.
That’s because you only see the houseman running around in the wards. BUT the specialist and medical officers not only have to do rounds but also need to see referrals from other departments, run clinics, do admin work, study for postgraduate exams and do surgeries. Houseman don’t do any of this. Specialist and medical officers also have bigger responsibilities as if anything goes wrong, it is not the housemen who would be blamed. The MO and specialist have to answer.
[…] ever made. A superb ending for the Batman trilogy. I have written twice on this topic above https://pagalavan.com/2011/11/07/for-future-doctors-the-storm-is-coming […]